Comorbidity in older surgical cancer patients: Influence on patient care and outcome

Published:August 03, 2007DOI:


      Evidence is scarce about the influence of comorbidity on outcome of surgery, whereas this information is highly relevant for estimating the surgical risk of cancer patients, and for optimising pre-, peri- and postoperative care. In this paper, the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I–III colorectal, stage I–II NSCLC or stage I–III breast cancer between 1995 and 2004 in the southern part of the Netherlands is summarised.
      Almost all patients with stage I–III colon cancer or rectal cancer underwent surgery regardless of age or comorbidity. In contrast, the resection rate among elderly patients with stage I–II NSCLC was clearly lower than among younger patients and was significantly lower when COPD, cardiovascular diseases or diabetes were present. Among patients with stage I–III breast cancer, those aged 80 or older underwent less surgery, and the resection rate appeared to be lower when cardiovascular diseases or diabetes were present.
      Among patients with resected colorectal cancer, postoperative morbidity and mortality were higher among those undergoing emergency surgery, and also among those with reduced pulmonary function, cardiovascular disease or neurological comorbidity. Among those with resected NSCLC, postoperative morbidity and mortality were related to reduced pulmonary function or cardiovascular disease. Since surgery for breast cancer is low risk, elective surgery, morbidity and mortality were not higher for elderly or those with comorbidity.
      Among patients with colorectal or breast cancer, comorbidity in general, cardiovascular diseases, COPD, diabetes (only colon and breast cancer) and venous thromboembolism had a negative effect on overall survival, whereas the effect of comorbidity on survival of stage I–II NSCLC was less clear.
      Elderly and those with comorbidity (especially cardiovascular diseases and COPD) among colorectal cancer and NSCLC patients had more postoperative morbidity and mortality. Prospective randomised studies are needed for refining selection criteria for surgery in elderly cancer patients and for anticipation and prevention of complications.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Janssen-Heijnen M.L.
        • Houterman S.
        • Lemmens V.E.
        • Louwman M.W.
        • Maas H.A.
        • Coebergh J.W.
        Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach.
        Crit Rev Oncol Hematol. 2005; 55: 231-240
        • Yancik R.
        • Wesley M.N.
        • Ries L.A.
        • Havlik R.J.
        • Edwards B.K.
        • Yates J.W.
        Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older.
        JAMA. 2001; 285: 885-892
        • Extermann M.
        • Overcash J.
        • Lyman G.H.
        • Parr J.
        • Balducci L.
        Comorbidity and functional status are independent in older cancer patients.
        J Clin Oncol. 1998; 16: 1582-1587
        • Repetto L.
        • Fratino L.
        • Audisio R.A.
        • et al.
        Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study.
        J Clin Oncol. 2002; 20: 494-502
        • Lopez-Encuentra A.
        • Pozo-Rodriguez F.
        • Martin-Escribano P.
        • et al.
        Surgical lung cancer. Risk operative analysis.
        Lung Cancer. 2004; 44: 327-337
        • Licker M.J.
        • Widikker I.
        • Robert J.
        • et al.
        Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends.
        Ann Thorac Surg. 2006; 81: 1830-1837
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Kieszak S.M.
        • Flanders W.D.
        • Kosinski A.S.
        • Shipp C.C.
        • Karp H.
        A comparison of the Charlson comorbidity index derived from medical record data and administrative billing data.
        J Clin Epidemiol. 1999; 52: 137-142
        • Lemmens V.E.
        • van Halteren A.H.
        • Janssen-Heijnen M.L.
        • Vreugdenhil G.
        • Repelaer van Driel O.J.
        • Coebergh J.W.
        Adjuvant treatment for elderly patients with stage III colon cancer in the southern Netherlands is affected by socioeconomic status, gender, and comorbidity.
        Ann Oncol. 2005; 16: 767-772
        • Lemmens V.E.
        • Janssen-Heijnen M.L.
        • Verheij C.D.
        • Houterman S.
        • Repelaer van Driel O.J.
        • Coebergh J.W.
        Comorbidity leads to altered treatment and worse survival of elderly colorectal cancer patients: a population-based study.
        Br J Surg. 2005; 92: 615-623
        • Pasetto L.M.
        • Pucciarelli S.
        • Agostini M.
        • Rossi E.
        • Monfardini S.
        Neoadjuvant treatment for locally advanced rectal carcinoma.
        Crit Rev Oncol Hematol. 2004; 52: 61-71
        • Schrag D.
        • Cramer L.D.
        • Bach P.B.
        • Begg C.B.
        Age and adjuvant chemotherapy use after surgery for stage III colon cancer.
        J Natl Cancer Inst. 2001; 93: 850-857
        • Molino A.
        • Giovannini M.
        • Auriemma A.
        • et al.
        Pathological, biological and clinical characteristics, and surgical management, of elderly women with breast cancer.
        Crit Rev Oncol Hematol. 2006; 59: 226-233
        • Bouchardy C.
