Our results show that resectional surgery can be performed at acceptable risk in elderly patients with cancer. It is unknown whether these results can be generalised to other regions, time periods or health care systems. Population-based studies tend to report higher operative mortality rates than studies from single institutions. Selection criteria are presumably different from those in trial series and publication bias hampers honest comparison. Even between population-based studies, selection criteria and definitions may differ. For example, a study from the US [3
] analysed operative mortality in patients aged 85 years and older and reported on gastrectomy (16%), colectomy (7%) and nephrectomy (5%), but only included elective operations. After emergency surgery, postoperative death may not be attributable to the resection itself because some patients would also have died after alternative treatment. A second difference is that the US study reported on in-hospital mortality, which produces higher rates than the 30-day definition.
Age-specific reference figures are essential for clinical decision-making but calendar age serves as a poor substitute for biological age, which in itself is difficult to define or determine [4
]. Preoperative assessment of the operative risk in geriatric patients is considered very important but current scoring methods provide little assistance [5
]. As a consequence, treatment decisions in the elderly cannot be based on general guidelines but will rather require tailored plans that need to be discussed with the patient and his or her family. In some cases, surgery may need to be postponed for the treatment of concomitant disease.
Apart from operative mortality, the remaining quality of life and the life expectancy should be taken into consideration. Non-fatal complications and lengthy hospital stays should not be taken too lightly and may severely impair daily living. The median life expectancy for men and women aged 90 years, is 3.3 and 4.1 years, respectively. The actual life expectancy, however, is difficult to predict and little is known about the course of cancer after suboptimal treatment. Especially in the elderly, preoperative assessment of the extent of disease is crucial to avoid senseless palliative surgery.
For breast cancer, studies have shown that primary hormonal treatment is inferior to direct surgery [6
], which is understandable given the low operative risk. For endometrial cancer, the operative risk is less than 2% and alternative treatments should be reserved for patients with severe comorbidity. For kidney cancer, nephrectomy should be considered when urinary function is acceptable, but cancer progression may be slow and a wait-and-see policy is a serious option in patients with smaller lesions. For abdominal surgery, the operative risk is substantial but this risk may still be worthwhile given the absence of other curative options. Whether an operative risk of 44% in nonagenarians with stomach cancer is ethically acceptable, is up to discussion. However, when faced with a guarantee of progressive cancer and no alternatives for cure, patients are willing to accept extremely high-risks [7
] that may even seem unacceptable to their physician. For abdominal tumours, emergency presentation is more common in the elderly and obstruction may lead to a quick death in case of non-surgical treatment. Laparoscopic interventions may, however, avert major surgery.