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LEARNING OBJECTIVES

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Learning Objectives

  1. Identify effective methods of colorectal cancer screening.

  2. Integrate appropriate colorectal cancer screening recommendations into health maintenance models of care for older adults, including potential discontinuation of screening when expected lifespan is fewer than 5 to 10 years.

  3. Recognize the overwhelming need to enroll older adult patients with gastrointestinal (GI) cancers in clinical trials.

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Key Clinical Points

  1. Colorectal cancer accounts for approximately 10% of all cancer-related deaths in the United States; it causes more deaths than prostate cancer in men 60 to 79 years and falls just short of breast cancer in women 80 years or older. Noncancer deaths account for a sizeable percentage of deaths in older adults with colorectal cancer; congestive heart failure, chronic obstructive pulmonary disease, and diabetes account for 9.4%, 5.3%, and 3.9% of deaths, respectively, in older patients with localized disease.

  2. Medicare covers surveillance fecal occult blood testing plus sigmoidoscopy or barium enema or colonoscopy for all beneficiaries; it may be reasonable to discontinue screening when life expectancy is shorter than the time a polyp progresses to a cancer, that is, 5 to 10 years.

  3. Men who were curatively treated with radiation for localized prostate cancer have a 70% increased risk of developing cancer in previously irradiated portions of the bowel and could potentially benefit from more frequent colorectal cancer screening.

  4. Perioperative mortality is lower for colorectal cancer surgery in high-volume centers versus low-volume centers. Further, less aggressive surgical intervention is more likely in low-volume centers and in older patients, and increases the risk of recurrence and cancer-related death. Finally, laparoscopic procedures have lower mortality and equivalent outcomes in older adults.

  5. Morbidity and mortality for surgery to treat resectable pancreatic or gastric cancer are similar in young and older adults.

  6. A large number of expanded options in chemotherapy (eg, targeted antibodies, kinase inhibitors) that are generally tolerated by older adults are now available and should prompt clinicians caring for older adults to seek medical oncology consultation even in those with advanced GI cancer.

  7. In those with esophageal cancer, African-American patients 65 years and older were noted to have a lower rate of surgical consultation and half the rate of curative surgery as their older adult Caucasian counterparts—very likely contributing to worse outcomes in minorities with esophageal cancer.

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INTRODUCTION

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Gastrointestinal cancers are primarily diseases of persons in their sixth, seventh, and eighth decades of life. Both incidence and mortality of gastrointestinal cancers increase with advancing age (Figures 100-1, 100-2, and 100-3). Many older persons, however, have additional medical problems that almost certainly contribute to inferior outcomes. This chapter will explore the epidemiology, presentation, treatment options, and disparities in the care of older persons with gastrointestinal malignancies.

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FIGURE 100-1.

Percentage of incident cases by age group for gastrointestinal (GI) malignancies (2007–2011).

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FIGURE 100-2.

Mortality rates for ...

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