The document discusses considerations for elderly surgical patients. Older patients represent a growing demographic undergoing more procedures. While age alone is a poor indicator of health, the aging process involves physiological changes that reduce cardiac, pulmonary, renal and other organ reserves. Careful preoperative evaluation of functional status is important to assess risks. Perioperative strategies aim to support compromised systems and avoid stressors that can precipitate complications in elderly patients.

1. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 1
1 THE ELDERLY SURGICAL PATIENT
Sylvia S. Kim, MD, and Michael E. Zenilman, MD, FACS
Older persons are the fastest-growing demographic group in status and advanced age is not considered an acceptable con-
the United States. It is estimated that by 2020, Americans traindication to surgery, adequate assessment of functional
older than 65 years will account for more than 20% of the age and physiologic reserve are of paramount importance in
total population. By 2030, their numbers will have doubled the elderly surgical patient.
to 70 million [see Figure 1], one fourth of whom will be 85
years of age or older.1 This segment of the U.S. population
Nature and Clinical Impact of Physiologic Changes
uses a substantial share of total health care resources. Centers
Associated with Aging
for Disease Control and Prevention (CDC) National Hospi-
tal Discharge Survey data for 2004 indicate that the rate
 
of interventional and surgical procedures in Americans
aged 65 years or older is 4,382.3/10,000. More than 50% of Aging is characterized by progressive loss of physiologic
coronary artery bypass graft procedures and large bowel reserve in nearly all organ systems [see Table 1]. The changes
resections—and approximately 35% of all procedures—are in cardiac function that occur in the elderly are particularly
performed in persons belonging to this age group.2 These significant. Cardiac output is the product of the heart rate
numbers will continue to increase as the elderly segment of and the stroke volume (which correlates with the end-
the population continues to grow. Accordingly, surgical care diastolic volume, or preload). In elderly myocardium, the
of elderly patients is likely to account for an increasing share resting heart rate, stroke volume, cardiac output, and ejection
of surgeons’ workloads. fraction are all maintained,6 but the way in which these
It must be kept in mind that the elderly are not a homoge- variables respond to stress is altered.7 The increased myocar-
neous population. The average additional life expectancy for dial stiffness typical of aging leads to decreased ventricular
a 65-year-old American is 18.4 years, and that for an 85-year- compliance and impaired end-diastolic filling.8,9 In addition,
old is 6.8 years3; however, there is significant variability within the blunted chronotropic and inotropic response of aged
each of these age groups. For example, there can be dramatic myocardium to adrenergic stimuli10 results in depression
differences between “fit” and “frail” elderly persons of the of both the maximal heart rate and the increase in ejection
same age. On the one hand, a fit 85-year-old woman may fraction in response to stress.11 Older persons thus are more
have an additional 10 years of life expectancy. On the other dependent on preload to maintain cardiac output in the
hand, the life expectancy of a frail 85-year-old man may be face of increased demand12 and, accordingly, are especially
closer to 2 years [see Figure 2]4—and possibly much less (e.g., sensitive to the dangers of hypovolemia.
a few months) if an acute event should occur that necessitates Cardiac complications remain a leading cause of peri-
hospitalization.5 Given that chronologic age, by itself, alone operative morbidity and mortality, especially in older
is a poor predictor of life expectancy, a more reliable approach patients. Myocardial infarction (MI) and congestive heart
to estimating life expectancy involves assessing overall func- failure (CHF) are responsible for one fourth of all cardiac
tional reserve, taking into consideration the myriad factors complications and perioperative deaths in elderly patients.13
that define the aging process. The first preoperative cardiac risk index for noncardiac
Aging is a multifactorial process that encompasses more surgical procedures was developed by Goldman and col-
than just physiologic changes. Although physiologic factors leagues in 1977.14 This index used nine clinical variables
are undoubtedly significant and must always be taken into that had been found to correlate with an increased risk of
account, there are several other factors (e.g., potential func- perioperative cardiac complications to determine a patient’s
tional limitations, depression, or polypharmacy) that should overall level of cardiac risk. Several of these variables
also be considered in dealing with older patients. Surgeons reflect correctable conditions, which suggests that in selected
are often well trained in addressing the former but not the patients, delaying surgery to permit medical treatment
latter; however, they will be able to achieve a more compre- may be a reasonable strategy. In 1999, Lee and colleagues
hensive assessment of an elderly person’s wellness and reserve developed a simplified index known as the Revised Cardiac
by considering all of these factors. Risk Index (RCRI), which included six variables that had
Various scoring systems are being applied in the elderly been found to be independent predictors of cardiac complica-
population in an effort to evaluate their overall functional tions [see ECP:4 Risk Stratification, Preoperative Testing, and
status in a more accurate and quantifiable manner. One Operative Planning].15 In the RCRI, one point is given for
example is the Comprehensive Geriatric Assessment (CGA), each of the following cardiac risk factors: (1) a history of
a tool that is commonly used within the geriatric medicine CHF, (2) a history of ischemic heart disease, (3) a history of
community and is currently being used with increasing cerebrovascular disease, (4) preoperative treatment with
frequency in the nascent field of geriatric surgery. Because insulin, (5) a preoperative serum creatinine level higher than
chronologic age alone is a poor predictor of performance 2.0 mg/dl, and (6) a high-risk surgical procedure. If none of
DOI 10.2310/7800.2008.S09C01
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2. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 2
Active cardiac conditions include unstable coronary syn-
dromes (e.g., recent MI or unstable angina), decompensated
heart failure, significant dysrhythmias (e.g., Mobitz II block,
third-degree block, symptomatic ventricular arrhythmia,
supraventricular arrhythmia with uncontrolled ventricular
rate, symptomatic bradycardia, and new ventricular tachycar-
dia), and severe valvular disease (e.g., severe aortic stenosis
with a pressure gradient greater than 40 mm Hg or a valvular
area smaller than 1 cm2, symptomatic aortic stenosis, or
symptomatic mitral stenosis). If any of these conditions is
present, the surgical procedure should be postponed until
further testing and treatment are complete. If no active
cardiac conditions demanding immediate attention are
present, the patient’s functional status should be evaluated.
For patients with good functional capacity (as evidenced
by the ability to perform activities of daily living [ADL]),
additional testing may not be necessary. For patients with
limited or unknown functional capacity, formal cardiovascu-
lar stress testing may be required, especially if the planned
procedure is an intermediate-risk (e.g., intra-abdominal or
intrathoracic) or high-risk (e.g., aortic, major vascular, or
Figure 1 Shown is projected U.S. population by age, peripheral vascular) operation.
