| Japanese Journal of Clinical Oncology | Pages |
Editorial: Gastrectomy in Elderly Patients
The average life span for those 80 or over is reportedly rather long, 7.13 years for men, and 9.47 years for women. Reflecting these social changes, surgeons are now taking the opportunity to treat aged patients with gastric cancer. However, if such a patient realizes that there is a chance of surviving longer than 5 years through successful gastrectomy, how does he or she react to doctors, by undergoing surgery, or submitting to the cancer? The question presents a dilemma for both doctors and patients and the final decision should be made by patients according to an individual's philosophy.
There are two papers in this issue which will help doctors in considering the implications of gastrectomy for elderly patients (1)(2). They evaluated the results of this with regard to immediate morbidity and mortality, and also long term survival relating to the preoperatively diagnosed extent of cancer and the complications. Both authors claim that age itself should not rule out the chance of undergoing radical surgery. In fact, a careful preoperative evaluation of possible complications can lead to satisfactory results even in elderly patients. Katai et al. stated that the five-year survival rate was 44% with 2.7% of operative mortality for aged patients, and he suggested that extended surgery should be limited to those who had no preoperative complication, because excessive intervention in elderly patients caused higher morbidity and mortality than in younger patients. Roviello et al. also insisted that standard gastrectomy should be limited to those who had either no preoperative diseases, or no more than one. It may be important for doctors to realize that calendar age is different from the physiological age, and, at the same time, to realize that elderly patients with concomitant medical illness are more fragile and less resistant to aggressive intervention than younger patients. Selecting the patients carefully and the correct method of surgery may present the opportunity to an elderly patient to survive for some time while enjoying a good quality of life. The late Dr Tamaki Kajitani was President Emeritus of the Japanese Research Society for Gastric Cancer and he was always proud of his successful gastrectomy on a particular elderly patient. The 92-year-old lady lived to be 104 and was honored by a local governor as the longest living survivor of this surgery. In this regard, both papers demonstrated from the surgical point of view the proper indication of surgery for elderly patients based on the extent of cancer and surgery and preoperative complications. Recent advances in surgical techniques have allowed less aggressive approaches such as endoscopic mucosal resection for mucosal cancer, and laparoscopic partial gastrectomy for small T1 or T2 tumors estimated to have no nodal involvement. These methods may be safer than the usual laparotomic gastrectomy, and may offer better indication for surgery on elderly patients.
On the other hand, technical skills should not be completely overlooked when analyzing the frequency of postoperative morbidity and mortality and readers should be very cautious in how they weigh up the results of these two papers before making their decision. If actual morbidity and mortality are high, it will not justify surgery in elderly patients with cancer. Generally speaking, Japanese patients are slimmer than patients in the West, allowing surgeons to perform fine and radical surgery. The nationwide registry of gastric cancer in Japan (reports that the operative mortality is 1.7% (3). A comparative study of these two papers from Japan and Europe will help readers to make the right decision.
Another aspect to consider, is the quality of life (QOL) after surgery. Neither author dealt with the issue of QOL after surgery in his paper, but it is mandatory for both doctors and patients to take QOL into account. Poor postoperative QOL will not justify surgery on elderly patients, even if they were to survive the actual surgery. Patients should be competent to give their informed consent for surgery after being given a full diagnosis and detailed information on the surgical treatment. Future studies should be directed towards addressing this issue.
In contrast with the traditional attitude of surgeons towards cancer, Dr Kitagawa, a pathologist and Director of the Cancer Institute, advocates a new concept of `Tenju gann' or `natural-end cancer' (4). The term natural-end cancer is defined as the cancer in people of advanced age leading to a peaceful death with minimal suffering. There might be some arguments regarding the definition of advanced age, or question as to whether any cancer allows the elderly to die peacefully. However, experienced surgeons may decide that surgery is not always the best option and there are cases which should be treated by alternative methods. For example, a slow growing cancer in the cardiac region in an elderly patient (85 or over for a male, and 90 or over for a female) is postulated to be a natural-end cancer. We have no detailed knowledge or statistics available on the natural-end history of gastric cancer in elderly patients and the arguments for and against need further research. However, it may be appropriate in a certain subset of elderly patients.
In conclusion, there should be debate amongst doctors and patients, with consideration given to the social aspects and the two papers in this issue are worthy in that they provide a guideline, at least, to the medical perspective.
References
Toshifusa Nakajima, M.D.
Cancer Institute Hospital, Tokyo
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Copyright© Japanese Journal of Clinical Oncology, 1998.
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