Impact of Age and Comorbidity on Multimodal Management and Survival from Colorectal Cancer: A Population-Based Study.

Ilmo Kellokumpu,Matti Kairaluoma,Eero Sihvo,Teijo Kuopio,Ville Väyrynen,Jukka-Pekka Mecklin,Toni T Seppälä,Henrik Kellokumpu,Erkki-Ville Wirta

doi:10.3390/jcm10081751

Abstract

This retrospective population-based study examined the impact of age and comorbidity burden on multimodal management and survival from colorectal cancer (CRC). From 2000 to 2015, 1479 consecutive patients, who underwent surgical resection for CRC, were reviewed for age-adjusted Charlson comorbidity index (ACCI) including 19 well-defined weighted comorbidities. The impact of ACCI on multimodal management and survival was compared between low (score 0–2), intermediate (score 3) and high ACCI (score ≥ 4) groups. Changes in treatment from 2000 to 2015 were seen next to a major increase of laparoscopic surgery, increased use of adjuvant chemotherapy and an intensified treatment of metastatic disease. Patients with a high ACCI score were, by definition, older and had higher comorbidity. Major elective and emergency resections for colon carcinoma were evenly performed between the ACCI groups, as were laparoscopic and open resections. (Chemo)radiotherapy for rectal carcinoma was less frequently used, and a higher rate of local excisions, and consequently lower rate of major elective resections, was performed in the high ACCI group. Adjuvant chemotherapy and metastasectomy were less frequently used in the ACCI high group. Overall and cancer-specific survival from stage I-III CRC remained stable over time, but survival from stage IV improved. However, the 5-year overall survival from stage I–IV colon and rectal carcinoma was worse in the high ACCI group compared to the low ACCI group. Five-year cancer-specific and disease-free survival rates did not differ significantly by the ACCI. Cox proportional hazard analysis showed that high ACCI was an independent predictor of poor overall survival (p < 0.001). Our results show that despite improvements in multimodal management over time, old age and high comorbidity burden affect the use of adjuvant chemotherapy, preoperative (chemo)radiotherapy and management of metastatic disease, and worsen overall survival from CRC.

Highlights

Colorectal carcinoma (CRC) is the third most common cancer worldwide [1,2] and the fourth leading cause of cancer death [1,2]
The incidence of right-sided colon cancers, medical comorbidities and older age was most frequent in the high adjusted Charlson comorbidity index (ACCI) group
The main findings of the present study were that preoperative radiotherapy, adjuvant chemotherapy, postoperative mortality and morbidity, management of metastatic disease and overall survival were adversely influenced by old age and high Charlson comorbidity burden despite improvements in multimodal therapy and management of metastatic disease over time

Summary

Introduction

Colorectal carcinoma (CRC) is the third most common cancer worldwide [1,2] and the fourth leading cause of cancer death [1,2]. Many improvements have been made in the management of colorectal cancer [3,4,5,6,7,8] These include diagnostic procedures, use of laparoscopic surgery, improvements in perioperative care, refinement of histopathological examination and the development of effective neoadjuvant, adjuvant and palliative treatments and extended indications for resection of metastatic disease. Due to frequent medical comorbidities and aging-related diminished physiological reserves, elderly patients are considered at higher risk for complications from major cancer surgery and chemotherapy and, increase the complexity of multimodal management of colorectal cancer. Comorbidity may lead to altered treatment, higher morbidity rates and worse survival [9,10,11]

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