Discussion on the management strategy of patients aged over 70 years with esophageal cancer_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

YE Jingting ¹ , TANG Shanwei ² , TANG Guiwang ³ , LU Shichun ¹ , SUN Chao ¹ , LV Xiaoxia ¹ , ZOU Hui ¹ ,  SHU Yusheng ¹

1. Department of Thoracic Surgery, Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu, P.R.China;
2. Department of Thoracic Surgery, Clinical Medical College of Yangzhou University, Yangzhou, 225001, Jiangsu, P.R.China;
3. Department of Thoracic Surgery, Xiangya No.2 Hospital of Central South University, Changsha, 410000, P.R.China;

Corresponding author：

SHU Yusheng, Email: yushengshusbyy@163.com

Keywords：

Esophageal cancer; elderly patients; management strategies

DOI：

10.7507/1007-4848.201711050

Video：

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Esophageal cancer (EC) is the eighth dangerous cancer in the world. As the global population ages, the management of elderly patients with EC poses a challenge as they have many aging-associated diseases and physiological changes. In addition, the data on the tolerability of cancer treatment and the use of combined therapies in the patients to guide their treatment are limited. In this paper, we reviewed the literatures and discussed the effect of surgical resection and the potential complications of elderly patients. We reviewed the basic principles of combined therapy and the potential benefits of chemotherapy or chemoradiotherapy for patients and focused on the management of elderly patients with EC as well as the role of comprehensive assessment for aging to provide treatment options for elderly patients.

Citation： YE Jingting, TANG Shanwei, TANG Guiwang, LU Shichun, SUN Chao, LV Xiaoxia, ZOU Hui, SHU Yusheng. Discussion on the management strategy of patients aged over 70 years with esophageal cancer. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(10): 895-899. doi: 10.7507/1007-4848.201711050 Copy

