Optimizing Colon Cancer Surgery for Elderly Patients: Fitness Over Age

Jump To Section

• Elderly Colon Cancer Prevalence and Treatment Shift
• Measuring Patient Fitness for Surgery
• The Pre-Rehabilitation Program
• Surgical Outcomes and Mortality Data
• The Age vs. Fitness Paradigm Shift
• Full Transcript

Elderly Colon Cancer Prevalence and Treatment Shift

Dr. Graeme Poston, MD, highlights a critical statistic: 75% of colorectal cancers are diagnosed in elderly patients. Historically, treatment for colon cancer in elderly patients was not aggressive. A psychological block existed, preventing oncologists from offering curative surgery to older adults. Dr. Anton Titov, MD, discusses how this paradigm is changing. The population is both older and fitter, demanding a new approach to cancer care that focuses on potential rather than chronological age.

Measuring Patient Fitness for Surgery

The main determinant for aggressive stage 4 metastatic cancer treatment is a patient's fitness level. Dr. Graeme Poston, MD, explains his team's method for assessing this. They use cardiopulmonary exercise testing to measure an elderly patient's anaerobic threshold. This involves putting the patient on a bicycle and measuring the point at which CO2 levels in the blood become excessive. This objective data provides a clear, numerical assessment of a patient's physiological readiness for the stress of a major operation.

The Pre-Rehabilitation Program

Dr. Graeme Poston, MD, advocates for a "pre-rehabilitation" program to enhance patient fitness before liver metastatic cancer resection. This proactive regimen is designed to prepare the body for surgery, which Dr. Poston likens to an Olympic event. The program is practical and effective. It involves three 40-minute sessions on an exercise bike per week for four weeks. This window of time often exists naturally while patients recover from chemotherapy and await their scheduled surgery date.

Surgical Outcomes and Mortality Data

The results from implementing this fitness-focused strategy are compelling. Dr. Graeme Poston, MD, published data from a large series of 180 patients over 70 who underwent liver resection. The operative mortality was 5%, or 1 in 20 patients. For patients under 70, mortality was even lower at 1%. Subsequent work has further improved these outcomes. Dr. Poston's team has now achieved an operative mortality of just 2% for stage 4 colorectal cancer patients over 80 years of age.

The Age vs. Fitness Paradigm Shift

Dr. Anton Titov, MD, and Dr. Graeme Poston, MD, agree that suitability for surgery is not about biological age. The pre-rehabilitation program for elderly colon cancer patients has fundamentally changed treatment philosophy. The conversation has shifted from "Are you too old?" to "How can we make you fit enough?". This patient-centered approach ensures that more individuals can access potentially curative surgery for advanced colon cancer, significantly improving prognosis and quality of life regardless of their date of birth.

Full Transcript

Dr. Anton Titov, MD: Seventy-five percent of colorectal cancers are diagnosed in elderly patients. Metastatic colon cancer treatment should be more aggressive in elderly patients. It is not about biological age, but about a patient’s fitness for surgery. Operative mortality in stage 4 colorectal cancer in patients over 80 years of age is just 2%.

What is a “pre-rehabilitation program”? How does it help to improve liver metastatic cancer resection results in elderly patients?

Dr. Graeme Poston, MD: Colon cancer treatment in elderly patients has nuances. Previously, treatment of colon cancer in elderly patients has not been aggressive. Colon cancer therapy in the elderly has not offered a real chance of survival.

This lack of aggressive cancer treatment in the elderly was true not only for colorectal cancer but also for other cancers. The association of cancer with older age was a psychological block.

Dr. Anton Titov, MD: It prevented oncologists from offering cancer treatment more aggressively in elderly patients. That is changing. What are the nuances of treating colorectal cancer and stage 4 metastatic colorectal cancer in elderly patients?

Dr. Graeme Poston, MD: This is a big pressure for us. As you rightly point out, the majority of our patients with colon cancer are elderly. More than half of colon cancer patients are over the age of 70. What's more, our population is getting older. We are going to have more older patients with colorectal cancer in the future.

