Rutten HJ, den Dulk M, Lemmens VE, van de Velde CJ, Marijnen CA
Lancet Oncol 2008 May 9(5):494-501
Commentary from Faculty Member Riccardo Audisio
This paper highlights the absolute necessity of tailoring treatment options to elderly patients with cancer. Optimal management of young individuals should not necessarily be assumed to be appropriate for the elderly cohort. This article revisited the value of total mesorectal excision (TME) when dealing with elderly patients with rectal cancer. The benefits of using this technique in older patients were assessed by analysing 30-day and six-month mortality in 1508 patients. A statistically significant excess of these outcomes was documented for older patients when compared with different age groups. The authors argued that the benefit of TME might be overshadowed by the increased vulnerability and reduced tolerance in the older age group of patients. Alternative treatment options, which are briefly discussed in this article, should be pursued in these patients. Comprehensive assessment tools are now available and their routine use in clinical practice should be encouraged in order to discriminate between the fit elderly to receive aggressive management versus the frail patients to be offered a minimalist approach in order to limit morbidity.
Author Response: Rutten HJ, den Dulk M, Lemmens VE, van de Velde CJ, Marijnen CA, Catharina Hospital, Eindhoven, Netherlands
We would like to thank Dr Audisio for his comment on our article. However, we would like to make some additional remarks. For this paper, not only the data of the TME study were used, but the findings were checked against the population based data from the Comprehensive Cancer Centers (CCC) South and West. In a previous paper based on these data, it was already concluded that survival of elderly patients with rectal cancer was not significantly improved after introduction of TME surgery and preoperative irradiation (Rutten et al., Eur J Cancer 2007, 43:2295-2300 [PMID:17709242]). However it was also concluded that the use of preoperative radiotherapy did not influence one-month and six-month postoperative mortality. Mainly surgery, before and after introduction of TME surgery is held responsible for the unfavorable postoperative mortality figures. Despite the fact that elderly patients with rectal cancer respond better to preoperative radiotherapy in the sense of an improved cancer-related survival, we learned from an ongoing study on the CCC data that elderly people were less likely to receive radiotherapy (data not shown). Therefore, we concluded in our article that the role of radiotherapy should be investigated in the future in order to reduce the magnitude of the surgical intervention. These new strategies should not be considered palliative, but rather curative new approaches specifically for the elderly patient. In daily practice we believe that the high postoperative mortality rates should be discussed with old patients with rectal cancer and the patients’ relatives. Instead of omitting radiotherapy in the treatment plan, it should have a prominent role. In some cases, major surgery may well be replaced by a lesser procedure or even a wait-and-see policy.
Commentary from Faculty Member Filippo La Torre
This study emphasizes the importance of evaluating the invasiveness of surgical and neo-adjuvant treatments, also taking into account the patient’s age and clinical condition, and of performing this evaluation in our daily experience of managing patients with rectal cancer. Here, the results of total mesorectal excision (TME) for rectal cancer in patients aged 75 years or older were analyzed in correlation to 30-day and six-month mortality in 1508 cases. Mortality was significantly increased in older patients compared to younger patients, showing that major invasive surgical treatment is not advantageous for all older patients. The authors, in their conclusion, discuss the importance of alternative treatment as a choice for selected groups of elderly patients which has showed good results (Dutch TME trial). A rational use of major invasive surgery for rectal cancer by our group for more than 20 years is related to the clinical condition and age of our patients as well as full-dose radiotherapy and other options. In my opinion, more discerning strategies must be suggested by similar multicenter studies to support a more comprehensive assessment in routine clinical practice.
Faculty of 1000 Medicine Evaluations, Dissents and Author responses for: [Rutten HJ et al. Controversies of total mesorectal excision for rectal cancer in elderly patients. Lancet Oncol 2008 May 9(5):494-501]. 2008 May 23 2008 Jun 11. www.f1000medicine.com/article/id/1109311/evaluation
Reviewed by Ramaz Mitaishvili, MD
