Abstract
Purpose
Colorectal cancer (CRC) is becoming increasingly common in adults ≥ 60 years old, yet postoperative prognosis of curative-intent surgery for the advanced elderly (≥ 80 years) remains controversial.
Methods
A retrospective cohort study included 971 CRC patients aged ≥ 60 years who underwent curative-intent surgery from January 2018 to December 2023 in Beijing Chaoyang Hospital. Patients were stratified into “ordinary elderly group” (OE) (60–79 years, n = 800) and “advanced elderly group” (AE) (≥ 80 years, n = 171). Clinicopathological variables, 30-day morbidity/mortality, disease-free survival (DFS), and overall survival (OS) were collected and analyzed the differences between the two groups. The study was presented in accordance with the STROBE reporting checklist.
Results
The AE had more right-sided CRC (P < 0.001) and higher rate of preoperative obstruction (P < 0.001). They underwent more emergency (P = 0.002) and open procedures (P < 0.001), resulting in longer postoperative stays P = 0.030). Overall, 30-day morbidity was comparable (P = 0.76), but perioperative mortality rate was higher in AE (P = 0.041). The median follow-up was 36.1 ± 22.1 months, and recurrence rates (P = 0.58) and 5-year DFS (log-rank P = 0.42) did not differ between groups. Multivariate analysis identified TNM stage, perineural invasion, vascular invasion, preoperative intestinal obstruction, and proficient Mismatch Repair (pMMR) as independent predictors of DFS; age ≥ 80 years was not prognostic (p = 0.81).
Conclusions
Despite a higher burden of comorbidities and increased perioperative mortality, no statistically significant difference in long-term oncological outcomes was observed between AE and OE following rigorous patient selection and perioperative management in CRC patients. Advanced age alone should not preclude standard curative resection.
Keywords: Colorectal cancer, Elderly patients, Postoperative prognosis, Disease-free survival
Introduction
With the gradual aggravation of aging, both the mortality and incidence of colorectal cancer (CRC) continue to rise. Global cancer statistics in 2022 documented nearly 2 million new CRC cases and approximately 900 thousand deaths attributed to the disease. CRC is the third most prevalent malignant neoplasm, takes the second place in terms of mortality figures [1]. By 2025, it is estimated that there will be 1.8 million new cases of CRC diagnosed in Asia [2]. Especially, the increase in the number of elderly patients with CRC is more noticeable. Thus, a comprehensive understanding of the clinical characteristics of CRC in elderly patients is increasingly crucial [3].
Aging can weaken the body’s anti-tumor defenses, rendering older adults more vulnerable to malignant disease [4]. At the same time, CRC in the elderly has its own characteristics. Compared with young patients, CRC in the elderly often presents with atypical symptoms, which brings certain difficulties to diagnosis and treatment [5, 6]. Due to the delayed diagnosis of elderly patients and their relatively weaker physical conditions, the postoperative prognosis of elderly patients with CRC is even worse. In comparison with young patients, elderly patients with CRC are prone to postoperative complications after undergoing surgery, and they are at a higher risk of perioperative death [7]. Furthermore, certain elderly patients with CRC might require a permanent stoma or undergo cognitive decline, which could result in the loss of their self-care ability and make them in need of long-term care. Consequently, this imposes a substantial economic and care burden on families as well as society [8]. Given the high prevalence of comorbidities such as cardiovascular disease and diabetes in this population, more rigorous perioperative management is essential [9]. There are still many controversies in the research on the long-term prognosis of elderly CRC patients. Some studies suggest that young patients have a higher incidence of advanced cancer and poorly differentiated cancer, and a lower survival rate [10–13]. However, recent large-scale studies have found that the OS of elderly patients with CRC is not worse than that of younger patients. These studies have drawn contradictory conclusions about the elderly CRC patients.
With the continuous growth of age, the body function of patients gradually declines, and the number of preoperative comorbidities gradually increases. There might be some alterations in prognosis of patients with CRC after surgery [14, 15]. Treatment strategies often vary by age, and selecting safe and effective surgical options for elderly patients remains a clinical challenge [16]. This study focused on elderly CRC patients over 60 years old, and divided them into the OE (60–79 years old) and the AE (≥ 80 years old) according to age. We tried to identify the differences between them, to provide certain guidance for the selection of treatment for advanced elderly CRC patients.
Methods
We investigated CRC patients who underwent surgery in Beijing Chaoyang Hospital from January 2018 to December 2023. One thousand eight hundred seventy-three CRC patients were included. All these patients received conventional treatment. Inclusion criteria: pathological results indicating colorectal adenocarcinoma, patients aged ≥ 60 years old, and patients who received curative-intent surgery. Exclusion criteria: patients with unresectable tumors who only underwent enterostomy, patients who received neoadjuvant chemoradiotherapy, and patients without complete postoperative follow-up records.