2000–2050.1 A number of randomized studies have examined the use
of perioperative beta blocker therapy to reduce the risk of
these risk factors is present, the probability of a major cardiac MI and death in noncardiac surgical patients [see ECP:4 Risk
complication is 0.4% to 0.5%; if one factor is present, 0.9% Stratification, Preoperative Testing, and Operative Planning].
to 1.3%; if two factors are present, 4% to 7%; and if three or Although the benefits demonstrated in early trials17,18 were not
more risk factors are present, 9% to 11%.15 seen in several later studies,19,20 most of the evidence still sug-
A 2007 report from an American College of Cardiology gests that perioperative beta blockade is beneficial, especially
(ACC)/American Heart Association (AHA) task force for in high-risk patients, such as those who have a history of
perioperative cardiovascular evaluation recognized the utility cardiac disease or who have risk factors and are undergoing
and efficacy of the RCRI and delineated a stepwise approach major surgery.16 A 2005 meta-analysis of all randomized
to perioperative cardiac assessment.16 The first step is a controlled trials evaluating the use of preoperative beta block-
basic clinical evaluation (history, physical examination, and ade in noncardiac surgery demonstrated that this measure
12-lead electrocardiography). The patient is assessed for had a protective effect.21 Aggregate data showed decreases
any active cardiac conditions or clinical risk factors that in long-term cardiac mortality (from 12% to 2%) and in
might have to be treated before surgery. (Obviously, such the incidence of myocardial ischemic events (from 33% to
assessment may not be feasible in emergency situations.) 15%).
a b
25 25
20 20
Life Expectancy (yr)
Life Expectancy (yr)
15 15
10 10
5 5
0 0
70 75 80 85 90 95 70 75 80 85 90 95
Age (yr) Age (yr)
Top 25th Percentile 50th Percentile Lowest 25th Percentile
Figure 2 Shown are upper, middle, and lower percentiles for life expectancy in (a) women and (b) men at selected ages.4
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3. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 3
Table 1 Physiologic Changes Associated with Aging172–174
Age-Related Changes Clinical Consequences Interventions
Decreased maximal heart rate, cardiac output, Greater reliance on preload or end- Initiate vigorous fluid resuscitation
and ejection fraction diastolic volume and ventricular to achieve and maintain optimal
Decreased ventricular compliance with slowed filling to achieve increases in ventricular filling
Cardiovascular system
ventricular filling; increased reliance on cardiac output Avoid tachycardia; correct
atrial contribution Intolerance of hypovolemia dysrhythmias
Decreased inotropic and chronotropic Intolerance of tachycardia and Avoid dysrhythmogenic medications
responses to sympathetic stimuli dysrhythmias such as atrial If pharmacologic support required,
Decreased baroreceptor sensitivity fibrillation consider nonvasoconstricting
Thickening of valvular ring and leaflets inotropes and afterload reduction
Thickening of vessel walls; tendency toward
vasoconstriction
Increased prevalence of CAD (clinically
apparent or occult)
Lowered threshold for dysrhythmias
Decreased lung compliance Decreased pulmonary capacity and Encourage early mobilization and
Decreased strength and endurance of reserve upright, rather than supine,
respiratory muscles Increased work of breathing position
Increased stiffness of chest wall and Predisposition to aspiration and Provide effective pain relief to
increased reliance on diaphragm function increased risk of pulmonary facilitate early mobilization and
Respiratory system
Decreased vital capacity and expiratory flow infections deep breathing; monitor closely if
rate Predisposition to hypoxemia narcotics used
Increased residual volume and functional Increased small airway closure, Use supplemental oxygen
residual capacity especially postoperatively and in postoperatively as needed
Increased alveolar-arterial gradient supine position, leading to Use nasogastric tubes sparingly
Decreased arterial oxygen tension increased atelectasis and shunting Encourage preoperative smoking
Decreased compensatory responses to Tachypnea and increased tidal cessation if applicable
hypoxia or hypercarbia volume may be less apparent as Assess influenza and pneumococcal
Decreased airway sensitivity; reduced respiratory failure develops immunization status
efficiency of mucociliary clearance Recognize decreased ventilatory
mechanisms responses to hypoxia and
Increased sensitivity to narcotic respiratory hypercarbia
depression
Decreased glomerular filtration rate Predisposition to hypovolemia with Pay meticulous attention to fluid and
Renal function, fluids, electrolytes
Reduced renal mass, renal blood flow, increased risk of dehydration and electrolyte status
glomerular filtration area, and permeability prerenal azotemia Estimate creatinine clearance using
Decreased renal tubular function with Predisposition to extracellular fluid age-adjusted formulas, recognizing
impaired ability to concentrate urine and volume expansion resulting that “normal” serum creatinine
conserve water and solute in electrolyte disorders (e.g., value actually reflects decreased
Reduced efficiency of water and solute hyponatremia) creatinine clearance because of
excretion Predisposition to hyperglycemia and concurrent decreased muscle
Dysregulation of renin-angiotensin system hyperosmolar states mass (with decreased creatinine
Lowered sensitivity to fluid and electrolyte Increased risk of nephrotoxicity excretion)
perturbations as consequence of decreased Avoid nephrotoxic drugs
Impairment of vitamin D metabolism creatinine clearance Adjust drug doses appropriately for
Decreased thirst mechanism renally eliminated drugs to
Increased renal glucose threshold compensate for diminished
creatinine clearance and altered
pharmacokinetics
Decreased salivary flow and impaired Decreased mucosal absorption of Exercise caution in prescribing
Gastrointestinal
swallowing medications medications utilizing cytochrome
Decreased stimulated gastric acid output Decreased intestinal motility. P-450 pathway
tract
Impaired GI mucosal protective mechanisms Decreased pancreatic exocrine Take bowel history and prescribe
Decreased intestinal motility and absorption function laxatives, especially when
Impairment of hepatic drug clearance Decreased elimination of hepatically concurrent narcotics used
metabolized drugs
Significantly decreased muscle mass Erosion of muscle mass during acute Support and maintain physical
Musculoskeletal system
Increased fat mass illness may result in rapid loss of function by providing effective
Decrease in bone mass muscle strength with clinical pain relief, avoiding unnecessary
consequences (e.g., impairing tubes and drains that impair
coughing, decreased mobility) mobility, and encouraging and
Altered volumes of drug distribution assisting early mobilization
Increased risk of falls and fractures Minimize fasting and provide early
with delayed healing of fractures nutritional support
Adjust drug doses for volume of
distribution
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4. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 4
Table 1 Continued
Age-Related Changes Clinical Consequences Interventions
Diminished sensitivity to ambient temperature Predisposition to hypothermia Initiate active warming measures to
Thermoregulation
Reduced efficiency of heat conservation, maintain normothermia during
production, and dissipation surgery
Blunted febrile response
Decrease in thyroxine Decreased fever response Monitor patient closely for glucose
Endocrine
