Undertreatment of breast cancer in the elderly

AIMS: The effect of undertreatment with adjuvant hormonal therapy, chemotherapy or radiation was studied in elderly women with breast cancer. METHODS: A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1997 and 2011. The presentation, pathologic findings, treatment and outcomes of 449 women over 65 were compared to the findings in 1049 younger patients. Moreover, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared. RESULTS: Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were signicantly more favorable than cancers in younger patients with more infiltrating lobular, fewer ductal carcinoma in situ and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary surgery, less adjuvant radiation therapy and more hormonal therapy. Fourty-six percent of the 449 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during follow-up without disease recurrence. CONCLUSIONS: Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated

Breast cancer surgery in elderly patients: postoperative complications and survival

AIMS AND BACKGROUND: Old age is associated with comorbidity and decreased functioning which influences treatment decisions in elderly breast cancer patients. The purpose of this study was to identify risk factors for complications after breast cancer surgery in elderly patients, and to assess mortality in patients with postoperative complications. METHODS: We retrospectively considered all female patients aged 65 years and older with invasive and in situ breast cancer who were diagnosed and treated between 1997 and 2012 in the Department of General and Geriatric Surgery of the University of Naples "Federico II". RESULTS AND CONCLUSION: 449 patients received surgery, of whom 18,2% (n = 82) developed one or more postoperative complications. The odds ratio of having postoperative complications show an increase with age, reaching statistical significance only for patients older than 85 [OR 5,75 (95% confidence interval 2,38-14,04); p < 0,001]. Number of concomitant diseases [OR 2,51 (95% CI 1,17 - 5,45); p = 0,01 for 3 or more concomitant diseases] and polypharmacy [OR 16,7 (95% CI 9,12 - 30,58); p < 0,0001) are associated to an increased risk of postoperative complications. Overall survival was worse in patients with postoperative complications [HR 2,06 (95% CI 1,52-2,70), p < 0,001]. This increased risk of mortality is probably due to geriatric parameters such as comorbidity or poor physical function, more than to higher complication rates

Emergency groin hernia repair: implications in elderly

BACKGROUND: Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients. METHODS: We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications. RESULTS: A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died. CONCLUSIONS: Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations

Outcomes after non-cardiac surgery: Mortality, complications, disability, and rehospitalization

In the last 25 years, the number of patients aged ≥75 years undergoing non-cardiac surgery has greatly increased. In elderly patients, frailty is significantly associated with an increased risk of adverse events, functional decline, procedural complications, prolonged hospitalization, and mortality. The relationship between frailty and increased mortality and morbidity requires an appropriate tool of assessment to accurately quantify the patient's clinical and perioperative conditions. The preoperative evaluation of elderly patients candidate for non-cardiac surgery should include assessment of frailty, sarcopenia and malnutrition, as these are related to high surgical risk. For colon-rectal surgery as also for gastric cancer surgery, especially early gastric cancer, the introduction of laparoscopy has yielded considerable benefits in terms of short-term postsurgical outcomes, e.g. lower rate of intraprocedural bleeding and reduced length of hospital stay. Despite the progress made in preoperative assessment, surgical procedures and postoperative management, the improvement of outcomes after non-cardiac surgery in elderly patients remains a challenge and calls for future, well-designed clinical studies.</p

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

BACKGROUND: Inguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia. METHODS: The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia. RESULTS: Evaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics. CONCLUSIONS: Clinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling

Day-surgery inguinal hernia repair in the elderly: single centre experience

BACKGROUND: Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients. METHODS: A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups. RESULTS: Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients. CONCLUSIONS: Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery

Breast conserving treatment for ductal carcinoma in situ in the elderly: Can radiation therapy be avoided? Our experience

AbstractIntroduction: Ductal Carcinoma In Situ (DCIS) is a heterogeneous, pre-malignant disease accounting for 15–20% of all new breast cancers. If appropriately managed, DCIS has a small chance of impacting on patient life expectancy. Despite the possibility of a further recurrence or of a development in an invasive form, we are unable to select treatment of choice especially in the elderly. In particularly we risk an overtreatment of women at low risk of progression to invasive breast cancer. The aim of this study was to retrospectively evaluate the outcome of elderly patients affected by DCIS not undergoing Radiation Therapy (RT) after Breast Conserving Surgery (BCS). Material and methods: We reviewed our prospectively-maintained database from 1998 to 2013, selecting all women over 65 years old diagnosed with DCIS who did not receive RT for personal choice. We considered two groups, according to the risk of local recurrence (Low Risk (Group 1) vs. High Risk (Group 2)). Results: We identified 44 cases of DCIS treated with surgery alone or with surgery followed by adjuvant tamoxifen. 24 patients presented low risk of local recurrence (Group 1) and 20 had characteristics associated to high risk of local recurrence (Group 2). At a median follow-up of 66.3 months, no local recurrences have been described in group 1. No patients presented distant metastases, while 4 patients died for other causes. At a median follow-up of 72 months we observed 5 local recurrences in the second group (p < 0.05). Conclusion: Our results suggest that radiation therapy can be safely avoided in a selected group of elderly patients affected by DCIS

evolution of surgical techniques for a progressive risk reduction

Advanced age is a strong predictor of high perioperative mortality in surgical patients and patients aged 75 years and older have an elevated surgical risk, much higher than that of younger patients. Progressive advances in surgical techniques now make it possible to treat high-risk surgical patients with minimally invasive procedures. Endovascular techniques have revolutionized the treatment of several vascular diseases, in particular carotid stenosis, aortic pathologies, and severely incapacitating intermittent claudication or critical limb ischemia. The main advantages of the endovascular approach are the low complication rate, high rate of technical success and a good clinical outcome. Biliary stenting has improved the clinical status of severely ill patients with bile duct stricture before major surgery, and represents a good palliative therapy in the case of malignant biliary obstruction