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Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged > 75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients.Prospective registration of 86 consecutive patients aged > 75 years undergoing elective surgery after irradiation 46–50 Gy for either primary locally advanced rectal cancer (n = 51) or recurrent rectal cancer (n = 35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75–85 years) in a national cancer hospital.Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P = 0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P = 0.248 ns), respectively.Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.