Data collection
Patients were stratified into two age-based cohorts: ordinary elderly group (OE) (60–79 years) and advanced elderly group (AE) (≥ 80 years). For patients enrolled in the study, we extracted their baseline clinical characteristics and surgery-related information from the electronic medical record system. Clinical characteristics included age, gender, preoperative comorbidities, American Society of Anesthesiologists (ASA) score, body mass index (BMI), tumor location, surgical approach (open vs. laparoscopic), emergency surgery, stoma creation, tumor differentiation, TNM stage, mismatch repair (MMR) status, postoperative hospital stay, and postoperative complications. The Charlson Comorbidity Index (CCI) was used to assess the preoperative comorbidity status of all patients enrolled in the study.
MMR status was determined by immunohistochemical assessment of MLH1, MSH2, MSH6, PMS2 expression in tumor tissue. If all proteins were normally expressed, it was defined as pMMR; if one or more proteins were not expressed, it was defined as dMMR (deficient mismatch repair).
Follow-up
A standardized surveillance program was used, asking patients to come to the outpatient clinic regularly for reexamination of tumor markers, abdominal CT, and electronic colonoscopy. Patients were followed up to determine whether postoperative adjuvant therapy was administered and the specific treatment regimen. Data were obtained from electronic outpatient records or structured telephone interviews. Patients who failed to complete postoperative follow-up at our institution or were lost to telephone follow-up were excluded via the complete case analysis approach.
Statistical analysis
Categorical variables were analyzed using the chi-square test, and continuous variables were analyzed using the t-test. To identify independent prognostic factors for 5-year DFS, we used COX regression analysis to determine the factors that might affect DFS. P < 0.05 was considered statistically significant. A post hoc power analysis was performed based on the actual enrolled sample size and effect sizes derived from prior studies. Results demonstrated that the statistical power for the primary outcome was 89.3%, confirming that the current sample size is adequately powered to ensure the reliability of the core findings.
This retrospective research was approved by the Medical Ethics Committee of Beijing Chaoyang Hospital. Agreed to give up informed consent (2025 −952). The process complies with the Helsinki Declaration. The study was presented in accordance with the STROBE reporting checklist.
Results
Patient characteristics
Ultimately, 971 patients met the inclusion and exclusion criteria. There were 800 patients in the OE and 171 in the AE (Fig. 1). We analyzed the clinical characteristics of these two groups (Table 1). It showed that the proportion of females was higher in the AE group (P < 0.01). The preoperative ASA score of the AE was higher (P = 0.016). Compared with the OE, cancer in right-sided colon was more common in the AE (P < 0.01); the AE had a markedly higher rate of preoperative intestinal obstruction (P < 0.01). Among the preoperative comorbidities, coronary heart disease (P < 0.01) and venous thromboembolism (P < 0.01) were more common in the AE; there was no significant difference in the CCI between the two groups. The preoperative forced expiratory volume in one second (FEV1) and cardiac ejection fraction of the patients were counted to evaluate their cardiopulmonary function. The results showed that with the increase of age, both the cardiac ejection fraction and FEV1 decreased to a certain extent, but the difference was not significant.
Fig. 1.
Study population and patient enrollment flowchart
Table 1.
