Presentation, management and outcome of oesophageal malignancy in patients aged over 75 years

Background: Subjects over 75 years old constitute an increasing proportion of the general population and hitherto the management of most malignant diseases in this elderly group has been predominantly palliative. The aim of this study was to assess the mode of presentation, management and outcome of treatment in patients aged over 75 years presenting with oesophageal malignancy. Methods: Data were collected prospectively from all patients aged over 75 years at presentation who were diagnosed at or referred to a single centre between October 1989 and May 1998. All patients underwent a full protocol of staging investigations and assessment of co‐morbid disease. The main modality of therapy and its outcome were analysed, as was the overall survival. Statistical analysis was with the χ 2 , Mann–Whitney and log rank tests. Results: Eighty patients were studied (41 men). The median age at presentation was 82 (range 75–97) years. Adenocarcinoma was the predominant histological subtype (46, 58 per cent) compared with squamous cell carcinoma (SCC; 34, 42 per cent). Most patients were referred by a gastroenterologist (34 patients) or general practitioner (25). Dysphagia and weight loss were the commonest presenting symptoms (67 patients), with dyspepsia a significantly more frequent symptom for adenocarcinoma (22 of 46 versus six of 34; P < 0·05). Patients with adenocarcinoma had more often received acid suppressing medication (20 of 46 versus seven of 34; P < 0·05). The median duration of symptoms was 5 months and was significantly longer for adenocarcinoma than SCC (7 versus 4 months; P < 0·05). Twenty‐nine (26 per cent) of 80 patients were unfit for surgery mainly because of co‐morbid cardiorespiratory disease, despite being staged as suitable for resection. A further 37 (46 per cent) were staged as having irresectable local disease or distant metastases and could not be offered surgery. Three patients declined surgery and two with high‐grade dysplasia in Barrett's oesophagus remain under surveillance. Thirty‐nine patients (49 per cent) were palliated with external beam and endoluminal radiotherapy, twenty‐eight (35 per cent) had oesophageal dilatation and endoprosthesis insertion, two patients had no intervention and a further two had laser therapy. Nine (11 per cent) underwent Ivor–Lewis subtotal oesophagectomy with two‐tier lymphadenectomy. The overall median survival for all modalities of therapy was 183 (95 per cent confidence interval 143–223) days. There was a significant survival benefit for those undergoing surgery compared with other options (402 versus 171 days; P = 0·0204). Survival following palliative measures was significantly better for radiotherapy than for dilatation and endoprosthesis insertion (214 versus 80 days; P = 0·0006). Conclusion: While surgical resection in selected patients offers the only chance of long‐term survival, the advanced nature of oesophageal malignancy at presentation coupled with the high incidence of significant co‐morbid disease precludes its use in most elderly patients. Thorough staging and careful assessment of overall fitness are crucial in identifying those suitable for surgery as well as establishing which palliative measures are most appropriate. © 1999 British Journal of Surgery Society Ltd