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Annals of Surgical Oncology 9:210-214 (2002)
© 2002 Society of Surgical Oncology

ORIGINAL ARTICLES

Esophageal Resection for Carcinoma in Patients Older Than 70 Years

Michael S. Sabel, MD, Judy L. Smith, MD, Hector R. Nava, MD, Kevin Mollen, MD, Harold O. Douglass, MD and John F. Gibbs, MD

From the Roswell Park Cancer Institute and State University of New York at Buffalo, Buffalo, New York.

Correspondence: Address correspondence and reprint requests to: John F. Gibbs, MD, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263; Fax: 716-845-3434; E-mail: john.gibbs{at}roswellpark.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: A larger number of older patients are presenting as candidates for esophageal resection. An aggressive surgical approach in this population is controversial.

Methods: Four hundred thirteen patients with esophageal cancer who presented to Roswell Park Cancer Institute from 1991 to 1998 were retrospectively reviewed. Clinical data, perioperative details, and postoperative courses were compared for patients older and younger than 70 years.

Results: One hundred forty-seven patients (36%) were older than 70 years. Risk factors, clinical symptoms, histology, and stage at presentation were equivalent for both age groups. A higher percentage of patients <70 years were candidates for curative resection. There were no significant differences between groups for estimated blood loss, intraoperative transfusions, length of stay, overall morbidity, or mortality. Only postoperative myocardial infarction and atrial fibrillation were increased in the older group. Excluding stage IV disease, there was a significant and similar improvement in median survival after resection for patients both <70 years and >70 years.

Conclusions: In conclusion, esophageal cancer in older patients warrants surgical resection because the benefit to the patient is the same as it is for younger patients, without a significant increase in operative morbidity or mortality.

Key Words: Esophageal cancer • Esophagectomy • Advanced age • Aggressive surgical approach • Postoperative complications • Prognosis


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Improvements in general health care have resulted in an increased population of aging Americans. In 1900, 4% of the US population was >65 years. This number has increased to 13% in 2000, and in the year 2030 at least 65 million Americans will be >65 years old. Because of the increased life expectancy of the general population, an increased number of potential candidates for major surgical procedures are 70 years of age or older.

For several reasons, the decision to recommend an aggressive surgical approach to patients >70 years old with esophageal cancer is controversial. Many physicians are concerned about potentially higher morbidity and mortality rates in older patients after esophagectomy. Some physicians believe that older patients more often present with advanced-stage disease, possibly because of a longer time between the onset of symptoms and diagnosis in the geriatric population. Survival rates after esophagectomy are disappointing overall, and the life expectancy of elderly individuals is shorter than for their younger counterparts. For these reasons, many physicians and surgeons may favor palliative approaches rather than an aggressive surgical approach. To investigate the validity of these arguments, we retrospectively reviewed our experience with esophageal cancer in the elderly population.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
From January 1991 to December 1998, 413 patients with cancer of the esophagus were seen at Roswell Park Cancer Institute. Of these, 266 (64%) were <70 years old and 147 (36%) were >70 years old. The patient records were reviewed, and clinical data, operative details, and postoperative courses were recorded for all patients. Perioperative data recorded included the type of procedure performed, operative mortality (defined as death within 30 days of operation or any time during hospitalization), and complications. The estimated blood loss and intraoperative transfusion requirements were also recorded. All follow-up information was obtained during annual office visits or from the referring physician.

The statistical difference between groups was determined by using {chi}2 tests or unpaired Student’s t-tests. A P value <.05 was considered significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient Demographics
From 1991 through 1998, 147 (36%) of 413 patients seen at Roswell Park Cancer Institute for cancer of the esophagus were aged >70 years. The average age for this group was 77.1 years (range, 70 to 95 years). The remaining 266 patients (64%) were younger than 70 years, with an average age of 57.9 years (range, 21 to 69 years). For both age groups, 65% of these cases were adenocarcinoma, and 35% were squamous cell carcinomas of the esophagus (Table 1). The male to female ratio was higher in the <70 group (4.6:1) than in the older age group (1.7:1). Although the overall distribution of histology was equal, the difference in the male to female ratio seems to be a result of a higher percentage of older women with squamous cell carcinoma.