Decrease in free and total testosterone and Decreased libido with sexual intolerance
system
estrogen dysfunction Maintain high index of suspicion for
Elevated fasting glucose level and impaired Increased risk of developing diabetes infection, even in absence of fever
sensitivity to insulin Increased bone demineralization as
result of increased serum PTH
Changes in T cell– and B cell–mediated Increased susceptibility to infection Maintain heightened awareness of
Immunologic
immunity Increased risk of cancer secondary to increased risk of infections
system
Decreased neutrophil turnover and function perturbed immune surveillance Provide early, effective, and
with decreased phagocytosis Impaired response to vaccines appropriate antibiotic treatment
Neuronal loss Increased risk of delirium Reduce risk of delirium through
Impaired memory and cognition Increased susceptibility to develop- screening, monitoring and
Neurologic
system
Prolonged reaction time ment of peripheral neuropathy treatment of infections, and
Impaired sensory function with visual, Altered pain perception regular orientation of patients, with
auditory, and olfactory loss Difficulty in obtaining informed frequent contact
Decreased peripheral nerve myelin consent and assessment of Assess and treat pain appropriately
decision-making capacity Work with family and caregivers
CAD—coronary artery disease PTH—parathyroid hormone
Invasive hemodynamic monitoring has been employed in inspiratory and expiratory forces.30 Forced expiratory volume
efforts to improve perioperative fluid management and reduce (FEV1) is reduced as well. Increased collapse of the small
postoperative morbidity and mortality. Historically, it has airways leads to uneven alveolar ventilation and ventilation-
been common practice to admit high-risk patients to the perfusion mismatch. Control of ventilation is also impaired,
intensive care unit preoperatively for placement of a pulmo- with decreased responses to both hypoxia and hypercapnia.
nary arterial catheter and optimization of cardiac function. Finally, reduced ability to clear the airway leads to an
Data concerning the efficacy of this practice are conflicting. increased risk of aspiration and pneumonia.
Some prospective studies and retrospective reviews suggested Pulmonary complications account for nearly 50% of post-
that monitoring with a pulmonary arterial catheter was ben- operative complications in the total population of surgical
eficial, especially in high-risk patients (e.g., elderly patients patients.31 They are even more frequent in the elderly surgical
with high cardiac risk indices who were scheduled to undergo population and are one of the most common complications
major abdominal or vascular surgery).22,23 A number of pro- seen in older patients.32,33 One large review of older patients
spective, randomized, controlled trials, however, failed to undergoing surgery for colorectal cancer found that the inci-
show any improvement in postoperative morbidity or mortal- dence of respiratory complications increased with advancing
age: such complications occurred in 5% of patients aged 64
ity with such monitoring, even in high-risk patients undergo-
years or younger, 10% of those aged 65 to 74, 12% of those
ing major noncardiac surgery.24,25 Several large-scale studies
aged 75 to 84, and 15% of those aged 85 years or older.34
actually found that invasive cardiac monitoring yielded
Elderly patients undergoing major abdominal surgery are
increased morbidity, without providing any demonstrable
at higher risk for postoperative pneumonia than younger
benefit.26,27 Increased rates of pulmonary embolism, CHF, patients are. These numbers are grounds for concern, in that
dysrhythmia, and noncardiac complications have been the development of pneumonia is associated with increased
observed in elderly, high-risk surgical patients who under- 30-day postoperative mortality.33
went pulmonary arterial catheter monitoring, compared with Risk factors for pulmonary complications include smoking,
those who did not.27,28 The current ACC/AHA task force chronic obstructive pulmonary disease (COPD), poor exer-
guidelines for perioperative cardiovascular evaluation cise capacity, shortness of breath, and active pulmonary
acknowledge the potential benefit of such monitoring in infection.35 Elderly patients should be screened with a base-
selected cases but do not endorse its routine use.16 line chest x-ray and baseline arterial blood gas determina-
tions. Preoperative routine pulmonary function testing has
 
not been demonstrated to be useful for procedures other
With aging comes a significant decline in respiratory than lung resection.36 Smoking cessation should be strongly
function.29 Decreased elastic recoil of the lung and increased encouraged.37 Bronchodilators and incentive spirometry may
stiffness of the chest wall lead to reduced lung and chest also be beneficial. Active respiratory infections should be
wall compliance and, consequently, to decreases in maximal treated before elective surgical procedures are performed.
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5. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
9 CARE IN SPECIAL SITUATIONS 1 THE ELDERLY SURGICAL PATIENT — 5
   
Aging is associated with a number of morphologic and Aging is associated with various structural and functional
histologic changes in the renal system, including reduced changes in the musculoskeletal system. Muscle mass is lost,
cortical mass and cortical area, interstitial fibrosis, tubular muscle strength declines, and body fat mass increases.56 By
atrophy, and glomerulosclerosis.38 As a result of these changes, the age of 80 years, lean muscle mass may have fallen by as
glomerular function declines with advancing age39: by the much as 40% to 50%.57,58 In addition, bone mass decreases,
age of 80, the glomerular filtration rate (GFR) may be as and bone remodeling and cartilage healing are impaired,
much as 45% lower. Impaired renal tubular function is resulting in cartilage damage and arthritis.59 These changes
evident as well, resulting in disturbances of water, glucose, predispose the elderly to progressive loss of mobility, gait and
and electrolyte balance.40 The renin-angiotensin axis is also balance disorders, and falls. To counter this predisposition,
altered with aging.41 Decreased plasma renin activity, renal early ambulation in the postoperative period, with assistance
vasoconstriction, reduced antidiuretic hormone responsive- as necessary, should be encouraged. The changes in body
ness, and an impaired thirst mechanism all may develop in composition that occur with aging also leave the elderly
this setting. vulnerable to protein malnutrition from depleted protein
These physiologic changes place elderly surgical patients reserves.58 Finally, the various structural changes predispose
at increased risk for dehydration and prerenal azotemia. elderly patients to soft tissue and joint injury. One should
Acute renal failure can increase postoperative mortality sub- therefore take extra care when positioning patients in the
stantially in these patients.42 Fluids and electrolytes should be OR, ensuring that appropriate padding and joint protection
carefully monitored, exposure to nephrotoxic drugs should are provided.
be minimized, and oliguria should be addressed promptly
and aggressively. Renal drug elimination is also impaired,  
and creatinine clearance is decreased; drug dosing should be A solid understanding of the physiologic changes associ-
modified accordingly. ated with aging can facilitate preoperative assessment of the
elderly patient’s functional reserve and thus, ultimately, help
 
ensure a more accurate assessment of the operative risk.