Clinical characteristics of the patients
| Characteristic | ≥ 80 group (n = 171) | 60–79 group (n = 800) | P-value | |
|---|---|---|---|---|
| Sex | Male | 81 (47.4%) | 490 (61.2%) | 0.001 |
| Female | 90 (52.6%) | 310 (38.8%) | ||
| BMI | 22.13 ± 6.04 | 24.13 ± 3.74 | 0.508 | |
| Heart ejection fraction | 67.51 ± 5.34 | 67.58 ± 5.79 | 0.112 | |
| FEV1/FVC | 87.55 ± 11.71 | 89.23 ± 11.16 | 0.874 | |
| ASA score | 0-Ⅱ | 71 (41.5%) | 413 (51.6%) | 0.016 |
| Ⅲ-Ⅳ | 100 (58.5%) | 387 (48.4%) | ||
| Tumor location | Rectum | 59 (34.5%) | 370 (46.3%) | 0.000 |
| Left colon | 49 (28.7%) | 247 (30.9%) | ||
| Right colon | 63 (36.8%) | 183 (22.9%) | ||
| Ileus | 52 (30.4%) | 98 (12.3%) | 0.000 | |
| Co-morbidities | Hypertension | 93 (54.4%) | 372 (46.5%) | 0.064 |
| Diabetes mellitus | 38 (22.2%) | 183 (22.9%) | 0.920 | |
| Coronary heart disease | 48 (28.1%) | 147 (18.4%) | 0.006 | |
| Venous thromboembolism | 15 (8.8%) | 28 (3.5%) | 0.006 | |
| Atrial fibrillation | 10 (5.8%) | 24 (3.0%) | 0.104 | |
| CCI | 2.53 ± 0.76 | 2.62 ± 1.09 | 0.189 |
BMI, body mass index; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; ASA score, American Society of Anesthesiologists score; CCI, Charlson Comorbidity Index
Surgical outcomes
Compared with the OE, the proportion of emergency surgery was larger in the AE (P < 0.01). The proportion of laparoscopic surgery is lower in AE (P < 0.01). No significant differences in tumor-related characteristics such as TNM stage, neural invasion, vascular invasion, tumor differentiation, or pMMR. Hospital stay after surgery was prolonged in AE (P = 0.03) (Table 2). In the OE, 113 patients (14.13%) had postoperative complications, while in the AE, 26 patients (15.21%) had postoperative complications. A significant difference was noted in the Clavien-Dindo classification of postoperative complications between the two groups (P = 0.047). When analyzing common complications by category, no significant difference was found in postoperative wound infection, anastomotic leakage, postoperative intestinal obstruction, or other complications. Nevertheless, the perioperative mortality rate was significantly higher in the AE than in the OE (P = 0.041) (Table 3).
Table 2.
Oncological outcomes of the patients
| Characteristic | ≥ 80 group (n = 171) | 60–79 group (n = 800) | P-value | |
|---|---|---|---|---|
| TNM stage | Ⅰ | 21 (12.3%) | 144 (18.0%) | 0.113 |
| Ⅱ | 76 (44.4%) | 325 (40.6%) | ||
| Ⅲ | 62 (36.3%) | 277 (34.6%) | ||
| Ⅳ | 4 (2.3%) | 43 (5.4%) | ||
| Perineural invasion | Yes | 57 (33.3%) | 231 (28.9%) | 0.247 |
| No | 114 (66.7%) | 569 (71.1%) | ||
| Vascular invasion | Yes | 73 (42.7%) | 360 (45.0%) | 0.581 |
| No | 98 (57.3%) | 440 (55.0%) | ||
| Tumor differentiation | High | 17 (9.9%) | 79 (9.9%) | 0.890 |
| Moderate | 125 (73.1%) | 592 (74%) | ||
| Poor | 29 (17.0%) | 129 (16.1%) | ||
| Surgical approach | open surgery | 26 (15.2%) | 48 (6.0%) | 0.000 |
| laparoscopic surgery | 145 (84.8%) | 752 (94.0%) | ||
| Emergency operation | YES | 12 (7.0%) | 15 (1.9%) | 0.001 |
| NO | 159 (93.0%) | 785 (98.1%) | ||
| Enterostomy | Yes | 39 (22.8%) | 647 (80.9%) | 0.290 |
| No | 132 (77.2%) | 153 (19.1%) | ||
| MMR status | dMMR | 17 (9.9%) | 64 (8.0%) | 0.405 |
| pMMR | 154 (90.1%) | 736 (92.2%) | ||
| Complications | Yes | 17 (9.9%) | 99 (12.4%) | 0.436 |
| No | 157 (91.8%) | 701 (87.6%) | ||
| Postoperative hospitalization days | 13.36 ± 13.02 | 11.84 ± 7.01 | 0.032 | |
MMR, mismatch repair; dMMR, deficient mismatch repair; pMMR, proficient mismatch repair
Table 3.
