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Colorectal Cancer in Elderly Patients Czech experience (view) in data

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Colorectal Cancer in Elderly Patients Czech experience (view) in data Jiří Hoch, Milan Blaha Department of Surgery, University Hospital Motol Charles University Prague Institute of Biostatistics and Analyses
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Colorectal Cancer in Elderly Patients Czech experience (view) in data Jiří Hoch, Milan Blaha Department of Surgery, University Hospital Motol Charles University Prague Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic Colorectal cancer in the Czech Republic: high incidence and mortality Incidence ASR(W) Mortality ASR(W) Slovakia Hungary Czech Republic The Netherlands Norway Denmark Italy Belgium Ireland Germany Slovenia Luxembourg Croatia Portugal United Kingdom Spain Bulgaria France (metropolitan) Sweden Serbia Iceland Austria Malta Switzerland Estonia Republic of Moldova Lithuania Poland FYR Macedonia Finland Russian Federation Belarus Ukraine Latvia Romania Montenegro Cyprus Bosnia Herzegovena Greece Albania other countries neighbour countries Czech Republic Hungary Slovakia Czech Republic Croatia Slovenia Serbia Denmark Republic of Moldova Russian Federation Norway Bulgaria Belarus Portugal Poland Ukraine The Netherlands Lithuania Malta Spain Ireland Latvia FYR Macedonia Romania Germany Estonia Italy Belgium United Kingdom Sweden France (metropolitan) Austria Montenegro Luxembourg Bosnia Herzegovena Switzerland Finland Greece Iceland Albania Cyprus other countries neighbour countries Czech Republic ASR(W): no. of cases per persons, world age-standardized Source: Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: Number of cases per persons Trends of CRCa incidence (CZ) C C19 C20 year Newly diagnosed cancers according age [%] Colorectal cancer patients (dg. C18-C20) Age Male/female Pacients up to 70 y. (50,2 %) Age at diagnosing Pacients over 70 y. (49,8 %) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 35,6 64,4 45,7 54,3 40,6 59,4 do a Celkem 70 70 Total let více let Female Male Source: National oncological register Proportion of new cancers according age [%] Proportion of colon, rectosigmoid and rectal cancers (dg.c18-c20) Age structure of patients with rectal, rectosigmoid and colon cancer Participation according age % 18 90% 16 80% 14 70% 12 60% 10 50% 8 40% 6 30% Age % 10% 0% Location: C20 - large bowel C19 - rectosigmoid C18 - rectum Age Source: National oncological register Proportion of new cancers according age [%] Proportion of new cancers according age [%] Age of patients Colon and rectosigmoid Rectum 20 Pacients above 70 y. - 52,5 %. 20 Pacients above 70 y. - 42,7 % Age C18-C19 C20 C18-C20 N = N = N = Average Median % 75% kvantil Age Source: National oncological register Proportion of patients according to age [%] Stage of colorectal cancer (dg. C18-C19) according to age Age according to stages Stages according to age % 18 90% 16 80% 14 70% 12 60% 10 50% 8 40% 6 30% 4 20% 2 10% 0 0% Stage: Not indicated due to objective reasons Not indicated incomplete record Source: National oncological register Stage of colorectal cancer (dg. C18 - C 20) according to age 70 Dg. C 8-C19 Dg. C20 Dg. C18-C20 N = N = N = N = N = N = % 90% 4% 11% 4% 13% 4% 12% 80% 70% 26% 24% 22% 20% 25% 23% 60% 50% 40% 30% 20% 23% 20% 25% 26% 25% 22% 20% 24% 20% 21% 24% 25% not indicated incomplete record Not indicated objective reason stage 4 stage 3 stage 2 Stage 1 10% 19% 18% 25% 23% 21% 19% 0% do 70 let 70 a více do 70 let 70 a více do 70 let 70 a více 70 70 70 70 70 70 let let let Source: National oncological register Treatment of patients with colorectal cancer Patients 70 y. Patients 70 y. N = N = ,1% 72,4% 27,6% 87,9% Treated (N = ) Not treated (N = 2 422) Treated (N = ) Not treated (N = 5 465) 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% C N = C N = C N = C N = C N = C N = Source: National oncological register Treatment - modalities used Dg. C18 Dg. C19 Dg. C20 Patients (%) Patients (%) Patients (%) Surgery Chemoth Radioth Other Not treated 70 y. (N = ) 70 y. (N = ) 70 y. (N = 2 848) 70 y. (N = 2 598) 70 y. (N = 6 408) 70 y. (N = 4 783) Source: National oncological register Treatment single modality and combination C18 C19 C20 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% N = N = N = N = N = N = Anticancer therapy: Non treated Non operative th. only Surgery + RTh + CHTh Surgery + RTh Surgery + CHTh Surgery only 0% do 70 let 70 a více do 70 let 70 a více do 70 let 70 a více 70 70 70 70 70 70 let let let Source: National oncological register Survivals Survival : patients aged less and more than 70 ( Dg. C18 C20 ) 70 y. 70 y. Time of survival (months) 70 y. (N = ) KM % 70 y. (N = ) 6 83,7 64, ,8 57, ,3 50, ,3 46, ,3 42, ,3 39, ,9 36, ,5 34, ,8 33,0 Time of survival (months) Age N Deaths N (%) Survival median (month) (95% IS) In average (months) (95 % IS) p-value Log Rank test 70 y (33,2 %) 39,8 (39,5; 40,2) 70 y (53,9 %) 19,1 (18,2; 20,0) 27,6 (27,3; 28,0) Total (43,5 %) 35,7 (34,5; 37,0) 33,8 (33,5; 34,0) 0,001 Survivals Survival : patients with large bowel cancer ( Dg. C18 ) 70 y. 70 y. Time of survival (months) Time of survival (months) 70 y. (N = ) KM % 70 y. (N = ) 6 81,9 63, ,0 55, ,6 49, ,2 45, ,9 42, ,6 39, ,5 37, ,6 35, ,5 33,8 Age N Deaths N (%) Survival median (month) (95% IS) In average (months) (95 % IS) p-value Log Rank test 70 y (33,4 %) 39,7 (39,1; 40,2) 70 y (54,3 %) 17,7 (16,5; 18,9) 27,4 (26,9; 27,9) total (44,6 %) 34,3 (32,5; 36,2) 33,1 (32,7; 33,5) 0,001 Survivals Survival : patients with rectosigmoid cancer ( Dg. C19 ) 70 y. 70 y. Time of survival KM % (months) 70 y. 70 y. (N = 2 848) N = 2 598) 6 84,0 67, ,5 59, ,3 53, ,4 48, ,5 45, ,7 41, ,5 38, ,9 36, ,3 34,5 Time of survival (months) Age N Deaths N (%) Survival median (month) (95% IS) In average (months) (95 % IS) p-value Log Rank test 70 y (33,8 %) 39,5 (38,5; 40,5) 70 y (51,6 %) 21,8 (18,9; 24,8) 29,0 (27,9; 30,1) Total (42,3 %) 38,1 (34,8; 41,5) 34,5 (33,7; 35,2) 0,001 Survivals Survival : patients with rectal cancer ( Dg. C 20 ) 70 y. 70 y. Time of survival (months) KM % 70 y. (N = 6 408) 6 86,7 67, ,4 59, ,6 52, ,0 46, ,7 41, ,1 38, ,2 34, ,5 32, ,5 30,2 70 y. (N = 4 783) Time of survival (months) Age N Deaths N (%) Survival median (month) (95% IS) In average (months) (95 % IS) p-value Log Rank test 70 y (32,6 %) 40,2 (39,6; 40,9) 70 y (54,0 %) 20,2 (18,7; 21,7) 27,4 (26,6; 28,2) Total (41,8 %) 37,1 (34,9; 39,2) 34,8 (34,2; 35,3) 0,001 age Survival decreased with increasing stage for stages II and III Older pts stage III less likely referred for chemotherapy Decrease in cancer-specific survival in groups 63.7% % % 2O patients Swedish National Colon Cancer Register older patients were more likely to be female (54% older/48% younger) have right-sided cancer (60% older/49% younger). the elderly were less often evaluated less often evaluated at a MDT conference (26% older/34% younger) more frequently underwent emergency surgery (22% older/19% younger) fewer elderly patients underwent a radical curative procedure (OR for noncurative resection 1.19; 95% CI ). Motto: The median age of patients diagnosed with colorectal cancer is ± 70 years, but little is known about specific characteristics and management in the elderly Increased amount of older patients without (precise) diagnose Increased amount of patients without treatment Increase of use one therapeutical modality only Worse survival in higher age Location of tumor Elective/emergency Who is old? Is 70 the border line? How to evaluate age and ability for treatment? Why