Advanced age and cancer - Forum

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Hans

Advanced age and cancer - Ärzteforum

Post#1 »

I read with interest the comments about the case of 85 y/o with possible lung met after colon cancer. I'd certainly go for the box of cigars and nice sherry, at least as long as the patient would be happy with it.

This week I operated a case which may show the difficulties we face.

87y/o adipose woman in reasonable health presents with her third colon cancer. A right cancer (3 years ago) and a rectosigmoid cancer (10 years ago), one of which was a Dukes C cancer. No metastasis.

What can be suggested for her treatment?

a) No operation

b) total colectomy

c) local excision of the new tumor.


canadian

Re: Advanced age and cancer - Ärzteforum

Post#2 »

I'd echo the comments about her almost being old enough to decide for
herself. She will probably go for a local resection, and not want an
ileostomy or subtotal, although there's maybe not too much left. BTW, could
I ask why she hasn't been enjoying colonoscopic surveillance after her first
cancer?

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Surgeon

Re: Advanced age and cancer - Ärzteforum

Post#3 »

Where is the current cancer?
What type of resections she had in the past?

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A Doctor

Re: Advanced age and cancer - Ärzteforum

Post#4 »

This is an entirely different situation. This is a patient with a curable
and presumably symptomatic lesion. We have something to offer her. And it
is a patient with an intact immune system and predisposition to develop
colorectal tumors. I would be aggressive and do the subtotal colectomy.

Hans

Re: Advanced age and cancer - Ärzteforum

Post#5 »

this is presumably a curable cancer - so certainly doesn't fall into the
palliate only group. It seems that even if curable if she lives more than a
few years she will get another. I would suggest a total colectomy is best -
{but the question is a bit philosophical at her age}. The small stump left
will be easily surveyed by a rigid scope avoiding the unpleasantness of a
colonoscopy in an elderly patient and if caught early any rectal recurrence
could be dealt with endoscopically (I am guessing you do endorectal
surgery). As to whether she should have an ileostomy or an IRA - the latter
if technically feasible.

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Doctor Green

Re: Advanced age and cancer - Ärzteforum

Post#6 »

I have several questions about this case; but, if they are going to operate, I
cannot understand why they recommend pneumonectomy instead of wedge resections.
As you know, for mets (which typically are peripheral lesions, but not always),
minimal margin is needed and "clearing" the lymphatics unnecessary. The only
reason I could possibly image is that one of the mets is large, central, and
near the hilum. If I were to operate, I would do everything I could to avoid
pneumonectomy. If someone already discussed this issue I apologize; if not,
surgeon, I would be curious to know the reason...I hope that your friend's father
is in good hands and wish him the best of luck.

Proctologist

Re: Advanced age and cancer - Ärzteforum

Post#7 »

The decision is not easy. One should remember that the life expectancy
of an 87 year old woman is about 10 years. This may sound incredible,
but it's true. Check any textbook on geriatrics (it is only 5-7 years
for an 85 years old man) Moreover, if the person is financially secure,
as it would be in a welfare state as Sweden, the quality of life is
excellent, at least in the eyes of the old themselves. Therefore the
age is not in itself a barrier for potentially curative surgery.

On the downside, the two previous major abdominal operations may make
the 3rd operation difficult. And obviously, the risks of any major
operation in an 87 years old are high, even if we assume that the lady
in question is otherwise fit. If she is not, than there is really no
choice.

I presume that by local excision PO does not talk about colonoscopic
removal, but a wedge resection with laparotomy. I would guess that in
expert hands, the added risk of TAC over wedge excision is marginal, as
the adhesions would have to be dealt with in any case. It may be a
technical decision that can only be made in situ.

It comes down to the following choices:
1. Curative operation (which must be total abdominal colectomy) with a
good chance of long term survival and increased risk of immediate death.

2. A smaller procedure (local excision) with poor chance of long term
survival and a somewhat lesser risk of immediate death;
3. Do nothing with no chance of cure, but no risk of immediate death.

While the choice between the first two could be a technical question,
the choice between these and the third is purely a value decision.
While we ought to make technical decisions for the patients, we cannot
make value decisions for them. We have to give them a accurate
assessment of the risks and benefits, and they should make the decision.


In this regard, we are not different from any other expert. Suppose I
bring in a plumber to fix your faucet. The plumber can use a silicone
gasket which costs say 10$ but will last 5 years, or a rubber gasket
which costs 5$ but will last only one year. The question now is not
which is better, but how I value 5$ vs. 10$ now. It is possible that I
can't afford the extra 5$ now. So it is up to me, not the plumber, to
decide, even though the silicone gasket is objectively a better choice.

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