Postoperative complications of the patients
| ≥ 80 group | 60–79 group | P-value | |
|---|---|---|---|
| Postoperative intestinal obstruction | 3 | 10 | 0.711 |
| Wound infection | 11 | 38 | 0.340 |
| Anastomotic leakage | 3 | 30 | 0.248 |
| Hemorrhage | 0 | 7 | 0.613 |
| Pulmonary infection | 1 | 4 | 1.000 |
| Intra-abdominal infection | 2 | 3 | 0.214 |
| Wound dehiscence | 0 | 2 | 1.000 |
| Myocardial infarction | 0 | 2 | 0.679 |
| Gastric retention | 1 | 2 | 0.441 |
| Urinary retention | 1 | 3 | 0.540 |
| Death | 3 | 2 | 0.041 |
| Cause of death | |||
| Pulmonary infection | 1 | 1 | |
| Intra-abdominal infection | 1 | ||
| Acute myocardial infarction | 1 | ||
| Acute intracerebral hemorrhage | 1 | ||
| Clavien-Dindo Ⅰ | 2 | 19 | 0.047 |
| Ⅱ | 10 | 55 | |
| Ⅲ | 2 | 22 | |
| Ⅳ | 0 | 1 | |
| Ⅴ | 3 | 2 |
Follow-up outcomes
The mean follow-up duration was 36.14 ± 22.12 months, including 36.49 ± 22.21 months in the OE and 34.47 ± 21.70 months in the AE. Upon comparison of the two groups, it was observed that the proportion of patients receiving adjuvant chemotherapy in the AE group was significantly lower. Furthermore, among those who underwent chemotherapy, the majority received only single-agent oral 5-Fu-based chemotherapy. In contrast, the proportion of patients receiving full-dose combined intravenous chemotherapy was significantly higher in the OE group (Table 4). There was no difference in the postoperative recurrence rate (18.75% vs 19.88%, P = 0.58). No significant difference was observed in recurrence-free survival between the two groups; nonetheless, the OS in the AE was significantly inferior to that in the OE (Fig. 2). The liver, local areas, and lungs are the three most frequently recurred sites (Table 5). We used COX regression analysis to identify factors that might affect DFS, and the results showed that TNM stage, nerve invasion, vascular invasion, preoperative intestinal obstruction, pMMR, and adjuvant therapy were independent risk factors for CRC recurrence (Table 6). Age, TNM stage, and preoperative ileus were identified as independent risk factors for OS in CRC patients (Table 7).
Table 4.
Postoperative adjuvant therapy
| ≥ 80 group (n = 171) | 60–79 group (n = 800) | P-value | |
|---|---|---|---|
| No adjuvant therapy | 112 | 286 | 0.000 |
| Single oral 5-FU chemotherapy | 35 | 118 | |
| Combined intravenous chemotherapy | 24 | 394 |
5-FU, 5-fluorouracil
Fig. 2.
Kaplan–Meier curves for disease-free survival (DFS) and overall survival (OS)
Table 5.
Pattern of recurrence
| ≥ 80 group (n = 171) | 60–79 group (n = 800) | P-value | |
|---|---|---|---|
| Overall recurrence | 34 | 150 | 0.747 |
| Primary recurrence site | |||
| Local recurrence | 5 | 29 | 0.820 |
| Liver | 9 | 35 | 0.550 |
| Lung | 3 | 31 | 0.250 |
| Lymphnode | 2 | 7 | 0.663 |
| Bone | 1 | 4 | 1.000 |
| Brain | 1 | 0 | 0.176 |
| Incision | 0 | 3 | 1.000 |
| Systemic recurrence | 13 | 41 | 0.200 |
Table 6.
Univariate and multivariate analysis of the DFS
| Variable | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| Hazard ratio (95% CI) | P-value | Hazard ratio (95% CI) | P-value | |
| Age | 0.766 (0.527–1.113) | 0.162 | ||
| Sex | 1.255 (0.926–1.701) | 0.143 | ||
| Tumor location | 1.117 (0.934–1.338) | 0.226 | ||
| Ileus | 1.977 (1.406–2.779) | 0.000 | 1.752 (1.240–2.475) | 0.001 |
| Hypertension | 0.771 (0.572–1.039) | 0.087 | 0.965 (0.718–1.303) | 0.827 |
| Diabetes mellitus | 0.756 (0.513–1.114) | 0.157 | ||
| Coronary heart disease | 0.825 (0.557–1.222) | 0.338 | ||
| Perineural invasion | 2.657 (1.980–3.567) | 0.000 | 1.460 (1.060–2.011) | 0.010 |
| Vascular invasion | 2.884 (2.115–3.932) | 0.000 | 1.795 (1.296–2.486) | 0.000 |
| Tumor differentiation | 1.387 (1.142–1.685) | 0.001 | 1.180 (0.945–1.473) | 0.143 |
| Surgical approach | 1.098 (0.657–1.836) | 0.721 | ||
| pMMR | 0.332 (0.147–0.750) | 0.008 | 0.463 (0.215–0.996) | 0.049 |
| Emergency operation | 1.374 (0.645–2.926) | 0.410 | ||
| Complications | 0.720 (0.437–1.188) | 0.198 | ||
| TNM | 2.414 (1.969–2.960) | 0.000 | 1.693(1.336–2.145) | 0.000 |
| ASA score | 1.291 (0.961–1.735) | 0.090 | 1.007 (0.750–1.351) | 0.965 |
| Adjuvant therapy | 2.437 (1.732–3.429) | 0.000 | 1.454 (1.013–2.087) | 0.042 |
ASA score, American Society of Anesthesiologists score; pMMR, proficient mismatch repair
Table 7.