We are having a much fitter older population than we used to have. We used to say, "Over the age of 60, we can't do anything to treat colon cancer aggressively. You are too old for surgery to resect a primary colon cancer tumor. We can't offer you surgery to resect metastatic colon cancer lesions."

Now we are saying that probably 80 years of age might be the cut-off for colorectal cancer surgery. We have done a lot of work on stage 4 metastatic cancer treatment in the elderly in my group. We looked at measuring the fitness of the metastatic colon cancer patient. We did not look at birth dates at all. We looked at fitness.

Dr. Anton Titov, MD: Sometimes patients come into the colorectal cancer treatment clinic. Is there a method that you could make elderly colon cancer patients fitter for surgery before you resect metastatic colon cancer lesions from the liver?

Dr. Graeme Poston, MD: A lot of work on improving patient fitness has already been done in cardiac surgery and vascular surgery. Initial work on increasing patient fitness before surgery was done in those fields because cardiovascular patients in general are less fit for various reasons. They smoke and they don't take exercise.

But we are looking at ways of measuring fitness in elderly patients with advanced colorectal cancer. We are looking at a thing called the anaerobic threshold. We study the anaerobic threshold through cardiopulmonary testing. We put elderly colon cancer patients on a bicycle.

We measure at what point their CO2 level becomes excessive in the blood circulation. That gives you an idea of how fit the elderly patient is. We prepare patients for the surgical operation to remove colon cancer metastases.

We then do a program for elderly colon cancer patients we call “pre-rehabilitation.” We try to get elderly colorectal cancer patients more fit before a surgical operation.

Dr. Anton Titov, MD: Not rehabilitation but pre-rehabilitation, "rehabilitation before surgery." It is a recurrent topic that I hear in many surgical fields. The goal is to get the patients as fit as possible before a surgical operation because a surgical operation is your Olympics.

Dr. Graeme Poston, MD: Yes, and in fact, it doesn't take very much for elderly patients to get more physically conditioned. They get fit before the surgery to remove colon cancer or metastatic colon cancer lesions. We have measured how much an elderly patient needs to get more fit.

To become more fit for the surgical operation, a colon cancer patient needs three sessions a week of forty minutes on an exercise bike. This fitness regimen needs to be done for four weeks. Often we have that luxury of time because the elderly colon cancer patients come to us. They finish their chemotherapy first.

Colon cancer elderly patients are going to have to wait six weeks before surgery to remove primary or metastatic liver tumors. We use that time productively to put elderly colon cancer patients on a bike. We get them exercising, we get their anaerobic threshold up. We get the elderly colon cancer patients fitter and stronger.

We published our stage 4 metastatic colon cancer in the liver resection results ten years ago. It is still the biggest single-center series of liver resection for metastatic stage 4 colorectal cancer in patients over the age of 70. We removed colon cancer liver metastases in 180 patients over the age of 70. But mortality was 5%. Only 1 in 20 patients died.

For stage 4 metastatic colon cancer patients with liver lesions under 70 years of age, mortality was 1%. Mortality was 1 in 100. We have now repeated our clinical trial of stage 4 colon cancer treatment in elderly patients. We have now got operative mortality down to 2% in patients under 80 years of age. Operative mortality in stage 4 colorectal cancer patients over 80 years of age is just 2%.

Dr. Anton Titov, MD: With a pre-rehabilitation program to get patients more fit before surgery, you are checking elderly colon cancer patients' aerobic threshold. With a pre-rehabilitation program, yes. A pre-rehabilitation program in elderly colon cancer patients changed everything.

Dr. Graeme Poston, MD: We now say that a patient's age doesn't matter. It is the fitness that matters for advanced colon cancer treatment by surgery.

Dr. Anton Titov, MD: A patient's suitability for aggressive stage 4 metastatic cancer treatment is not about the biological age. There is more and more medical data that is coming in about this. It is all about personal fitness. That is very important for colon cancer surgery.

Dr. Graeme Poston, MD: Absolutely, yes. Colon cancer treatment in elderly patients: fitness is important, not biological age.

Dr. Anton Titov, MD: A "pre-rehabilitation" program improves liver metastases surgery results.