GI changes associated with aging include decreased basal An appreciation of the characteristically diminished func-
and stimulated salivary flow rates (which can lead to impaired tional reserve in this population also highlights the increased
swallowing),43 reduced mucosal protection of the stomach,44 vulnerability of elderly patients to the effects of surgical
and prolonged intestinal motility.45 Hepatobiliary function is complications, thereby underscoring the need for meticulous
altered by age-related decreases in liver size and volume,46 as perioperative care aimed at minimizing the likelihood of
well as by histopathologic changes leading to impaired elimi- potential complications whenever possible. Studies have
nation of drugs, especially drugs metabolized by the cyto- shown that the development of postoperative complications
chrome P-450 system.47 Clinicians should be aware of the risk (e.g., pulmonary infection and renal insufficiency) is associ-
of potentially important cytochrome P-450–mediated drug ated with a higher 30-day postoperative mortality,60 as well
interactions, particularly in the setting of polypharmacy. as an increased risk of death within the first 3 months after
surgery.61 The occurrence of a postoperative complication
  
has also been identified as a predictor of impaired recovery
Aging is associated with disruption of thermoregulation. of functional independence in elderly patients who have
In comparison with younger patients, elderly patients are undergone major abdominal surgery.62
less sensitive to alterations in environmental temperature and
less able to maintain thermal homeostasis.48 These changes
account for the higher risk of both hypothermia and heat- Preoperative Assessment of the Elderly Patient
stroke in this population. Heat conservation is impaired in
the elderly, and the capacity for vasoconstriction in response   
to cold stimulus may be decreased. The ability to shiver to In 1987, the National Institutes of Health (NIH) Con-
produce metabolic heat is also impaired, and when this ability sensus Conference on Geriatric Assessment Methods for
is used, it can impose substantial metabolic stress on an Clinical Decision-making defined the CGA as a “multidisci-
older person.49 Therefore, maintaining normothermia during plinary evaluation in which the multiple problems of older
surgical procedures is of particular importance in elderly persons are uncovered, described, and explained, if possible,
patients.50,51 Intraoperative hypothermia has been associated and in which the resources and strengths of the person are
with increased wound infection rates and longer hospital catalogued, need for services assessed, and a coordinated
stays in elderly patients undergoing major abdominal care plan developed to focus interventions on the person’s
surgery.52 problems.”63 The CGA differs from a standard preoperative
Abnormal thermoregulation accounts for the blunted evaluation in that it is a truly multidimensional evaluation of
febrile response seen in elderly persons fighting infections. the elderly patient. In addition to assessing comorbid condi-
The immune system is also affected by aging,53 with both tions, cognitive ability, mental function, socioenvironmental
cellular54 and humoral55 immunity being impaired. The factors, and nutrition status, it also scrutinizes medications
increased sensitivity to infection and the reduced ability to and functional ability.
mount a febrile response underscore the importance of main- The CGA may be used both to identify at-risk individuals
taining a high index of suspicion for postoperative infection and to guide interventions. When evaluated as a screening
in all elderly patients, even when fever is absent. tool in the geriatric community, it has been shown to detect
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6. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
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new and unsuspected problems in 76% of elderly persons postoperative morbidity and mortality.71 The preoperative
living at home.64 It has been found to be potentially beneficial level of functional performance has also been shown to be an
in reducing the incidence of hospitalization, falls, delirium, independent predictor of the extent to which elderly patients
and readmission in geriatric medical studies.65 It is predictive recover functional independence after major abdominal
of both morbidity and mortality in older patients.66 surgery.62
Because the CGA is designed to take into account the The performance status scores commonly used in oncology
multidimensional nature of aging, it may provide the best include the Eastern Cooperative Oncology Group (ECOG)
estimate of functional reserve in the elderly population, grade [see Table 3] and the Karnofsky score [see Table 4]. Both
as well as a gross estimate of life expectancy.67 Although of these are essentially global indicators of overall functional
the CGA has not yet been standardized, there are several status. Studies involving older cancer patients have shown
elements that, in our view, should always be included in the that adding assessment of ADL and IADL substantially
evaluation [see Table 2]. enhances the functional status evaluation provided by Karn-
ofsky scores or ECOG grades alone. In one study of older
Function patients with ECOG grades of at least 2, more than half had
Functional status may be measured in several diferent significant limitations in IADL.72
ways. In geriatric medicine, evaluation of functional status Recognizing the limitations of questionnaire-based assess-
typically includes assessment of the patient’s ability to per- ments for predicting true functional status, some groups have
form ADL and instrumental activities of daily living (IADL). elected to integrate objective performance-based measures of
ADL are personal care tasks, such as bathing, showering, functional status into the CGA. Among the most commonly
eating, getting in and out of a bed or chair, using the toilet,
maintaining continence, and walking68; they are skills neces-
sary for maintaining independent living at home. IADL are Table 3 Eastern Cooperative Oncology Group*
Performance Assessment175
everyday tasks, such as housework, laundry, preparing meals,
shopping, managing personal finances, negotiating transpor- Grade Patient Description
tation, and taking medications69; they are skills necessary
0 Fully active and able to carry out all predisease
for maintaining independence within the community. activities without restriction
Impaired ability to perform ADL and IADL has been associ-
1 Restricted in physically strenuous activity but ambula-
ated with increased mortality in older patients both within tory and able to carry out work of light or sedentary
the community and in the hospital.64,70 In particular, pre- nature (e.g., light house work, office work)
operative impairment of ADL or IADL capacity has been
2 Ambulatory and capable of all self-care but unable to
found to place elderly surgical patients at increased risk for carry out any work activities; up and about more
than 50% of waking hours
Table 2 Multidisciplinary Workup of Elderly Patients: 3 Capable of only limited self-care; confined to bed or
Elements of Comprehensive Geriatric Assessment67,106,112,113 chair more than 50% of waking hours
Domain Measure 4 Completely disabled and not capable of any self-care;
confined to bed or chair
Functional status Activities of daily living
Instrumental activities of daily living 5 Dead
Karnofsky score *Used by permission of Eastern Cooperative Oncology Group, Robert Comis,
ECOG grade M.D., Group Chair
Timed up and go test
Number of falls within past 6 months