Univariate and multivariate analysis of the OS
| Variable | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| Hazard ratio (95% CI) | P-value | Hazard ratio (95% CI) | P-value | |
| Age | 0.478 (0.275–0.829) | 0.009 | 0.513 (0.290–0.906) | 0.022 |
| Sex | 1.499 (0.882–2.549) | 0.135 | ||
| Tumor location | 1.177 (0.866–1.600) | 0.298 | ||
| Ileus | 2.838 (1.646–4.894) | 0.000 | 2.126 (1.201–3.761) | 0.001 |
| Hypertension | 0.793 (0.477–1.317) | 0.370 | 0.827 | |
| Diabetes mellitus | 1.233 (0.697–2.182) | 0.471 | ||
| Coronary heart disease | 0.997 (0.530–1.875) | 0.993 | ||
| Perineural invasion | 2.654 (1.604–4.393) | 0.000 | 1.353 (0.765–2.393) | 0.293 |
| Vascular invasion | 1.799 (1.085–2.983) | 0.023 | 1.051 (0.607–1.822) | 0.858 |
| Tumor differentiation | 1.255 (0.880–1.790) | 0.209 | ||
| Surgical approach | 0.941 (0.404–2.191) | 0.887 | ||
| pMMR | 0.515 (1.161–1.644) | 0.008 | 0.673 (0.209–2.167) | 0.507 |
| Emergency operation | 1.352 (0.417–4.380) | 0.615 | ||
| Complications | 0.672 (0.269–1.679) | 0.395 | ||
| TNM | 2.887 (2.021–4.124) | 0.000 | 2.662 (1.794–3.951) | 0.000 |
| ASA score | 1.121 (0.677–1.856) | 0.658 | ||
| Adjuvant therapy | 1.336 (0.787–2.267) | 0.283 | ||
ASA score, American Society of Anesthesiologists score; pMMR, proficient mismatch repair
Discussion
Over the past few decades, the continuous growth of the global population, coupled with the increasing life expectancy, has given rise to a significant demographic shift characterized by profound ageing. Given that the proportion of elderly people suffering from CRC is higher, it is projected that the number of older patients in need of surgical treatment will increase sharply.
As an important prognostic factor, age has been mentioned by many researchers [17–19]. Older age may mean a higher burden of comorbidities or worse physical function [20]. The surgical risk of these patients is significantly increased, and the surgical benefits are reduced. Our findings confirm that patients ≥ 80 years had worse preoperative comorbidity profiles and poorer cardiopulmonary function.
Previous studies have reported a rightward shift in tumor location with advancing age [21], which was also observed in our cohort. As patients keep getting older, the symptoms of CRC are gradually becoming atypical, and the advanced elderly cannot receive regular colonoscopy screening. Some elderly patients seek medical treatment only when they have obstruction symptoms, which may lead to a higher incidence of preoperative intestinal obstruction in the advanced elderly group. Consequently, a higher proportion of elderly patients underwent emergency surgery. In addition, the cardiopulmonary function of the elderly patients decreases, and their tolerance to carbon dioxide pneumoperitoneum is reduced, which increases the probability of open surgery to a certain extent.
Several studies have reported that the risk of postoperative complications increases with age [22–24]. Several studies have reported that elderly patients are more prone to developing systemic complications following surgery (including respiratory, cardiovascular, renal, and infectious complications) [25]. In our cohort, however, no significant difference was observed in postoperative complications between the OE and AE. Due to the compromised physical function and a higher burden of comorbidities requiring perioperative management in the very elderly population, postoperative hospital stays may be prolonged.
Five individuals passed away during the perioperative period. Notably, 3 out of them were aged over 80 years. This finding indicates a significantly higher perioperative mortality rate in the advanced elderly group. This difference is presumably attributed to the greater burden of preoperative comorbidities and higher ASA scores in the AE, highlighting the critical importance of precise postoperative monitoring for this population.
Additionally, the study revealed no significant difference in long-term oncological prognosis with increasing age. DFS did not appear to be associated with age. However, the present study exclusively included patients who met the eligibility criteria for surgical treatment. Among individuals aged ≥ 80 years, a subset of elderly patients with advanced disease or frailty declined surgical intervention on account of their advanced age, which may further introduce a certain extent of selection bias. In terms of the OS, the AE exhibited a significantly shorter survival time compared with the OE. This observation may be attributed to the fact that the life expectancy of individuals over 80 years old is lower than that of patients under 80 years old. Our study further revealed that the proportion of elderly patients aged ≥ 80 years undergoing chemotherapy was significantly lower, with the majority receiving oral chemotherapy alone. COX regression analysis did not demonstrate a significant association between chemotherapy and DFS, indicating that an appropriate dose reduction of chemotherapy may be warranted for elderly patients aged ≥ 80 years.
