Advanced surgical approaches may benefit elderly patients with colorectal, bladder cancers

Advanced surgical techniques such as robotic-assisted operations and minimally invasive surgical procedures may extend survival and improve recovery in octogenarians with bladder and colorectal cancers when compared with patients who undergo conventional open operations according to two new studies presented at the 2012 Annual Clinical Congress of the American College of Surgeons.

Boston University investigators found robotic-assisted bladder procedures may be a viable option in selected patients aged 80 years and older who would not otherwise have an operation to remove the cancer, according to Vikrant Uberoi, MD, a urology resident, Boston University (BU) School of Medicine, who presented the findings. Researchers conducting a separate study of minimally invasive colorectal operations found that the laparoscopic surgical approach achieved favorable outcomes when compared with traditional open operations, said study presenter Therese Gannon Kerwel, MD, a fellow in colorectal surgery at Spectrum Health, Grand Rapids, MI.

Robotic-Assisted Bladder Operations
Colon, rectal, and bladder cancers disproportionately affect older people. According to the National Cancer Institute Surveillance Epidemiology and End Results (NCI SEER) Program, the median age at diagnosis for colon and rectal cancers is 69 years and the median age of death from these cancers is 74 years. For bladder cancer, the median age at diagnosis is 73 years old, while the median age at death is 79 years old. NCI SEER estimates that in 2012, 143,460 adults will be diagnosed with colorectal cancer while 51,690 will die from the disease; 73,510 adults will be diagnosed with bladder cancer, while 14,880 will die of the disease.

The Boston University surgeons studied the records of 17 patients between ages 80 and 88 who underwent robotic-assisted cystectomy operations to remove their bladders. The opera-tions were performed by Ingolf Tuerk, MD, PhD, a robotics-assisted surgeon at St. Elizabeth’s Medical Center in Boston, MA. “The standard of care for muscle-invasive bladder cancer is to undergo cystectomy,” Dr. Uberoi said. “However, what we were seeing was that patients over age 80 were not being offered cystectomy; they were more likely to be treated with alternatives such as chemotherapy and radiation instead because of their age and comorbidities.”

Dr. Uberoi reported that the average postoperative length of hospital stay was seven days. Within the first 90 days after surgery, only three complications were reported. More- over, none of the patients in the study died from surgical complications.

Dr. Uberoi cautioned that robotic-assisted operations are not appropriate for all octo-genarians with bladder cancers. “These patients have to be able to undergo anesthesia for four to six hours, tolerate fluid shifts, and possible large blood loss,” he said. “The patient with severe coronary artery disease or chronic occlusive pulmonary disease with an extremely limited life expectancy is likely not a good candidate.” Furthermore, the availability of robotic-assisted bladder procedures is somewhat limited, Dr. Uberoi noted. While most academic centers typi-cally offer robotic-assisted operations, the equipment and highly skilled surgeons required for this procedure may not always be available at the community level.

Laparoscopic Operations for Colon and Rectal Cancers

Spectrum Health researchers investigating laparoscopic operations for colon and rectal cancers in the elderly aimed to determine if this minimally invasive approach achieved any benefit in terms of disease-free survival over traditional open operations. The surgeons looked at records for 216 patients who were evenly divided between laparoscopic and open operations over a 6.5-year period starting in mid-2004 and ending in July 2010.

“Our study results showed the laparoscopic patient group lived a median of two years longer than the group that had open surgery,” Dr. Kerwel reported. “The laparoscopic group was also much more likely to undergo chemotherapy in stage III disease. Given that the average age in our study was 81.5 years, the laparoscopic approach for colorectal cancer patients revealed a significant survival benefit.”

Stage III cancer is a more advanced stage of cancer; stage IV is the most advanced stage. The standard of care for stage III colorectal cancer involves two phases of treatment: (a) removal of the tumor via an operation followed by (b) treatment of the affected area with a course of chemotherapy. However, many patients 75 years and older who have an open oper-ation to remove the tumor are often too frail afterward to start their course of chemotherapy in a timely manner, Dr. Kerwel said. In this study, 63 percent of the laparoscopic group went on to chemotherapy while only 29 percent in the open surgery group did so, which may explain the better survival in the former group, Dr. Kerwel added.

While other studies have found that laparoscopic operations typically result in faster recovery, shorter hospital stays, and fewer short-term complications than open surgeries, Dr. Kerwel noted that her group’s study goal was to evaluate longer-term survival rates in elderly patients with colorectal cancer. Overall, almost 60 percent of the laparoscopic group patients were disease free and alive five years after the operation compared with about 40 percent of the open surgery group, she noted.

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Coauthor of the Boston University study with Drs. Uberoi and Tuerk was Audley Osbourne, MD.

Coauthors of the Spectrum Health study were Theodor Asgeirsson, MD; Amanda McClure, MD; Rebecca Hoedema, MD, FACS, FASCRS; Ryan Figg, MD, FACS, FASCRS; Nadav Dujovny, MD, FACS, FASCRS; Donald G. Kim, MD, FACS, FASCRS; Heather Slay, MD, FACS, FASCRS; and Martin Luchtefeld, MD, FACS, FASCRS.

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