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  		TABLE 1. Demographics and prognostic indicators for esophageal cancer in patients older and younger than 70 years
 
Presentation
The most common symptom prompting medical attention in both age groups was dysphagia, representing 85% of the younger group and 73% of the older group (Table 2). Weight loss was the second most common symptom in both groups, although it was rarely the primary symptom prompting work-up. A minority of patients in both age groups had their cancers identified secondary to upper gastrointestinal bleed, symptoms of gastroesophageal reflux disease (or Barrett’s surveillance), or pain. The duration of symptoms before medical attention was sought was also similar, with the average duration being 3.7 months (median, 2 months) for both age groups.


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  		TABLE 2. Primary symptoms prompting medical attention in patients older and younger than 70 years
 
Prognostic Signs
Older patients did not present with higher grade or more aggressive tumors, with the distributions of grade and length being equivalent (Table 1). Likewise, patients older than 70 years did not present at an advanced stage. In fact, they tended to present at an earlier stage of disease than their younger counterparts, although this was not statistically significant (P = .08). In this patient population, 33% of older patients presented with early-stage disease (stage 0, I, or IIa), compared with 21% of younger patients. Conversely, only 26% of older patients presented with metastatic disease (stage IV), compared with 36% of younger patients.

Surgical Candidacy
As would be expected, a higher percentage of patients under the age of 70 years were deemed to be surgical candidates. Overall, 37% of patients under the age of 70 years underwent esophageal resection, compared with only 18% of patients >70 years (P < .01). The poor surgical candidates among patients >70 years more often had squamous cell carcinoma. For patients with adenocarcinoma, nearly half were candidates for resection in the <70 group, whereas 32% of patients in the >70 group were candidates. These numbers decreased to 19% and 12%, respectively, for patients with squamous cell carcinoma, despite the decreased number of patients >70 years with stage IV disease. Overall, 95 patients younger than 70 years with esophageal cancer had surgical resection, whereas 24 patients older than 70 years underwent resection.

Surgery
The characteristics of the patients undergoing curative resection for their esophageal cancer are listed in Table 3. Approximately 77% of the resections in patients <70 years were performed at Roswell Park Cancer Institute, and the remainder were performed at outside institutions with postoperative referral to Roswell Park either for adjuvant therapy or recurrent disease. Eighty-five percent of patients >70 years had their surgery performed at our institution. Seventy-six (80%) of 95 esophagectomies in patients <70 years were Ivor-Lewis resections with regional lymphadenectomies. There were nine thoracoabdominal approaches, five esophagogastrectomies, and three transhiatal resections. Twenty-two (85%) of 26 esophagectomies in the older age group were also Ivor-Lewis resections.


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  		TABLE 3. Characteristics of patients older and younger than 70 years undergoing curative resection for esophageal cancer
 
Blood loss, intraoperative transfusions, and length of hospital stay were equivalent in both groups. The average blood loss in the <70 group was 1068 ± 738 ml (range, 250 to 3700 ml). The average requirement for intraoperative transfusions was .9 ± 1.4 U of packed red blood cells. Sixty-four percent of patients did not require an intraoperative transfusion. Average estimated blood loss in the older age group was 938.6 ± 445.6 ml. These patients required an average of .7 ± 1.0 U of packed red blood cells, transfused intraoperatively. Again, 65% of patients did not require a transfusion. The average length of stay in the hospital was 22 ± 15 days for patients <70 years and 26 ± 21 days for patients >70 years.

Adjuvant therapy was used equally in the two age groups. In patients <70 years, adjuvant therapy was administered in 59% of patients, whereas 41% were treated with surgery alone. These numbers were 54% and 46%, respectively, for patients >70 years. The type of adjuvant therapy was also equally distributed between the two groups, as indicated in Table 4.


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  		TABLE 4. Adjuvant therapy in patients older and younger than 70 years
 
Morbidity and Mortality
The morbidity rate was relatively equal in both groups. Figure 1 demonstrates the morbidity rates for esophageal resection in both patient populations. Older patients did not have an increased rate of stricture or anastomotic leak. The method of anastomosis was similar in both groups (80% hand sewn, 20% stapled). There was also no difference in the rate of pulmonary complications (including pneumonia, empyema, acute respiratory distress syndrome, or ventilator dependence) or infectious complications. Atrial fibrillation, a common complication of thoracic surgery, particularly in the elderly, occurred in 12 patients (13%) <70 years and 6 patients (23%) >70 years. This difference was noticeable but not statistically significant. The only significant difference in complications between the two groups was the occurrence of perioperative myocardial infarction (MI). There were no occurrences in patients under the age of 70 years. Three patients (8%) over the age of 70 years had an MI. One of these patients had a resultant heart block requiring placement of a pacemaker; however, none of the three MIs was fatal. The mortality rate was low for both groups. There were two operative mortalities in the younger age group (2%) and one mortality in the older age group (4%).



