**7. Delayed discharge home after surgery for colorectal cancer**

Delays in the discharge of older patients from the acute hospital may be attributed to various factors. A study from our institution by Pizzuto et al. noted 'the reasons for delayed discharge of patients were due to social care issues, in particular, due to delays in transfer home because of the lack of a package of care or to a community hospital due to a lack of beds' [71], even when the postoperative recovery

of the older patient was uneventful. Pizzuto et al. and others advocate the early involvement of the local geriatric services in order to minimize avoidable acute hospital stays, a situation referred to as 'bed blocking.' Care of the elderly physicians may help by optimizing the medical management and addressing the psychosocial needs of these patients. Well-organized and coordinated hospital and community geriatric services, are therefore necessary to help improve outcomes such as survival and ensure that the older cancer patients recovering from cancer surgery reside in their own homes [72, 73].

Despite the aforementioned risks, some older patients do very well after curative surgery for colorectal cancer, but unfortunately, others will not [74, 75]. It is quite clear from the literature that the risks and benefits of surgery for CRC in the elderly have not been clearly reviewed [74]. There is, therefore, still no agreement on how actively the older patients should be treated and when not to offer them surgery, which could lead to physical disability and a worse quality of life. Over 74% of patients interviewed in a study by Ahmed et al. stated that they would refuse, or be reluctant, to receive treatment leading to severe functional impairment [75]. Therefore, the discussions with older patients and their significant others regarding treatment options should be made with careful consideration of life expectancy, morbidity and mortality, quality of life (physical, social, and psychological aspects), as well as the possibility of never returning home and needing permanent residential care.

#### **8. Rectal cancer surgery in the older patients**

The treatment of older patients with rectal cancer differs from that of colonic cancer, so it deserves a special mention. Surgery for rectal cancer takes longer to carry out than surgery for colonic cancer of a similar stage, thus increasing the risk of systemic complications. The risk of local complications after curative restorative surgery for rectal cancer, such as anastomotic leak, and pelvic abscess, is also higher than for colonic surgery. Therefore, in general, a more conservative approach in the treatment of rectal cancer in the older patient is preferred to more radical treatment in order to avoid high rates of postoperative morbidity [76].

The aim of rectal cancer surgery in older patients should be a reduction in local recurrence, as well as improvement in quality of life. Rather than age itself, the frailty of patients and preoperative sphincter function should determine the type of surgery for rectal cancer [77, 78]. Some older patients are keen to avoid a permanent stoma and may accept a higher risk of local recurrence to achieve this. However, sphincter preservation in older patients could result in poor functional results, especially in those with preexisting rectal and sphincter dysfunction. Studies have shown that older patients with the 'anterior resection syndrome' have a very poor quality of life. Patients with a risk of developing these functional bowel problems, following restorative rectal resection, should therefore be identified preoperatively and counseled appropriately on the construction of a stoma [79]. Although stomas are not without their problems, such as herniation and prolapse, a properly constructed stoma can lead to functional independence and enhanced quality of life.

Bhangu et al. [80] analyzed the results of local resection of rectal cancer in older patients, using techniques such as transanal resection of tumor (TART), transanal endoscopic microsurgery (TEMS), and transanal minimally invasive surgery (TAMIS). They showed that, in patients with pT1 tumors, local excision achieved the same results as radical surgery. However, in patients having local resection of pT2 cancers, the survival is less compared to radical surgery in the general population. The difference with the general population is most likely due to the prevalence

#### *Surgery for Colorectal Cancer in Older People DOI: http://dx.doi.org/10.5772/intechopen.111510*

of comorbidities in the older patient group, with the older patients not being fit for radical surgery or chemoradiotherapy. Transanal endoscopic surgery can, therefore, be considered as suitable palliative treatment option in such patients.

Chemoradiotherapy (CRT) or radiotherapy (RT) alone may be used instead of, or as an adjunct to, surgery for rectal cancer. Studies have shown that older patients with rectal cancer are treated less often with RT [81–83]. Fewer older patients are likely to receive preoperative RT with proportionately more receiving palliative RT instead [84]. Older patients with stage II or III rectal cancer who are fit enough for surgery are generally fit enough for preoperative neoadjuvant RT. Although the tolerability and response rates are similar to those seen in younger patients, Stockholm I and II trial results have shown the distinct side effects of neoadjuvant radiotherapy in older patients. Such side effects, which include deep vein thrombosis, femoral neck and pelvic ring fractures, small bowel obstruction, and fistulas, were significantly more prevalent after preoperative radiotherapy in the older age group [77, 81].

A number of patients who undergo neoadjuvant CRT have a complete pathological response. A complete pathological response means that there is no detectable residual rectal cancer on sigmoidoscopy or MRI. A strategy known as 'watch and wait' was proposed and pioneered by Habr-Gama et al. for these patients in order to spare them unnecessary resection [85]. They published a series of 'watch and wait' in 70 patients with tumor stages of pT2- and pN1-2 who were treated with CRT. Forty-seven patients had a complete clinical response, with 8 (17%) developing an early recurrence and four had a late recurrence. All had subsequent radical R0 surgery and were disease-free 56 months later. This could be an option for patients who are not considered fit for surgery. It does not have to be considered as a palliative treatment as such, but a possible standard treatment with a 50% probability of cure in frail elderly patients [80].

A study by Smith et al. [86] showed that older patients, because of their higher surgical risk, obtained the greatest benefit from the 'watch and wait' policy with an improved survival at 1 year after treatment. More recently, the results of a joint study between Glasgow University and Memorial Sloan Kettering in New York [87] concluded 'a watch and wait strategy for select rectal cancer patients who had a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation and pelvic tumor control; however, in the watch and wait group, worse survival was noted along with a higher incidence of distant progression in patients with local regrowth vs those without local regrowth.'

The groups of patients that present a significant regression of their rectal cancer with neoadjuvant CRT, and especially those with lymph node regression (ypN0), could be candidates for alternative treatments without needing radical surgery. Transanal endoscopic surgical techniques could be used in these patients [80]. Local excision following CRT is associated with a 15% risk of recurrence. In older patient with comorbidities, such a risk may be an acceptable alternative to radical surgery [87–91].