In general, advancing age per se is not regarded as an adverse prognostic factor for CRC, nor should it serve as a justification for withholding standard treatment [26–28]. The findings of our study demonstrated, despite the AE presenting with a higher burden of preoperative comorbidities, a greater incidence of preoperative intestinal obstruction, and prolonged postoperative hospital stays. In either postoperative complication rates or oncological prognosis between the AE and the OE, we observed no significant difference, which provided that adequate preoperative assessment and close postoperative monitoring were implemented [29].
Previous research has demonstrated that the implementation of Enhanced Recovery After Surgery (ERAS) guidelines in elderly patients aged 65 years and older is associated with improved 3-year survival outcomes, while also confirming the safety and efficacy of this perioperative management model [30]. Formulating individualized treatment regimens for elderly CRC patients remains a major clinical challenge, and the substantial heterogeneity within this population must be fully considered. It is therefore clinically unacceptable to determine a patient’s treatment plan solely based on advanced age.
Advancements in total neoadjuvant therapy (TNT) have been accompanied by accumulating evidence from multiple clinical trials, which consistently demonstrate that TNT confers substantial advantages in augmenting the probability of achieving pathological complete response (PCR) and improving DFS among patients with locally advanced rectal cancer (LARC) [31, 32]. In elderly patients deemed ineligible for surgical intervention due to poor tolerability, the administration of TNT may yield superior prognostic outcomes in this specific subset of CRC patients. Further investigations are imperative to delineate the efficacy and safety of TNT in the very elderly population.
A multitude of studies have been conducted with the aim of delving into the prognostic determinants among elderly CRC patients, but these studies usually define the elderly as those over 65 years old. However, studies on patients over 80 years old are also important. Due to the special situation of ultra-elderly patients, there are relatively few studies on the characteristics of in CRC patients over 80 years old.
First, the study cohort comprised exclusively of elderly patients who underwent surgical intervention, and these individuals were inherently in favorable physical condition at baseline. During the study period, a total of 42 CRC patients aged ≥ 80 years admitted to our institution did not undergo surgical intervention. All candidates underwent preoperative multidisciplinary team (MDT) evaluation. The majority were deemed unfit for radical resection due to poor cardiopulmonary function precluding surgical tolerance, while others had surgery declined by their families given the extremely high perioperative risk. Among these patients, 5 were discharged following sole placement of an intestinal stent. Notably, the CCI of this non-operated cohort was significantly higher than that of the operated group (3.60 vs. 2.53, P < 0.01). This discrepancy may introduce a certain degree of selection bias, thereby restricting the generalizability of our findings to the entire population of elderly individuals aged ≥ 80 years.
This study adopts retrospective design, which inherently relies on the accuracy and completeness of data records. However, data on patients’ functional independence and cognitive status were incompletely documented at our institution. Consequently, we were unable to analyze indicators such as frailty index, performance status (ECOG/WHO score), cognitive function, and activities of daily living (ADL)—all of which play a crucial role in patients’ postoperative outcomes. This may introduce unmeasured confounding bias. For instance, frailty could potentially mediate the association between advanced age and perioperative mortality, while nutritional risk might influence postoperative complication rates and treatment response. We plan to conduct prospective studies in the future, incorporating standardized geriatric assessment tools (e.g., Fried Frailty Phenotype, ECOG Performance Status, Mini-Nutritional Assessment) to characterize the elderly population and clarify the independent effects of these variables on oncologic prognosis more accurately.
In the present study, we found that the proportions of open surgery and emergency surgery were significantly higher in the advanced elderly group than in the general elderly group. Both adverse factors may increase short-term mortality, and the advanced elderly group also had a lower rate of chemotherapy administration, all of which may confound survival outcomes. Due to our inability to fully retrieve cause-specific mortality data for all patients, readers should avoid overinterpreting the OS differences between age groups. Non-cancer mortality, a common competing risk in the advanced elderly population, may be a key contributor to the shorter OS in the ≥ 80-year-old cohort, rather than inferior oncologic outcomes.
Notwithstanding this limitation, the study provides contemporary, real-world evidence from a high-volume academic center showing that, with careful patient selection and meticulous surgical care, no statistically significant difference in morbidity and DFS was identified between advanced elderly CRC patients and the younger elderly counterparts.
Author contributions
Jian-jun Chen: Conceptualization, Methodology, Data Curation, Writing Original Draft. Yong Yang and Zhu-lin Li: Data Curation, Formal Analysis, Investigation. Zhen-jun Wang: Supervision, Project Administration. All authors read and approved the final manuscript.