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  		FIG. 1. Comparison of surgical morbidities after esophageal resection between patients <70 years ({square}) and patients >70 years old ({blacksquare}). MI, myocardial infarction; SVT, supraventricular tachycardia.

 
Survival
The overall mean survival from the time of diagnosis was 1.45 ± 1.4 years for patients <70 years old and 1.32 ± 1.2 years for patients >70 years old (not significant). Patients undergoing curative resection had a mean survival of 2.29 ± 1.6 years in younger patients compared with 2.0 ± 1.1 years in the older patients. This is in contrast to nonsurgical patients, who had survivals of .97 ± .99 years and 1.09 ± 1.16 years, respectively. The stage by stage survival (excluding stage IV disease) is listed in Table 5. The overall survival for early-stage cancer (stage I and IIa) was similar in both age groups. Although the overall survival was slightly lower in older patients with stage IIb or stage III disease, a similar improvement in survival as a result of resection was demonstrated. Excluding stage IV disease, there was a significant improvement in the median survival of patients undergoing surgery for both patients <70 years (1.87 vs. .73 years; P < .01) and patients >70 years (1.82 vs. .85 years; P < .01).


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  		TABLE 5. Survival of patients older and younger than 70 years with esophageal cancer
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The selection of optimal treatment for elderly patients with esophageal cancer is difficult but must be made more frequently because the incidence of esophageal cancer increases as the age of the general population in the Western world advances. Many physicians are reluctant to subject their older patients to an esophageal resection. There is a conception that the risks of esophagectomy in this population do not outweigh the benefits. In regard to the risks, it has been reported that the mortality rate in this age group is higher1 and that complications, especially pulmonary or cardiac, occur more frequently.2,3 There is also a perception that the benefits of surgery are also diminished in older patients, because their life expectancy at the time of diagnosis is shorter than that of younger patients. Therefore, many older patients who have surgically resectable cancer of the esophagus and are suitable surgical candidates are referred instead for nonsurgical care. To examine whether there is any justification for this approach, we reviewed our experience with esophageal cancer in the elderly at Roswell Park Cancer Institute.

A reason physicians may be hesitant to aggressively treat esophageal cancer in older patients is the perception that the disease is more aggressive or advanced compared with in younger patients. Our data do not substantiate this belief. Older patients presented with a similar constellation of symptoms, with dysphagia and weight loss being the most common presentation. Likewise, there was no detectable delay in diagnosis in older patients. Patients older and younger than 70 years sought medical attention after a median of 2 months from the onset of symptoms. In accordance with this, the stage of disease at initial presentation was similar in both age groups. In fact, although not statistically significant, a greater percentage of older patients presented without evidence of metastatic disease at the time of presentation.

Despite the lower percentage of stage IV patients, a smaller portion of patients >70 years were considered to be suitable candidates for surgery. The most common reasons that patients were not deemed operative candidates were associated cardiac or pulmonary comorbidities. Thirty-seven percent of patients <70 years received esophagectomy, whereas only 18% of patients >70 years received surgery. Significant medical comorbidities were more prevalent in the patients with squamous cell carcinoma, in whom only 12% of patients >70 years were deemed surgical candidates (compared with 32% of older patients with adenocarcinoma). Given the association between squamous cell carcinoma and tobacco and alcohol use, it is not surprising that this population had a higher rate of comorbidities such as coronary artery disease or chronic obstructive lung disease. The lower rate of operability for older patients has been described previously.4 However, there are suggestions that the number of older patients being referred for operation is increasing.1,5

The safety of esophageal resection for older patients remains a controversial issue, because it has one of the highest operative mortality rates of any elective surgical procedure.6 Previously published reports describe extremely high mortality rates in older patients6,7 and implicate advanced age as a contraindication to esophagectomy.8 Our data, however, demonstrate no increase in mortality in older patients, confirming more recent reports from other institutions.5,9,10

