Ann Thorac Surg 1997;63:1225-1226
© 1997 The Society of Thoracic Surgeons
Medical University of South Carolina, Charleston, South Carolina
The article in this issue by Jougon and associates  addresses the feasibility of offering esophageal resection to patients aged 70 years and older. It is a question of consequence because the population is progressively aging, and the projected life expectancy of septuagenarians and octogenarians has increased. Patients 70 years old and older accounted for 74% of new esophageal cancer cases registered in Scotland each year between 1981 and 1990 .
Although we do not know the total number of patients 70 years old and older diagnosed or referred for operation, this cohort represented 16.5% of patients undergoing resection by Dr Jougon and colleagues. This percentage is slightly lower than the 25% reported by Ellis and associates  or the 26.5% reported by Muehrcke and Donnelly , but is similar to the recently completed Intergroup 113 trial (17%; personal communication, Dr Robert Ginsberg, 1997). In Jougon and associates' series, elderly patients were considered from the outset to be at increased risk and underwent preoperative risk assessment that included nutritional status, echocardiogram, exercise stress testing, and pulmonary function testing. Jougon and associates suggested that elderly patients were held to more rigid criteria, and none were offered neoadjuvant therapy because of their "frail" condition. More of the older group had resection with a one-stage thoracic approach than occurred in the younger group (67.4% versus 34.6%, respectively), which may partially be due to the preponderance of adenocarcinoma of the distal esophagus and cardia (76.4% versus 53%, respectively).
See also page 1423.
Despite selection bias, a difference in tumor histology and surgical approach in the elderly group, the morbidity and mortality reported by Jougon and associates were impressive and not different from those of patients younger than 70 years. Naunheim and associates  reported an operative mortality of 18% in septuagenarians and quoted a range of 13% to 18% in five series reported from 1985 through 1992. In Naunheim and associates' report, two-thirds of the patients suffered major morbidity. In the Intergroup 113 trial, there is no difference in morbidity or mortality in the group of patients older than 70 years undergoing operation alone or induction therapy followed by operation (personal communication, Dr Robert Ginsberg, 1997).
The issue of esophagectomy in the elderly is not unlike that of resection for lung cancer. Not surprisingly, some authors have found that older patients suffer increased morbidity and mortality and others have reported that age is not a significant risk factor. A question always arises as to what is an acceptable mortality in a universally fatal disease.
I would suggest that the question of who should undergo esophagectomy be broadened. Rational consideration should be given to answering similar issues raised by Drs Yellin and Benfield  in regard to lung cancer resection in the elderly: (1) What is the life expectancy of the patient? (2) What is the risk of esophagectomy? (3) What are the consequences of alternative treatment? (4) What is the value of an operative approach?
I have already addressed the issue of life expectancy. Clearly, the cancer, not age, is the life-limiting factor. The risk of esophagectomy in any patient is significant. Although the mortality of esophagectomy in elderly patients is increased in many series, the usual conclusion has been that it is "acceptable." The caveat, of course, is that patients are selected carefully with attention to comorbidities. I would add that the operation must also be performed expertly. One must ask who should decide what mortality is acceptable: the insurer, the physician, or the patient? Because of associated illnesses, increased morbidity would not be unexpected in patients 70 years old and older. Careful perioperative management is essential. It is reassuring that postoperative morbidity in the elderly was not significantly different from that of younger patients in the large American multiinstitutional study.
The consequences of alternative treatment need continued rational investigation. It is apparent that chemoradiation must be considered a viable option. Although adding chemotherapy to radiation increases toxicity, treatment mortality is minimally affected, and long-term survival is respectable (30% at 5 years in the study by Al-Sarraf and associates ). In fact, in a study by the Tran-Tasman Radiation Oncology Group , patients having chemoradiation alone had equivalent 3- and 5-year survivals to the group undergoing induction chemoradiation followed by operation.
The value of esophagectomy is seen when reviewing series of patients with resectable esophageal cancer undergoing chemoradiation alone. When compared with trimodality therapy, the local recurrence rate is increased (33.7% versus 12.8%, respectively) . Because increased survival in phase II induction studies has occurred in patients with complete pathologic response and survival in nonresponders is dismal, it can be asked whether esophagectomy should be added only to clinical responders. When weighing therapy options, issues of quality of life after treatment, types of morbidity, and reintervention needs are important and have not yet been adequately addressed.
In summary: Who should undergo esophagectomy? The answer requires a much broader assessment than age alone. Continued investigation must include randomized trials; selection criteria based on defined comorbidities and optimal T and N staging; standardization of therapeutic protocols, surgical techniques, pathologic examination, and survival curves; better identification of responders to induction therapy; definitions of complications; and attention to quality of life and cost issues. Analysis of these factors will help clarify who should undergo esophagectomy.
Address reprint requests to Dr Reed, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425.
This article has been cited by other articles:
C. Alexiou, D. Beggs, F. D. Salama, E. T. Brackenbury, and W. E. Morgan
Surgery for esophageal cancer in elderly patients: The view from Nottingham
J. Thorac. Cardiovasc. Surg., October 1, 1998; 116(4): 545 - 553.
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