less treatment both surgery and CT / RT? Trials? Emergent surgery? MIS? Who is old, assement of capability Categories o younger seniors y. o seniors y. o oldest seniors above 85 y. For medical decisions National Institute on Aging, National Institute of Health, USA physiological age is more significant than calendary CGA comprehensive geriatric assessment - functional investigation of daily activities - general condition - co-morbities - polypragmasy - - nutrition - mental condition and cognitive involvement - socio-economic backround - geriatric syndroms Kaźmierska J. Assessement of health status in elderly patiens with cancer. Rep Pract Oncol Radiother 2012; 18(1): doi: / j.rpor CGA comprehensive geriatric assessment Groups: Fit Intermediate / vulnerable Frail increased risk of mortality and complications 5 signs of frailty: decrease of - nutrition - mobility - force - energy - physical activity Fried LP et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Med Sci 2001; 56(3): M146 M156. Hemaker ME et al. The value of geriatric assessments in predicting treatment tolerance and all-cause mortality in older patiens with cancer.oncologist 2012; 17(11): doi: / theoncologist Balducci L, Extermann M. Management of cancer in older persons: a practical approach. Oncologist 2000; 5(3): Kaźmierska J. Do we protect or discriminate? Representation of senior adults in clinical trials. Rep Pract Oncol Radiother 2013; 18(1): doi: / j.rpor.2012 Why less (intensive/extensive) treatment surgery, CT, RT? Tendency to less extensive/intesive treatment due to decrease physiological functional capacity/reserve Less tolerancy to surgery, radiotherapy, systemic therapy Risk of postoperative, systemic or toxic complications Cardiovascular problem (MI, ischaemic disease, reduced ejection fraction), respiratory (impaired ventilation and perfusion), obstruction and restriction), liver, renal functions, nutrition Clinical guidelines absent, CRT not applied in patients above 65 y. trials needed Emergent surgery Elective and emergent surgery same procedure? Extent of colorectal /and other surgery Risk of anastomosis One, two, three stages surgery? Stoma when stoma, what after? Or stoma forever? Protective measures why, which and when? Complication management possible? Miniinvasive colorectal surgery et the elderly Meta-analysis 52 laparoscopic colorectal surgery trials in majority no restrictions regarding cardiac (40; 77%) function and pulmonary (41; 79%) function 30 (58%) no restrictions regarding ASA score 44% trials excluded the elderly on age or comorbidity or organ function Participation of the elderly in trials is very limited 2014 Single study 140 pts older than 75 y., 6O laparoscopic, 80 open CR surgery postoperative complications 48% after open and 34% after laparoscopic surgery Martínek L. et al. Ist das Alter ein Risikofaktor für laparoskopische kolorektale Operationen? Zentralbl Chir CGA comprehensive geriatric assessment Groups: Fit standard treatment Intermediate / vulnerable individualized/patient tailored treatment Frail symptomatic/paliative treatment increased risk of mortality and complications 5 signs of frailty: decrease of - nutrition - mobility - force - energy - physical activity Fried LP et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Med Sci 2001; 56(3): M146 M156. Hemaker ME et al. The value of geriatric assessments in predicting treatment tolerance and all-cause mortality in older patiens with cancer.oncologist 2012; 17(11): doi: / theoncologist Balducci L, Extermann M. Management of cancer in older persons: a practical approach. Oncologist 2000; 5(3): Kaźmierska J. Do we protect or discriminate? Representation of senior adults in clinical trials. Rep Pract Oncol Radiother 2013; 18(1): doi: / j.rpor.2012 2000
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