Older Colon Cancer Patients May Be OK for Lap Surgery

Long-term results with laparoscopic procedures came out even with open surgery in an unblinded randomized trial involving patients 75 and older needing colorectal cancer resection, Japanese researchers reported.

Among 190 patients evaluable for 5-year outcomes, no significant differences were seen in any measure of survival — overall, disease-free, recurrence-free, or cancer-specific, according to Shoichi Fujii, MD, PhD, of Yokohama City University in Japan, who presented the results via video at the virtual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) annual meeting.

Overall survival at 5 years for all primary tumor locations, for instance, was just over 80% in both groups.

At the 2013 SAGES meeting, Fujii’s group had reported short-term results from the trial, which focused on perioperative outcomes such as bleeding, early complications, and bowel obstructions. These all favored laparoscopic procedures, by wide margins in some cases.

But the lack of significant differences in the long-term follow-up was not the end of the story. Point estimates for the long-term outcomes favored open surgery for many of the survival outcomes, failing to reach statistical significance by narrow margins in some cases.

For example, 20.4% of the laparoscopic group experienced recurrence compared with 13.0% of patients getting open surgery (P=0.175), suggesting that the trial might not have had sufficient power to detect differences.

Similarly, rates of disease-free survival differed by about 5 percentage points in favor of open surgery, but with a P value of 0.276.

While surgery type was not a significant predictor of recurrence in the study, Fujii and colleagues did identify three others that were:

• Vascular invasion: HR 2.74 (95% CI 1.12-6.71)
• Lymph node metastasis: HR 3.05 (95% CI 1.28-7.28)
• Rectal cancer: HR 3.19 (95% CI 1.33-7.66)

In his presentation, Fujii acknowledged the “strong tendency toward local recurrence” with laparoscopic procedures, calling it “an important problem.” All such cases involved rectal tumors, he said.

One potential factor in the results was that more than half of the laparoscopic group showed vascular invasion at enrollment, compared with 25% of the open-surgery group. That may explain the higher rate of recurrence following laparoscopic procedures, Fujii said, rather than the procedure itself.

Although patients age 75 and up could be enrolled, and some in their 90s were included, the median age was 79 in the open surgery group and 75 for laparoscopic procedures — indicating that most participants were at the lower end of the range. Tumor locations were divided roughly equally among right- and left-side tumors. Almost all had tubular adenocarcinomas.

Fujii noted that the trial was conducted only in a single institution, which held down the number of patients available for enrollment. He said a larger trial is needed to establish definitively whether laparoscopic surgery is genuinely as effective as open procedures for elderly patients.