1.	Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol, 2013, 19(34): 5598-5606.
2.	Bollschweiler E, Wolfgarten E, Gutschow C, et al. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer, 2001, 92(3): 549-555.
3.	Arnold M, Soerjomataram I, Ferlay J, et al. Global incidence of oesophageal cancer by histological subtype in 2012. Gut, 2015, 64(3): 381-387.
4.	Institut RK. Bericht zum Krebsgeschehen in Deutschland 2016. Berlin: Robert-Koch-Institut, 2016.
5.	Theou O, Brothers TD, Peña FG, et al. Identifying common characteristics of frailty across seven scales. J Am Geriatr Soc, 2014, 62(5): 901-906.
6.	Balducci L. Studying cancer treatment in the elderly patient population. Cancer Control, 2014, 21(3): 215-220.
7.	Rosso AL, Eaton CB, Wallace R, et al. Geriatric syndromes and incident disability in older women: results from the women's health initiative observational study. J Am Geriatr Soc, 2013, 61(3): 371-379.
8.	Hurria A, Wildes T, Blair SL, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw, 2014, 12(1): 82-126.
9.	Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults: a systematic review. JAMA, 2012, 307(2): 182-192.
10.	Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer, 2012, 118(13): 3377-3386.
11.	Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol, 2011, 29(25): 3457-3465.
12.	Pech O, Bollschweiler E, Manner H, et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg, 2011, 254(1): 67-72.
13.	Prasad GA, Wu TT, Wigle DA, et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett's esophagus. Gastroenterology, 2009, 137(3): 815-823.
14.	Le Page PA, Velu PP, Penman ID, et al. Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma. Surgeon, 2016, 14(6): 315-321.
15.	Cummings LC, Kou TD, Schluchter MD, et al. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc, 2016, 84(2): 232-240.
16.	Markar SR, Karthikesalingam A, Thrumurthy S, et al. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus, 2013, 26(3): 250-262.
17.	Zehetner J, Lipham JC, Ayazi S, et al. Esophagectomy for cancer in octogenarians. Dis Esophagus, 2010, 23(8): 666-669.
18.	Finlayson E, Fan Z, Birkmeyer JD. Outcomes in octogenarians undergoing high-risk cancer operation: a national study. J Am Coll Surg, 2007, 205(6): 729-734.
19.	Moskovitz AH, Rizk NP, Venkatraman E, et al. Mortality increases for octogenarians undergoing esophagogastrectomy for esophageal cancer. Ann Thorac Surg, 2006, 82(6): 2031-2036.
20.	Tapias LF, Muniappan A, Wright CD, et al. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg, 2013, 95(5): 1741-1748.
21.	McLoughlin JM, Lewis JM, Meredith KL. The impact of age on morbidity and mortality following esophagectomy for esophageal cancer. Cancer Control, 2013, 20(2): 144-150.
22.	Straatman J, van der Wielen N, Cuesta MA, et al. Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME Trial. Ann Surg, 2017, 266(2): 232-236.
23.	Khan O, Nizar S, Vasilikostas G, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. J Thorac Dis, 2012, 4(5): 465-466.
24.	Li J, Shen Y, Tan L, et al. Is minimally invasive esophagectomy beneficial to elderly patients with esophageal cancer? Surg Endosc, 2015, 29(4): 925-930.
25.	Oakley B, Lamb C, Vohra R, et al. Achieving long term survival in oesophagectomy patients aged over 75. Ann Med Surg (Lond), 2016, 9: 15-21.
26.	Sjoquist KM, Burmeister BH, Smithers BM, et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol, 2011, 12(7): 681-692.
27.	van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med, 2012, 366(22): 2074-2084.
28.	Hölscher AH, Bollschweiler E, Bogoevski D, et al. Prognostic impact of neoadjuvant chemoradiation in cT3 oesophageal cancer - A propensity score matched analysis. Eur J Cancer, 2014, 50(17): 2950-2957.
29.	Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet, 2002, 359(9319): 1727-1733.
30.	Allum WH, Stenning SP, Bancewicz J, et al. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol, 2009, 27(30): 5062-5067.
31.	Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med, 2006, 355(1): 11-20.
32.	Ychou M, Boige V, Pignon JP, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol, 2011, 29(13): 1715-1721.
33.	Cunningham D, Langley R, Nankivell M, et al. LBA-03* neoadjuvant chemotherapy for resectable oesophageal and junctional adenocarcinoma: results from the UK Medical Research Council randomised OEO5 trial (ISRCTN 01852072). Ann Oncol, 2015, 26(suppl 4): iv117-iv118.
34.	Kelsen DP, Ginsberg R, Pajak TF, et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med, 1998, 339(27): 1979-1984.
35.	Kelsen DP, Winter KA, Gunderson LL, et al. Long-term results of RTOG trial 8911(USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer. J Clin Oncol, 2007, 25(24): 3719-3725.
36.	Lorenzen S, Pauligk C, Homann N, et al. Feasibility of perioperative chemotherapy with infusional 5-FU, leucovorin, and oxaliplatin with (FLOT) or without (FLO) docetaxel in elderly patients with locally advanced esophagogastric cancer. Br J Cancer, 2013, 108(3): 519-526.
37.	Homann N, Pauligk C, Luley K, et al. Pathological complete remission in patients with oesophagogastric cancer receiving preoperative 5-fluorouracil, oxaliplatin and docetaxel. Int J Cancer, 2012, 130(7): 1706-1713.
38.	Schulz C, Kullmann F, Kunzmann V, et al. NeoFLOT: Multicenter phase Ⅱ study of perioperative chemotherapy in resectable adenocarcinoma of the gastroesophageal junction or gastric adenocarcinoma-Very good response predominantly in patients with intestinal type tumors. Int J Cancer, 2015, 137(3): 678-685.
39.	Al-Batran SE, Pauligk C, Homann N, et al. The feasibility of triple-drug chemotherapy combination in older adult patients with oesophagogastric cancer: a randomised trial of the Arbeitsgemeinschaft Internistische Onkologie (FLOT65+). Eur J Cancer, 2013, 49(4): 835-842.
40.	Shapiro J, van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol, 2015, 16(9): 1090-1098.
41.	Stahl M, Stuschke M, Lehmann N, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol, 2005, 23(10): 2310-2317.
42.	Semrau R, Herzog SL, Vallböhmer D, et al. Radiotherapy in elderly patients with inoperable esophageal cancer. Is there a benefit? Strahlenther Onkol, 2012, 188(3): 226-232.
43.	Lin SH, Zhang N, Godby J, et al. Radiation modality use and cardiopulmonary mortality risk in elderly patients with esophageal cancer. Cancer, 2016, 122(6): 917-928.
44.	Molena D, Stem M, Blackford AL, et al. Esophageal cancer treatment is underutilized among elderly patients in the USA. J Gastrointest Surg, 2017, 21(1): 126-136.

1. Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol, 2013, 19(34): 5598-5606.
2. Bollschweiler E, Wolfgarten E, Gutschow C, et al. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer, 2001, 92(3): 549-555.
3. Arnold M, Soerjomataram I, Ferlay J, et al. Global incidence of oesophageal cancer by histological subtype in 2012. Gut, 2015, 64(3): 381-387.
4. Institut RK. Bericht zum Krebsgeschehen in Deutschland 2016. Berlin: Robert-Koch-Institut, 2016.
5. Theou O, Brothers TD, Peña FG, et al. Identifying common characteristics of frailty across seven scales. J Am Geriatr Soc, 2014, 62(5): 901-906.
6. Balducci L. Studying cancer treatment in the elderly patient population. Cancer Control, 2014, 21(3): 215-220.
7. Rosso AL, Eaton CB, Wallace R, et al. Geriatric syndromes and incident disability in older women: results from the women's health initiative observational study. J Am Geriatr Soc, 2013, 61(3): 371-379.
8. Hurria A, Wildes T, Blair SL, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw, 2014, 12(1): 82-126.
9. Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults: a systematic review. JAMA, 2012, 307(2): 182-192.
10. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer, 2012, 118(13): 3377-3386.
11. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol, 2011, 29(25): 3457-3465.
12. Pech O, Bollschweiler E, Manner H, et al. Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers. Ann Surg, 2011, 254(1): 67-72.
13. Prasad GA, Wu TT, Wigle DA, et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett's esophagus. Gastroenterology, 2009, 137(3): 815-823.
14. Le Page PA, Velu PP, Penman ID, et al. Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma. Surgeon, 2016, 14(6): 315-321.
15. Cummings LC, Kou TD, Schluchter MD, et al. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc, 2016, 84(2): 232-240.
16. Markar SR, Karthikesalingam A, Thrumurthy S, et al. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus, 2013, 26(3): 250-262.
17. Zehetner J, Lipham JC, Ayazi S, et al. Esophagectomy for cancer in octogenarians. Dis Esophagus, 2010, 23(8): 666-669.
18. Finlayson E, Fan Z, Birkmeyer JD. Outcomes in octogenarians undergoing high-risk cancer operation: a national study. J Am Coll Surg, 2007, 205(6): 729-734.
19. Moskovitz AH, Rizk NP, Venkatraman E, et al. Mortality increases for octogenarians undergoing esophagogastrectomy for esophageal cancer. Ann Thorac Surg, 2006, 82(6): 2031-2036.
20. Tapias LF, Muniappan A, Wright CD, et al. Short and long-term outcomes after esophagectomy for cancer in elderly patients. Ann Thorac Surg, 2013, 95(5): 1741-1748.
21. McLoughlin JM, Lewis JM, Meredith KL. The impact of age on morbidity and mortality following esophagectomy for esophageal cancer. Cancer Control, 2013, 20(2): 144-150.
22. Straatman J, van der Wielen N, Cuesta MA, et al. Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME Trial. Ann Surg, 2017, 266(2): 232-236.
23. Khan O, Nizar S, Vasilikostas G, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. J Thorac Dis, 2012, 4(5): 465-466.
24. Li J, Shen Y, Tan L, et al. Is minimally invasive esophagectomy beneficial to elderly patients with esophageal cancer? Surg Endosc, 2015, 29(4): 925-930.
25. Oakley B, Lamb C, Vohra R, et al. Achieving long term survival in oesophagectomy patients aged over 75. Ann Med Surg (Lond), 2016, 9: 15-21.
