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We live in an ageing population. Life expectancy has doubled over the last century; the number of people aged >65 years has doubled and the number over 85 years has quadrupled.1 By 2050, those over 65 years of age will account for 20% of the population in the developed world.2 This epidemiological explosion places a tremendous burden on health resources and provides unique challenges in the area of geriatric oncology. Senescence generates numerous physiological and biological changes that can impact on treatment selection. Patients are presenting who would never have previously been considered for cancer treatment. Are we able to holistically assess them? Can we accurately predict perioperative risk and overall survival (OS) for the different treatment options using assessment tools designed for a younger population? Is their consent supported and informed as it is with their younger counterparts? Do we have a clear understanding of their psycho-oncological and social needs? Is their overall management truly multidisciplinary? In this chapter, we consider the general issues surrounding cancer surgery in older patients and include specific comments on the four commonest cancers: breast, lung, prostate and colorectal.

Modern oncological treatment planning is based on evidence. Unfortunately, there are no national standards of care or evidence-based guidelines for older cancer patients because in this age group they have often been excluded from trials. Following publication of trial results, there has been limited independent validation of cancer treatments for older patients. Older patients are underrepresented in clinical trials3 and we regularly offer treatment options as the gold standard based on clinical trials undertaken in younger population groups. This includes the use of breast-conserving surgery and radiotherapy instead of mastectomy, based on the results of the Milan trials, which did not recruit any individuals over the age of 70 years. Even some recent trials targeted at this patient group (Endocrine +/− Surgical Therapy for Elderly Women with Mammary Cancer [ESTEeM]4 and Adjuvant Cytotoxic Chemotherapy in Older Women [ACTION]5) have closed early due to recruitment problems. Methodologically sound investigations do not readily transpose to the geriatric oncology setting, as illustrated in the area of total mesorectal excision for rectal cancer, which has significantly reduced loco-regional recurrence and survival in younger patients but may not do so in older patients.6 As care providers, we must be cognizant of the limited validity of evidence-based practice in the setting of cancer in the older cancer population.

Surgery remains the most effective cancer ablative therapy. The increase in length of stay, requirements for critical care organ support, complication rates and mortality can preclude oncological benefit. Differences in patient management may be related to the lack of clinical evidence to determine treatment efficacy in older women; patient preferences; surgical preferences; anaesthetic assessment; the influence of family, friends and carers; comorbidities and frailty that contraindicate treatment options; and, unfortunately, innate ageism. Undertreatment may be related to a perceived lack of tolerance ...

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