Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy

Abstract

The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35-0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54-2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6-6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62-0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64-0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.

Multicenter questionnaire survey on patterns of care for elderly patients with esophageal squamous cell carcinoma by the Japan Esophageal Oncology Group

“…Some reports still warn about the importance of careful selection of esophagectomy for elderly ESCC patients. It is repeatedly recommended that specialized evaluation of elderly patients should be performed, although there is a lack of validated or proposed criteria for esophagectomy (10)(11)(12)(13).…”

Esophageal cancer in elderly patients: a population-based study

“…The median age of the included patients was 66 (95% CI, 65.88-66.13) years. The median [interquartile range (IQR)] follow-up time was 8 [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] months. Figure 1 shows the age distribution of all EC patients, and the peak age at incidence was between 60 and 80 years.…”

“…Several studies (4,5) and a meta-analysis (6) demonstrated that, compared to younger patients, patients 70 years of age and older undergoing surgical resection for EC had lower survival rates. However, no significant differences were observed in survival between elderly and younger patients after esophageal resection in some studies (7)(8)(9)(10)(11), suggesting that advanced age should not be considered a contraindication to esophagectomy.…”

“…As most of study on elderly EC stated the age threshold of 70 years used to define the elderly cohort (4)(5)(6)(7)(8)10), this study were to compare the clinical characteristics, treatment modality, outcomes and independent prognostic factors for EC in selected patients younger than 70 years of age to those in patients 70 years of age or older and to explore the role of resection or RT among the elderly.…”

Evolution in Surgical Management of Esophageal Cancer

“…A recent systemic review and pooled analysis assessing the association of elderly age and the outcome of surgical resection documented that elderly patients had reduced overall 5-year survivorship and reduced cancer-free 5-year survival. Elderly patients were also at increased risk of pulmonary and cardiac complications and perioperative mortality [44]. …”