Table 4 Karnofsky Score176
Comorbidity Cumulative Illness Rating Scale–Geriatrics
Charlson Comorbidity Index Score Patient Description
Older American Resources and Services
Subscale 100 Normal, with no complaints or signs of disease
Nutrition Mini Nutritional Assessment 90 Showing minor signs and symptoms but capable of
Body mass index normal activity
Percentage of unintentional weight loss within 80 Showing some signs or symptoms but capable of normal
past 6 months activity with some effort
Cognition Mini-Mental State examination 70 Capable of self-care but unable to do active work
Blessed Orientation-Memory Concentration
Test 60 Requiring occasional assistance but able to take care of
most personal needs
Depression Geriatric Depression Scale
Hospital Anxiety and Depression Scale 50 Requiring frequent medical care
Beck Depression Scale 40 Disabled, requiring special care and assistance
Social support RAND Medical Social Support Scale 30 Severely disabled, hospitalized
Medical Outcome Study Social Support
Survey 20 Hospitalized and very ill, requiring active supportive
Seeman and Berkman Social Ties Score treatment
Polypharmacy 10 Moribund, with rapidly progressing fatal disease process
ECOG—Eastern Cooperative Oncology Group 0 Dead
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7. © 2008 BC Decker Inc ACS Surgery: Principles and Practices
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used measures of physical mobility is the timed “up and go” 1.0
performance test,73 which measures (in seconds) the time it 0.9
takes a person to stand up from a standard armchair with a
seat height of 46 cm, walk a distance of 3 m, return to the 0.8
chair, and sit again. Other measures include walking a short
Proportion Surviving
0.7
course, assessing grip strength, and having the patient stand
0.6
on one leg. Many patients who have good performance status
according to their ECOG grades have been found to have 0.5
poor performance when timed tests of basic mobility are 0.4
employed.74 Such measures also seem to be predictive of
progressive declines in the ability to carry out ADL and IADL 0.3
at 1 year and 4 years.75 Whether these measures correlate 0.2
with overall survival in elderly surgical patients remains to
be studied. It is likely that they will prove to be just as impor- 0.1
tant as the well-established comorbidities of the cardiac, 0
pulmonary, and renal systems. 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000
Time after Operation (days)
Comorbidity
Comorbid conditions are common in elderly surgical ASA I (N = 241) ASA III (N = 240)
patients and frequently translate into adverse outcomes.76,77 ASA II (N = 345) ASA IV or V (N = 44)
The scoring system that is almost universally employed for
assessing comorbidity in surgical patients is the American Figure 3 Depicted is correlation between American Society of
Society of Anesthesiologists (ASA) physical status classifica- Anesthesiologists (ASA) grade and postoperative survival.171
tion [see Table 5].78 For decades, the ASA score has been
used to stratify the operative risk of all patients who undergo
surgery. It accurately reflects how the severity of a patient’s scores are independently predictive of mortality in older
comorbidities reliably predicts surgical outcome in terms of surgical patients.70 The CCI, initially developed as a method
postoperative morbidity and mortality [see Figure 3]. In one of estimating the risk of death on the basis of comorbid dis-
multicenter prospective study, the ASA score was the single ease and designed for prospective use in longitudinal studies,
best predictive measure of postoperative morbidity and the examines 19 categories of comorbidity, each weighted accord-
second best predictive indicator of postoperative mortality.79 ing to the adjusted risk of 1-year mortality [see Table 6].
Analyses aimed at identifying risk factors predictive of According to the original study by Charlson and colleagues,
adverse outcome specifically in geriatric surgical patients have with each increase in the level of the comorbidity index, there
shown that a high ASA score is an independent predictor of is a statistically significant, stepwise increase in the cumula-
postoperative morbidity and mortality in older surgical tive mortality attributable to comorbid disease.83 The 1-year
patients.80,81 mortality rates for a score of 0, 1–2, 3–4, and 5 or greater
Additional measures of comorbidity include the Cumula- were 12%, 26%, 52%, and 85%, respectively. The CCI can
tive Illness Rating Scale–Geriatrics (CIRS-G)82 and the be used today to provide a summary score denoting the
Charlson Comorbidity Index (CCI).83 The CIRS-G is a burden of illness, which correlates both with ability to tolerate
global assessment of the severity of comorbid disease. treatment and with overall survival.84,85
Fourteen organ systems are evaluated for the presence of
comorbid disease. Weights are assigned according to the Nutrition
severity of disease in terms of disability, chronicity, and Impaired nutritional status is highly prevalent among
end-organ failure. A total score is then calculated; higher the elderly. As many as 12% of men and 8% of women in the
healthy geriatric population are undernourished.71 Nutritional
impairment is even more common among hospitalized
Table 5 American Society of Anesthesiologists Physical patients, with reported rates ranging from 37% to 85%.86–88
Status Classification Malnutrition is known to be associated with adverse surgical
outcomes. Higher rates of surgical complications89 and
Class* Patient Status
increased postoperative mortality have been observed in
I Healthy patient patients with poor nutritional status, as determined by a
II Patient with mild systemic disease low body mass index (BMI),70 weight loss,90 a low preopera-
tive serum albumin level,89,91 or a low Mini Nutritional
III Patient with severe but not incapacitating systemic
Assessment (MNA) score.92 In the National Veterans Affairs
disease
(VA) Surgical Risk Study, declining serum albumin levels
IV Patient with severe systemic disease that poses constant were associated with an exponential increase in mortality
threat to life
(from less than 1% to 29%) and morbidity (from 10% to
V Moribund patient who is not expected to survive 65%) in patients undergoing major noncardiac operations.91
without surgery In a 2002 study, the MNA, which measures 18 factors by
VI Patient who has been declared brain-dead and whose means of a self-reporting questionnaire and anthropometric
organs are being removed for donor purposes measurements to assess nutritional status in elderly patients,
*Suffix E added for emergency operations. was predictive of mortality in hospitalized geriatric patients.92
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Table 6 Charlson Comorbidity Index83
to 40% of geriatric patients routinely screened for depression
as part of a CGA may exhibit depressive symptoms.106 Depres-
Condition Assigned Weight sion has been linked to decreased survival in older patients
Myocardial infarction undergoing orthopedic104 or oncologic surgical procedures.108
Congestive heart failure The lack of social support has also been correlated with
Peripheral vascular disease higher mortality in the geriatric and geriatric oncology litera-
Cerebrovascular disease ture.109,110 A tool that is commonly employed in screening
Dementia
1 for depression in the elderly is the Geriatric Depression
Chronic pulmonary disease
Connective tissue disease Scale (GDS) [see Table 8]. According to this simple 15-point
Ulcer disease scale, a score greater than 5 in an elderly patient diagnoses
Liver disease, mild depression with 69% sensitivity and 77% specificity rates.