Morbidity rates were also extremely similar. Esophageal resection in older patients did not result in greater blood loss, longer hospital stays, or an increased rate of surgical complications such as anastomotic leaks or postoperative strictures. With use of an Ivor-Lewis resection in the majority of cases for older and younger patients, we found no difference in the rate of pulmonary complications in the older age group, nor was there any difference in the rate of infectious complications. There were, however, a greater number of cardiac complications in the older group. Atrial fibrillation is a well-described complication of noncardiac thoracic surgery, and this occurred in 13% of patients <70 years and in 23% of patients >70 years, although this difference was not statistically significant. There were no cases of MI in the younger age group, whereas three patients >70 years had MIs. Given the decreased percentage of patients >70 years who made it to surgery, it is clear that there was a selection bias in this group of patients as opposed to the younger age group. At our institution, we routinely use multiple gated acquisition scan and pulmonary function tests to assess the cardiopulmonary status of potential surgical candidates. These data demonstrate that in appropriately selected patients >70 years old, esophageal resection can be performed as safely as in younger patients, without modification of surgical approach and without increased operative mortality.

Simply because an operation can be performed safely does not necessarily mean that it should be performed. It is believed that the overall poor prognosis of esophageal carcinoma combined with the high morbidity of esophagectomy and the short life expectancy of older patients precludes surgical resection. It is clear that the morbidity of esophageal resection in the older population does not carry a higher morbidity, but the question remains whether there is a survival benefit to make the procedure worthwhile. Overall median survival in this series was similar for both age groups (1.45 vs. 1.32 years). It is more important to note that the improvement in survival with surgical over nonsurgical management was the same for older patients as it was for younger patients. This was not secondary to adjuvant therapy, because it was applied equally between groups. Excluding stage IV disease, there was a significant improvement in the median survival of patients undergoing surgery for both patients <70 years (1.87 vs. .73 years; P < .01) and patients >70 years (1.82 vs. .85 years; P < .01). Although the mean survival was slightly lower (albeit not significant) in older patients undergoing surgery for stage IIb or III disease, a similar improvement in survival was seen over nonsurgical therapy. Therefore, the benefit to the patient >70 years was proportionally as great as for younger patients. The concept that a shorter life expectancy in older patients makes resection less beneficial does not seem true.

In conclusion, esophageal cancer in older patients warrants surgical resection because the benefit to the patient is the same as it is for younger patients, without a significant increase in operative morbidity or mortality. Because this population will have a higher percentage of cardiac and pulmonary risk factors, especially those with squamous cell carcinoma, thorough preoperative evaluation and a selective approach are reasonable. Likewise, an increased vigilance for cardiac complications should be applied postoperatively. However, age alone should not preclude esophageal resection for cancer in otherwise healthy patients.


   Footnotes
 
Presented at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.

Received for publication March 17, 2001. Accepted for publication October 25, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Thomas P, Doddoli C, Neville P, et al. Esophageal cancer resection in the elderly. Eur J Cardiothorac Surg 1996; 10: 941–6.[Abstract]
  2. Fan ST, Lau WY, Yip WC, et al. Prediction of postoperative pulmonary complications in eosophagogastric cancer surgery. Br J Surg 1987; 74: 408–10.[Medline]
  3. Griffin S, Desai J, Charlton M, et al. Factors influencing mortality and morbidity following oesophageal resection. Eur J Cardiothorac Surg 1989; 3: 419–24.[Abstract]
  4. Samet J, Hunt WC, Key C, et al. Choice of cancer therapy varies with age of the patients. JAMA 1986; 255: 3385–90.[Abstract/Free Full Text]
  5. Ellis FH Jr, Williamson WA, Heatley GJ. Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes? J Am Coll Surg 1998; 187: 345–51.[CrossRef][Medline]
  6. Muller JM, Erasmi H, Stelzner M, et al. Surgical therapy of oesophageal carcinoma. Br J Surg 1990; 77: 845–57.[Medline]
  7. Muehreke DD, Kaplan DK, Donnelly RJ. Oesophagogastrectomy in patients over 70. Thorax 1989; 44: 141–5.[Abstract/Free Full Text]
  8. O’Rourke I, Tait N, Bull C, et al. Oesophageal cancer: outcome of modern surgical management. Aust N Z J Surg 1995; 65: 11–6.[Medline]
  9. Jougon JB, Ballester M, Duffy J, et al. Esophagectomy for cancer in the patient aged 70 years and older. Ann Thorac Surg 1997; 63: 1423–7.[Abstract/Free Full Text]
  10. Adam DJ, Craig SR, Sang CTM, Cameron EWJ, Walker WS. Esophagectomy for carcinoma in the octogenarian. Ann Thorac Surg 1996; 61: 190–4.



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