26. Sjoquist KM, Burmeister BH, Smithers BM, et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol, 2011, 12(7): 681-692.
27. van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med, 2012, 366(22): 2074-2084.
28. Hölscher AH, Bollschweiler E, Bogoevski D, et al. Prognostic impact of neoadjuvant chemoradiation in cT3 oesophageal cancer - A propensity score matched analysis. Eur J Cancer, 2014, 50(17): 2950-2957.
29. Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet, 2002, 359(9319): 1727-1733.
30. Allum WH, Stenning SP, Bancewicz J, et al. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol, 2009, 27(30): 5062-5067.
31. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med, 2006, 355(1): 11-20.
32. Ychou M, Boige V, Pignon JP, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol, 2011, 29(13): 1715-1721.
33. Cunningham D, Langley R, Nankivell M, et al. LBA-03* neoadjuvant chemotherapy for resectable oesophageal and junctional adenocarcinoma: results from the UK Medical Research Council randomised OEO5 trial (ISRCTN 01852072). Ann Oncol, 2015, 26(suppl 4): iv117-iv118.
34. Kelsen DP, Ginsberg R, Pajak TF, et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med, 1998, 339(27): 1979-1984.
35. Kelsen DP, Winter KA, Gunderson LL, et al. Long-term results of RTOG trial 8911(USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer. J Clin Oncol, 2007, 25(24): 3719-3725.
36. Lorenzen S, Pauligk C, Homann N, et al. Feasibility of perioperative chemotherapy with infusional 5-FU, leucovorin, and oxaliplatin with (FLOT) or without (FLO) docetaxel in elderly patients with locally advanced esophagogastric cancer. Br J Cancer, 2013, 108(3): 519-526.
37. Homann N, Pauligk C, Luley K, et al. Pathological complete remission in patients with oesophagogastric cancer receiving preoperative 5-fluorouracil, oxaliplatin and docetaxel. Int J Cancer, 2012, 130(7): 1706-1713.
38. Schulz C, Kullmann F, Kunzmann V, et al. NeoFLOT: Multicenter phase Ⅱ study of perioperative chemotherapy in resectable adenocarcinoma of the gastroesophageal junction or gastric adenocarcinoma-Very good response predominantly in patients with intestinal type tumors. Int J Cancer, 2015, 137(3): 678-685.
39. Al-Batran SE, Pauligk C, Homann N, et al. The feasibility of triple-drug chemotherapy combination in older adult patients with oesophagogastric cancer: a randomised trial of the Arbeitsgemeinschaft Internistische Onkologie (FLOT65+). Eur J Cancer, 2013, 49(4): 835-842.
40. Shapiro J, van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol, 2015, 16(9): 1090-1098.
41. Stahl M, Stuschke M, Lehmann N, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol, 2005, 23(10): 2310-2317.
42. Semrau R, Herzog SL, Vallböhmer D, et al. Radiotherapy in elderly patients with inoperable esophageal cancer. Is there a benefit? Strahlenther Onkol, 2012, 188(3): 226-232.
43. Lin SH, Zhang N, Godby J, et al. Radiation modality use and cardiopulmonary mortality risk in elderly patients with esophageal cancer. Cancer, 2016, 122(6): 917-928.
44. Molena D, Stem M, Blackford AL, et al. Esophageal cancer treatment is underutilized among elderly patients in the USA. J Gastrointest Surg, 2017, 21(1): 126-136.

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