Diabetes
Hemiplegia Social Support
Renal disease, moderate or severe Several tools are available for quantifying social support
Diabetes with end-organ damage resources in elderly patients. One such tool is the Medical
2
Any malignancy
Leukemia
Outcome Study Social Support Survey (MOS-SSS), which
Malignant lymphoma yields a score on a scale of 0 to 100 and includes “emotional”
and “tangible” subscales.111 Another commonly used mea-
Liver disease, moderate or severe 3
sure of social support is the Seeman and Berkman Social
Metastatic solid malignancy 6 Ties Score, which measures social ties in four areas: marital
AIDS status, close contact with at least two close friends or rela-
tives, church attendance, and membership in other groups.
The presence of social ties has been found to be inversely
related to mortality in the elderly.109
Preoperative identification of malnourished patients and
nutritional supplementation before major surgical procedures Polypharmacy
may reduce the chances of an adverse outcome.93,94 The physiologic changes associated with aging lead to
Cognition alterations in pharmacokinetics, and these alterations, in
conjunction with polypharmacy, leave the older patient
Preoperative cognitive dysfunction has been associated susceptible to adverse drug interactions. Review of the
with increased postoperative complications and worse sur- patient’s medication list is an integral component of the
vival in elderly surgical patients.95–97 Such dysfunction may CGA. Nonessential mediations should be discontinued and
take the form of either dementia or delirium. Dementia is a potential drug interactions screened for.
chronic baseline impairment of cognitive function. Demented
patients are known to experience higher postoperative mor- Summary
tality than patients with intact cognitive function.98 Delirium The variables examined during the course of the CGA are
is an acute confusional state associated with multiple possible often predictive of morbidity and mortality in elderly patients.
causes. The incidence of postoperative delirium in older Accordingly, there is growing support for use of the CGA in
patients ranges from 20% to 60%.99,100 This state is associated the assessment of older patients undergoing evaluation for
with a prolonged hospital stay, functional decline, and surgery.112,113
increased mortality.101–104 Risk factors for the development In the field of geriatric surgical oncology, this assessment is
of postoperative delirium include preexisting dementia, visual taken one step further by the tool known as the Preoperative
impairment, alcohol consumption, infection, narcotic use, Assessment of Cancer in the Elderly (PACE).71 The PACE
and polypharmacy. incorporates several components of the CGA, as well as the
Cognitive ability can be assessed with the Mini-Mental ECOG performance grade, the ASA classification, and the
State examination (MMSE) [see Table 7].105 Baseline cogni- Brief Fatigue Inventory (BFI) score. It is currently being
tive function should be established preoperatively. Studies assessed in a multinational study as a tool for evaluating func-
in elderly cancer patients that used a screening cognitive tional capacity and overall health status in older cancer
examination as part of the CGA found that in 25% to 50% patients being considered for surgery. Preliminary results
of patients, abnormalities were discovered that prompted with this tool support the correlation between functional
further evaluation.106 Cognitive impairment assessed by the status (as measured by capacity for ADL and IADL) with
MMSE within an ambulatory primary care setting has been subsequent postoperative outcomes.
associated with an increased risk of mortality, even after
confounding effects from chronic comorbid conditions have
been controlled for.107 In addition to identifying at-risk Special Surgical Considerations
patients, the MMSE provides a standard measure that may The elderly account for the majority of cancer patients:
be applied if postoperative cognitive deterioration becomes a according to data from the National Cancer Institute (NCI)
concern. Surveillance, Epidemiology, and End Results (SEER) pro-
gram for the 5-year period from 2000 to 2004 (inclusive),
Depression 56% of all newly diagnosed cancers and 70% of cancer deaths
Depression and the lack of social support are also linked to are found within the group of patients aged 65 years and
adverse outcomes in older surgical patients. As many as 14% older [see Figure 4].114 The increased incidence and preva-
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Table 7 Mini-Mental State Examination for Cognitive Function105
Maximum Score Score Item
Orientation
5 () ‘What is the date?’ Give 1 point each for year, season, date, day, month.
5 () ‘Where are we?’ Give 1 point each for state, county, town, building, floor, or room.
Registration
3 () Name three objects. Take 1 second to say each, then ask patient to name all three.
Give 1 point for each correct answer. Repeat until patient learns all three (for later testing).
Attention and Calculation
5 () Ask patient to subtract serial sevens, starting at 100. Give 1 point for each correct answer.
Stop after five answers. (Alternatively, ask patient to spell ‘world’ backward.)
Recall
3 () Ask patient to name the three objects mentioned previously. Give 1 point for each correct answer.
Language
Point to a pencil and a watch and ask patient to name them. Give 1 point for each correct answer.
Ask patient to repeat the following: ‘No ifs, ands, or buts.’ Give 1 point if successful.
Give patient a three-stage command: ‘Take a paper in your right hand, fold it in half, and put it on the
9 ()
floor.’ Give 1 point for each correct action.
Ask patient to read and obey the following: ‘Close your eyes.’ Give 1 point if patient closes eyes.
Ask patient to write a sentence. Give 1 point if sentence has a subject and a verb and makes sense.
Ask patient to copy a simple design. Give 1 point if drawing is correct.
30 () Total Score*
*A score of 24 or more is considered normal.
Table 8 Geriatric Depression Scale (Mood Scale) lence of cancer in older patients, coupled with the increased
(Short Form)177 projected longevity within the geriatric population, make
cancer treatment in the elderly a common concern.