Funding
None.
Data availability
All data generated or analyzed during this study are included in this published article. Further information can be obtained from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Medical Ethics Committee of Beijing Chaoyang Hospital affiliated to Capital Medical University, and agreed to give up informed consent (2025 -323), carried out in accordance with the Helsinki Declaration.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I et al (2024) Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 74(3):229–263 [DOI] [PubMed] [Google Scholar]
- 2.Fu M, Li Y, Wang J (2025) Incidence and mortality of colorectal cancer in Asia in 2022 and projections for 2050. J Gastroenterol Hepatol 40(5):1143–1156 [DOI] [PubMed] [Google Scholar]
- 3.Luo S, Gong J, Zhu Y, Wang L, Zhang K (2025) Global, regional, and national burden of colorectal cancer in the elderly (aged > 60 years): a comprehensive analysis across 204 countries and territories (1990–2021). BMC Gastroenterol 25(1):570 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ye J, Baer JM, Faget DV, Morikis VA, Ren Q, Melam A et al (2024) Senescent CAFs mediate immunosuppression and drive breast cancer progression. Cancer Discov 14(7):1302–1323 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Niu C, Zhang J, Lian J, Utsav J, Iyer C, Low S et al (2023) Anatomical location, risk factors, and outcomes of lower gastrointestinal bleeding in colorectal cancer patients: a national inpatient sample analysis (2009–2019). Int J Colorectal Dis 38(1):205 [DOI] [PubMed] [Google Scholar]
- 6.Willemsen P, Devriendt S, Heyman S, Van Fraeyenhove F, Perkisas S (2023) Colorectal cancer surgery in octogenarians: real-world long-term results. Langenbecks Arch Surg 409(1):13 [DOI] [PubMed] [Google Scholar]
- 7.Mothes H, Bauschke A, Schuele S, Eigendorff E, Altendorf-Hofmann A, Settmacher U (2017) Surgery for colorectal cancer in elderly patients: how can we improve outcome? J Cancer Res Clin Oncol 143(9):1879–1889 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gibson DC, Raji MA, Holmes HM, Baillargeon JG, Kuo YF (2022) Risk of an opioid-related emergency department visit or hospitalization among older breast, colorectal, lung, and prostate cancer survivors. Mayo Clin Proc 97(3):560–570 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Itatani Y, Kawada K, Sakai Y (2018) Treatment of elderly patients with colorectal cancer. Biomed Res Int 2018:2176056 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Okamoto K, Sasaki K, Nozawa H, Murono K, Emoto S, Yamauchi S et al (2024) Poor prognosis of young male patients with stage III colorectal cancer: a multicenter retrospective study. J Surg Oncol 129(4):785–792 [DOI] [PubMed] [Google Scholar]
- 11.Mueller M, Schneider MA, Deplazes B, Cabalzar-Wondberg D, Rickenbacher A, Turina M (2021) Colorectal cancer of the young displays distinct features of aggressive tumor biology: a single-center cohort study. World J Gastrointest Surg 13(2):164–175 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Shen D, Wang P, Xie Y, Zhuang Z, Zhu M, Wang X et al (2023) Clinical spectrum of rectal cancer identifies hallmarks of early-onset patients and next-generation treatment strategies. Cancer Med 12(3):3433–3441 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Khan A, Ituarte PHG, Raoof M, Melstrom L, Li H, Yuan YC et al (2021) Disparate and alarming impact of gastrointestinal cancers in young adult patients. Ann Surg Oncol 28(2):785–796 [DOI] [PubMed] [Google Scholar]
- 14.Ueda Y, Shiraishi N, Kawasaki T, Akagi T, Ninomiya S, Shiroshita H et al (2020) Short- and long-term outcomes of laparoscopic surgery for colorectal cancer in the elderly aged over 80 years old versus non-elderly: a retrospective cohort study. BMC Geriatr 20(1):445 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Shalata W, Gluzman A, Man S, Cohen AY, Abu Jama A, Gothelf I et al (2024) Colorectal cancer in elderly patients: insights into presentations, prognosis, and patient outcomes. Medicina. 10.3390/medicina60121951 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Yamamoto S, Hinoi T, Niitsu H, Okajima M, Ide Y, Murata K et al (2017) Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan. J Gastroenterol 52(6):695–704 [DOI] [PubMed] [Google Scholar]
