RESULTS OF SELECTIVE USE OF MULTIMODALITY TREATMENT IN ELDERLY
PATIENTS WITH RECTAL CANCER.
Faisal Elagili M.D.1, Luca Stocchi M.D.1, Kalady MF M.D.1,Abdel-Wahab M MD2, David W Dietz,
M.D1
1:Department
of
Colorectal
Surgery,
Digestive
Disease
Institute,
Cleveland
Clinic,
Cleveland/OH
2:Department of Radiation Oncology, Cleveland Clinic, Cleveland/OH
Background: Chemoradiation followed by surgery is recommended for stage II- III rectal cancer
and selectively used for stage IV. Elderly patients are less frequently offered multimodality
therapy. The aims of our study were to assess the reasons for chemoradiotherapy omission and
the oncologic outcomes of elderly patients with rectal cancer.
Patients and methods: Patients≥ 70 years old with stage II-IV rectal cancer treated between
1990-2007 were identified from an institutional, IRB-approved cancer database and chart
review. All patients underwent radical resection using total mesorectal excision principles.
Patients receiving multimodality treatment were compared to patients undergoing surgery alone
for clinic pathological variables, surgery type, postoperative morbidity and cancer outcomes.
Results: 209 patients were identified (40% females, mean age 76 ±5) with a mean follow-up of
4.2 years, 104 of whom (49.8%) had surgery alone vs. 105 patients (50.2%) who received
multimodality treatment. Patients receiving multimodality treatment were significantly younger
(75 vs. 78 years, p=0.001) males (68% vs. 53%, p=0.03), with decreased Charlson Comorbidity
Index score (3.1 vs. 4.0, p=0.005) and had greater proportion of stage III disease. Omission of
chemoradiation was reportedly due to patient preference (n=12), previous pelvic radiotherapy
(n=2), surgeon preference (n=58), and medical comorbidity (n= 32). Tumor grade, radial margin
involvement, mean distance from the anal verge (7.5 vs 8.4 cm, p=0.17) rates of restorative
procedures (57% vs. 64%, p=0.57) and postoperative morbidity were similar. Oncologic
outcomes were similar including within individual disease stages (Table). Stage IV and poor
tumor differentiation were factors independently associated with both OS and DSS, while age
was independently associated with OS only and stage III disease with DSS only. Use of
chemoradiotherapy was not independently associated with cancer outcomes.
Conclusion: Selective omission of multimodality treatment in elderly patients in a single
specialized unit was not associated with significant deterioration of oncologic outcomes with
more advanced staging indirectly indicates the benefits.
Table. Stage distribution, cancer outcomes and post op morbidity in patients treated with
multimodality treatment vs. surgery alone.
Multimodality
Surgery alone
P value
treatment
N=104
N=105
Tumor stage
II
32 (30.5%)
55 (52.9%)
0.003
III
57 (54.3%)
34 (32.7%)
IV
16 (15.2%)
15 (14.4%)
Postoperative morbidity
37(35%)
25(25%)
0.12
5- year oncologic outcomes
OS
44.3 %
47.4 %
0.86
DFS
40.1 %
45.5 %
0.79
DR
13 (12.4%)
14 (13.5%)
0.82
LR
5 (4.8%)
4 (3.8%)
1
DSS
63.5 %
68.1 %
0.49
OS: Overall survival, DFS: Disease-free survival, DR: Distant recurrence, LR: local recurrence,
DSS: Disease-specific survival