Patient Name: Give 1 point if
The cancer treatment plans employed in elderly patients
Date: answer is:
Choose the best answer for how you differ from those employed in younger patients. One
have felt over the past week: difference is that elderly patients may not receive surgical
1. Are you basically satisfied with your No treatment for many potentially curable cancers. In a compre-
life? hensive SEER database analysis published in 2004, the rates
2. Have you dropped many of your Yes
of curative surgery for adenocarcinoma of the breast, esopha-
activities and interests? gus, stomach, pancreas, colon, or rectum; non–small cell lung
carcinoma (NSCLC); and sarcoma were compared across
3. Do you feel that your life is empty? Yes
age groups.115 For all categories of local-stage cancers, onco-
4. Do you often get bored? Yes logic resection rates declined steadily with increasing age.
5. Are you in good spirits most of the No Whether this decline is a reflection of appropriate patient
time? selection based on objective risk assessment or of undertreat-
6. Are you afraid that something bad is Yes ment of elderly cancer patients is difficult to determine.
going to happen to you? Those elderly patients who do undergo oncologic resection
7. Do you feel happy most of the time? No can fare well. The Surgical Task Force report from the
International Society for Geriatric Oncology (Société
8. Do you often feel helpless? Yes
Internationale d’Oncologie Gériatrique; SIOG) reported in
9. Do you prefer to stay at home, rather Yes 2004 that for many neoplasms, surgical outcomes were much
than going out and doing new things?
the same for older patients as for younger patients.116
10. Do you feel you have more problems Yes Another difference is that adjuvant treatment measures,
with memory than most?
such as chemotherapy117 and radiation therapy,118 may be
11. Do you think it is wonderful to be No underused in older cancer patients. Yet another difference is
alive now?
that the elderly are substantially underrepresented in cancer
12. Do you feel pretty worthless the way Yes treatment trials, especially in view of the much greater cancer
you are now? burden in the geriatric population.119–122
13. Do you feel full of energy? No In what follows, we focus on selected topics germane to
14. Do you feel that your situation is Yes the treatment of elderly patients with some of the more com-
hopeless? monly seen cancers, where surgical intervention is generally
15. Do you think that most people are Yes accepted to be part of the standard of care.
better off than you are?

Total: ___
The incidence of breast cancer is six times higher in older
For clinical purposes, a score > 5 points is suggestive of depression and
warrants a follow-up interview. Scores > 10 almost always indicate patients than in younger ones.123 Many elderly breast cancer
depression. patients may be undertreated119: studies have shown that
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Figure 4 Depicted is cancer incidence for 1994–1998 by age group (all SEER sites combined, both sexes).114
such patients are less likely to undergo radiation treatment, offers a real therapeutic benefit has come under scrutiny and
chemotherapy, or axillary dissection.124–126 Even when comor- remains controversial.134
bidity is adjusted for, patient age is predictive of prescribed Postoperative radiation therapy is an important adjunctive
treatment plans.124 Choosing to proceed with adjuvant measure for preventing local recurrence after BCT.135,136 The
treatment in an elderly patient can be a difficult decision. benefit of adding radiation therapy has been confirmed by
Whereas older women are more likely than younger women studies that look selectively at older breast cancer patients.137
to present with advanced-stage breast cancer,127 their disease In a 2004 trial involving older patients with early breast
may be less aggressive than it would be in a nongeriatric pop- cancer, the recurrence rate was lower in those who were
ulation. There is evidence to suggest that the biologic behav- treated with BCT, tamoxifen, and radiation (0.6%) than in
ior of breast tumors differs in the elderly. Older women with those who were patients treated with surgery and tamoxifen
breast cancer are more likely to have estrogen receptor (ER)– alone (7.7%).138 Despite the benefits with regard to local con-
positive tumors that are amenable to hormonal therapy.128 trol and survival, radiation therapy is often omitted in the
In addition, they are more likely to have a lower rate of elderly population.124 A 2006 report addressing the omission
tumor cell proliferation, diploidy, normal p53 expression, and of radiotherapy in older breast cancer patients found that the
reduced HER-2/neu expression.129 The potential differences frequency of omission increased significantly with increasing
in tumor biology seen in older patients, the common comor- age (7% in those aged 50 to 64, 9% in those aged 65 to 74,
bid conditions, and the typical functional impairments must and 26% in those aged 75 and older).139 Omission of radio-
be taken into consideration in planning treatment, along with therapy was associated with reductions in local control,
the understanding that undertreatment is associated with cancer-specific survival, and overall survival. The risks of
higher recurrence rates and increased mortality.130,131 omitting radiation treatment should be carefully considered
Surgery remains a mainstay of breast cancer treatment in the light of the patient’s overall life expectancy, the comor-
[see 3:5 Breast Procedures]. Older patients tolerate breast- bid conditions present, and the toxicity of treatment. Although
conserving therapy (BCT) and mastectomy as well as younger serious adverse effects are rare (incidence < 1%), they can be
patients do. In elderly women with breast cancer, overall severe, including radiation pneumonitis, pericarditis, and
operative mortality is typically quite low: less than 1% for possible rib fractures.
relatively fit patients.132 Generally, operative morbidity and Hormonal treatment is commonly employed in the elderly
mortality reflect the severity of any comorbid conditions breast cancer population. In particular, tamoxifen has proved
present, rather than the patient’s chronologic age.133 Axillary beneficial in numerous studies.140,141 These findings are par-
lymph node dissection had been considered part of the stan- ticularly germane to older patients, more than 80% of whom
dard of care in breast cancer surgery as a means of controlling are likely to be ER positive and endocrine responsive. In
nodal disease and providing accurate staging. Whereas it approximately 1% of patients treated with tamoxifen, serious
is clear that fewer elderly breast cancer patients are offered adverse effects may occur, including endometrial carcinoma
axillary dissection, it is not clear whether the morbidity asso- and thromboembolism. The newer aromatase inhibitors (e.g.,
ciated with the procedure is indeed more prevalent among anastrozole, letrozole, and exemestane) may have better toxi-
the elderly. Ultimately, this may be a moot point. With the city profiles than tamoxifen does and may confer a survival
increasingly widespread application of sentinel lymph node benefit. The American Society of Clinical Oncology (ASCO)
biopsy, the issue of whether axillary lymph node dissection recommends the aromatase inhibitors for postmenopausal
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women with ER-positive breast cancers142; however, the The advent of minimally invasive techniques, such
optimal timing and duration of treatment have not yet been as video-assisted thoracoscopic surgery (VATS) [see 4:10
established. The optimal approach to endocrine therapy in Video-Assisted Thoracic Surgery], has also made an impact on
elderly patients remains to be determined.143 lung cancer treatment in the elderly. Several studies have
The use of chemotherapy in elderly breast cancer patients shown VATS to be efficacious in the treatment of early
is also an area under scrutiny.144 According to the latest SEER NSCLC.152,154 One study found that whereas survival rates
registry data, a substantial proportion of elderly breast cancer did not differ significantly between patients who underwent
patients have poor prognostic factors that warrant consider- thoracotomy and those who underwent VATS, patients in the
ation of adjuvant chemotherapy. In a study involving more latter group experienced fewer postoperative complications,
than 23,000 elderly (> 65 years old) women with breast despite having more comorbid conditions.155 VATS, being
cancer, 35% had positive lymph nodes, and as many as 24% less invasive than thoracotomy, can allow patients with
had other poor prognostic markers, such as a large tumor or impaired cardiopulmonary reserve to tolerate surgery. How-
ER-negative status.129 At present, little evidence is available ever, patients with poor performance status who are unable
concerning the performance of elderly patients on chemo- to perform their ADL will have a high perioperative mortality
therapy regimens, in part because of the underrepresentation even with minimally invasive surgery156—a result that, once
of elderly participants in clinical trials. However, one analysis again, underscores the importance of appropriate patient
of SEER registries done by a group from the Memorial Sloan- selection.
