Rectal Cancer in the Elderly: To Operate or Not to Operate? A Nationwide Retrospective Study of the Italian Society of Surgical Oncology–Colorectal Cancer Network Collaborative Group

BACKGROUND: Patients older than 70 account for 44% of all rectal cancer cases. Although surgery is the gold standard treatment, elderly patients can also be offered other treatments, such as total neoadjuvant therapy with watch and wait. OBJECTIVE: This study aimed to investigate whether postoperative 90-day mortality is increased in the elderly compared to younger patients. DESIGN: This nationwide retrospective study included all consecutive resections of rectal cancer between 2005-2016 using data from the RALAR study. Patients were divided into 2 groups based on their age: non-elderly <70 years and elderly ≥70. SETTING: Data were obtained from 19 Italian referral centers for colorectal surgery. PATIENTS: A total of 3,573 patients underwent rectal surgery: non-elderly (2,071 [57.9%]) and elderly (1,502 [42%]). MAIN OUTCOME MEASURES: The primary endpoint was 90-day postoperative mortality. Secondary endpoints included intensive care unit stay, hospitalization, surgical and general postoperative complications, overall survival, disease-specific survival, and recurrence rate. RESULTS: Ninety-day postoperative mortality was comparable between groups (0.41% non-elderly vs 1.05% elderly, p = 0.087). Elderly patients were monitored more frequently in intensive care unit and developed more postoperative general complications, while no differences were found between the groups in terms of postoperative surgical complications. Hospitalization was longer in elderly (median [IQR]: 12.3 [9.7] vs 11.1 [14.6] days). Five-year overall survival was higher in non-elderly (77.3%) compared to elderly (45.8%, adjusted OR 1.70, 95% CI: 0.57, 5.65), while the disease-specific survival was similar between groups. LIMITATIONS: There are limitations inherent in this retrospective study, i.e., the long accrual period and the unknown proportion of patients who didn’t undergo surgery. CONCLUSIONS: Although elderly patients experience a higher rate of postoperative general complications without an increase in postoperative mortality, rectal surgery yields similar surgical and oncological outcomes compared to younger patients. This study suggests that age alone shouldn't exclude someone from surgery. See Video Abstract .