- 17.Ruan GT, Zhang Q, Zhang X, Tang M, Song MM, Zhang XW et al (2021) Geriatric nutrition risk index: prognostic factor related to inflammation in elderly patients with cancer cachexia. J Cachexia Sarcopenia Muscle 12(6):1969–1982 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Toquero P, Mondejar R, Romero-Laorden N, Mendez E, Castillo L, Hernandez Marin B et al (2024) Is older age an independent prognostic factor of survival in metastatic colorectal cancer? Oncology 102(9):747–758 [DOI] [PubMed] [Google Scholar]
- 19.Zhang L, Li Q, Hu C, Zhang Z, She J, Shi F (2023) Real-world analysis of survival benefit of surgery and adjuvant therapy in elderly patients with colorectal cancer. Sci Rep 13(1):14866 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Drews G, Bohnsteen B, Knolle J, Gradhand E, Wurl P (2022) Laparoscopic surgery for colorectal cancer in an elderly population with high comorbidity: a single centre experience. Int J Colorectal Dis 37(9):1963–1973 [DOI] [PubMed] [Google Scholar]
- 21.de Reif Paula T, Simon HL, da Profeta Luz MM, Keller DS (2021) Right sided colorectal cancer increases with age and screening should be tailored to reflect this: a national cancer database study. Tech Coloproctol 25(1):81–89 [DOI] [PubMed] [Google Scholar]
- 22.Prabhakaran S, Kong JC, Williams E, Bell S, Warrier S, Simpson P et al (2022) Comparison of colorectal cancer outcomes in young adults and octogenarians. Am J Surg 223(5):951–956 [DOI] [PubMed] [Google Scholar]
- 23.Shiraishi T, Ogawa H, Ozawa N, Suga K, Komine C, Shibasaki Y et al (2022) Risk and protective factors for postoperative complications in elderly patients with colorectal cancer. Anticancer Res 42(2):1123–1130 [DOI] [PubMed] [Google Scholar]
- 24.Shi JX, Cui J, Li ZJ, Ma FH, Gao LL, Cao XL et al (2022) Contrastive analysis about the postoperative clinical characteristics of elderly patients with colorectal cancer in different age groups. Zhonghua Yi Xue Za Zhi 102(8):563–568 [DOI] [PubMed] [Google Scholar]
- 25.Grosso G, Biondi A, Marventano S, Mistretta A, Calabrese G, Basile F (2012) Major postoperative complications and survival for colon cancer elderly patients. BMC Surg 12(1):S20 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Hashida H, Mizuno R, Iwaki K, Kanbe H, Sumi T, Kawarabayashi T et al (2020) Laparoscopic surgery for colorectal cancer in super-elderly patients: a single-center analysis. Surg Laparosc Endosc Percutan Tech 31(3):337–341 [DOI] [PubMed] [Google Scholar]
- 27.Liu JY, Perez SD, Balch GG, Sullivan PS, Srinivasan JK, Staley CA et al (2021) Elderly patients benefit from enhanced recovery protocols after colorectal surgery. J Surg Res 266:54–61 [DOI] [PubMed] [Google Scholar]
- 28.Hanaoka M, Hino H, Shiomi A, Kagawa H, Manabe S, Yamaoka Y et al (2022) The Eastern Cooperative Oncology Group Performance Status as a prognostic factor of stage I-III colorectal cancer surgery for elderly patients: a multi-institutional retrospective analysis. Surg Today 52(7):1081–1089 [DOI] [PubMed] [Google Scholar]
- 29.Konstantinou I, Shapey IM, Papamichael D, de Liguori Carino N (2021) Outcomes following potentially curative therapies for older patients with metastatic colorectal cancer. Eur J Surg Oncol 47(3 Pt A):591–596 [DOI] [PubMed] [Google Scholar]
- 30.Tidadini F, Trilling B, Quesada JL, Foote A, Sage PY, Bonne A et al (2023) Association between Enhanced Recovery After Surgery (ERAS) protocol, risk factors and 3-year survival after colorectal surgery for cancer in the elderly. Aging Clin Exp Res 35(1):167–175 [DOI] [PubMed] [Google Scholar]
- 31.Xia F, Wang Y, Wang H, Shen L, Xiang Z, Zhao Y et al (2024) Randomized phase II trial of immunotherapy-based total neoadjuvant therapy for proficient mismatch repair or microsatellite stable locally advanced rectal cancer (TORCH). J Clin Oncol 42(28):3308–3318 [DOI] [PubMed] [Google Scholar]
- 32.Thompson HM, Omer DM, Lin S, Kim JK, Yuval JB, Verheij FS et al (2024) Organ preservation and survival by clinical response grade in patients with rectal cancer treated with total neoadjuvant therapy: a secondary analysis of the OPRA randomized clinical trial. JAMA Netw Open 7(1):e2350903 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in this published article. Further information can be obtained from the corresponding author on reasonable request.