Kettering Cancer Center did demonstrate a survival benefit
in patients aged 66 years or older who had endocrine- 
unresponsive tumors that were treated with adjuvant chemo- Colorectal cancer is the second most common cancer in
therapy.145 Optimal chemotherapy regimens for elderly the United States, with over 150,000 new cases and 50,000
patients have yet to be established. Commonly used regimens deaths estimated for 2007.157 It is predominantly a disease of
include cyclophosphamide with methotrexate and fluoroura- the elderly. Whether elderly colorectal cancer patients have a
cil (CMF) and an anthracycline (e.g., doxorubicin) with worse prognosis than younger patients is a subject of debate.
cyclophosphamide (AC). Anthracycline-containing regimens A large cancer database study from the United Kingdom
are known to have cardiotoxic side effects (including CHF) reported that outcomes grew progressively worse with increas-
and must therefore be used cautiously in the elderly. At lower ing age in elderly patients who underwent colorectal cancer
doses, however, AC therapy may prove to be less toxic and surgery.158 However, these elderly patients also had higher
more effective in older breast cancer patients.146,147 Trials ASA grades, more frequent emergency operations, and more
aimed at determining optimal treatment of breast cancer in frequent palliative procedures, all of which would portend
older women are currently under way. worse outcomes for any age group. In contrast, other studies
 have been able to demonstrate good oncologic outcomes in
selected elderly colorectal cancer patients after surgery,159,160
Lung cancer is the leading cause of cancer-related death in thereby emphasizing the importance of using other criteria
Western nations.148 More than 50% of persons diagnosed besides chronologic age alone in the process of patient
with lung cancer are older than 65 years. According to the selection.
latest SEER data, the median age of lung cancer patients is The mainstay of curative treatment for colorectal cancer is
73 years.149 surgery: segmental resection for colon cancer and additional
For patients with early NSCLC, surgery affords the best
total mesorectal excision (TME) for rectal cancer [see 5:34
chance of a cure [see 4:14 Pulmonary Resection]. Lobectomy
Segmental Colon Resection and 5:35 Procedures for Rectal
(i.e., removal of one of the five lobes of the lung, along with
Cancer]. In selected elderly patients, functional outcomes
associated lymph nodes) is currently the surgical standard
after low anterior resection may be as good as those in younger
of care for these patients. Traditionally, advanced age has
patients, with similar subjective findings of satisfaction
been considered a risk factor for postoperative death after
with bowel function and similar objective findings from
thoracotomy. In multiple early single-institution studies,
manometry data.161
postoperative mortality for patients aged 70 years or older
Minimally invasive procedures may have an emerging
was as high as 14% after lobectomy and higher than 20%
role to play in surgical management of colorectal cancer in
after pneumonectomy.150 Subsequent improvements in peri-
the elderly. A number of series have shown laparoscopic
operative care, anesthesia, and patient selection, however,
colectomy to be safe and efficacious for treatment of colon
have caused the reported postoperative mortality to drop
below 5%.151 Because the morbidity and mortality of lung cancer.162,163 It yields complication rates and survival out-
cancer surgery are directly correlated with the amount of comes comparable to those of open colectomy, and it results
tissue removed, considerable attention has been focused on in faster recovery and earlier return to daily activity.162 Such
examining the efficacy of lung-sparing procedures such as advantages may be especially important with elderly patients,
segmentectomy and wedge resection. These procedures are for whom postoperative alterations in the ability to carry out
now being performed with increasing frequency in elderly ADL can precipitate the transition from independence to
lung cancer patients, with good long-term results.151,152 An dependent living situations.
extensive analysis of SEER data from 5,219 patients aged Since randomized trials established that fluorouracil-based
65 to 74 years and 2,382 patients aged 75 years or older adjuvant chemotherapy after resection of stage III colon
who underwent curative surgery for early NSCLC concluded cancers reduces mortality by as much as 30%, adjuvant
that wedge resection and lobectomy had similar long-term chemotherapy has become the standard of care for stage III
survival benefits for patients older than 71 years.153 colon cancer.164 The extent to which adjuvant therapy is
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employed in the elderly population has been studied by some chemotherapy protocols. Some studies have suggested
investigators. One large retrospective cohort study using a that toxicity rates are higher in elderly patients undergoing
SEER/Medicare linked database found that the chemother- adjuvant chemotherapy than in younger patients,165–167 but
apy treatment rate declined markedly with chronologic age.117 the data are by no means unanimous on this point. There
The cause of this apparent reluctance to use chemotherapy in is, in fact, a growing body of evidence supporting the idea
the elderly population is probably multifactorial. One factor that elderly patients are capable of tolerating adjuvant chemo-
is the underrepresentation of the elderly in clinical trials, therapy and deriving a demonstrable survival benefit compa-
which hinders the extrapolation of study results to treatment rable to that observed in younger patients.168–170 Increasingly,
recommendations for these patients. Another is the higher the data suggest that elderly patients who are fit enough to
prevalence of comorbid conditions in older persons; these tolerate chemotherapy will reap its benefits. Judicious use
conditions are competing causes of mortality. Impaired of chemotherapy in the elderly surgical population should
functional status may also impair the ability of elderly therefore be considered and should not be rejected solely
patients to tolerate the toxic effects associated with current on the basis of the advanced age of the patients.
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