        • Rapiti E.
        • Fioretta G.
        • et al.
        Undertreatment strongly decreases prognosis of breast cancer in elderly women.
        J Clin Oncol. 2003; 21: 3580-3587
        • Louwman W.J.
        • Janssen-Heijnen M.L.
        • Houterman S.
        • et al.
        Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study.
        Eur J Cancer. 2005; 41: 779-785
        • Gajdos C.
        • Tartter P.I.
        • Bleiweiss I.J.
        • Lopchinsky R.A.
        • Bernstein J.L.
        The consequence of undertreating breast cancer in the elderly.
        J Am Coll Surg. 2001; 192: 698-707
        • Hurria A.
        • Leung D.
        • Trainor K.
        • Borgen P.
        • Norton L.
        • Hudis C.
        Factors influencing treatment patterns of breast cancer patients age 75 and older.
        Crit Rev Oncol Hematol. 2003; 46: 121-126
        • Bergman L.
        • Dekker G.
        • van Kerkhoff E.H.
        • Peterse H.L.
        • van Dongen J.A.
        • van Leeuwen F.E.
        Influence of age and comorbidity on treatment choice and survival in elderly patients with breast cancer.
        Breast Cancer Res Treat. 1991; 18: 189-198
        • Bergman L.
        • Kluck H.M.
        • van Leeuwen F.E.
        • et al.
        The influence of age on treatment choice and survival of elderly breast cancer patients in south-eastern Netherlands: a population-based study.
        Eur J Cancer. 1992; 28A: 1475-1480
        • Vulto A.J.
        • Lemmens V.E.
        • Louwman M.W.
        • et al.
        The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995–2002.
        Cancer. 2006; 106: 2734-2742
        • Smith B.D.
        • Haffty B.G.
        • Hurria A.
        • Galusha D.H.
        • Gross C.P.
        Postmastectomy radiation and survival in older women with breast cancer.
        J Clin Oncol. 2006; 24: 4901-4907
        • Peake M.D.
        • Thompson S.
        • Lowe D.
        • Pearson M.G.
        Ageism in the management of lung cancer.
        Age Ageing. 2003; 32: 171-177
        • Dexter E.U.
        • Jahangir N.
        • Kohman L.J.
        Resection for lung cancer in the elderly patient.
        Thorac Surg Clin. 2004; 14: 163-171
        • Janssen-Heijnen M.L.
        • Smulders S.
        • Lemmens V.E.
        • Smeenk F.W.
        • van Geffen H.J.
        • Coebergh J.W.
        Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancer.
        Thorax. 2004; 59: 602-607
        • Sawada S.
        • Komori E.
        • Nogami N.
        • et al.
        Advanced age is not correlated with either short-term or long-term postoperative results in lung cancer patients in good clinical condition.
        Chest. 2005; 128: 1557-1563
        • de Rijke J.M.
        • Schouten L.J.
        • ten Velde G.P.
        • et al.
        Influence of age, comorbidity and performance status on the choice of treatment for patients with non-small cell lung cancer; results of a population-based study.
        Lung Cancer. 2004; 46: 233-245
        • Dy S.M.
        • Sharkey P.
        • Herbert R.
        • Haddad K.
        • Wu A.W.
        Comorbid illnesses and health care utilization among Medicare beneficiaries with lung cancer.
        Crit Rev Oncol Hematol. 2006; 59: 218-225
        • Finlayson E.V.
        • Birkmeyer J.D.
        Operative mortality with elective surgery in older adults.
        Eff Clin Pract. 2001; 4: 172-177
        • Damhuis R.A.
        • Schutte P.R.
        Resection rates and postoperative mortality in 7899 patients with lung cancer.
        Eur Respir J. 1996; 9: 7-10
        • Damhuis R.
        • Coonar A.
        • Plaisier P.
        • et al.
        A case-mix model for monitoring of postoperative mortality after surgery for lung cancer.
        Lung Cancer. 2006; 51: 123-129
        • Bolliger C.T.
        • Jordan P.
        • Soler M.
        • et al.
        Exercise capacity as a predictor of postoperative complications in lung resection candidates.
        Am J Respir Crit Care Med. 1995; 151: 1472-1480
        • Rostad H.
        • Naalsund A.
        • Strand T.E.
        • Jacobsen R.
        • Talleraas O.
        • Norstein J.
        Results of pulmonary resection for lung cancer in Norway, patients older than 70 years.
        Eur J Cardiothorac Surg. 2005; 27: 325-328
        • Samain E.
        • Schauvliege F.
        • Deval B.
        • Marty J.
        Anesthesia for breast cancer surgery in the elderly.
        Crit Rev Oncol Hematol. 2003; 46: 115-120
        • Houterman S.
        • Janssen-Heijnen M.L.
        • Verheij C.D.
        • et al.
        Comorbidity has negligible impact on treatment and complications but influences survival in breast cancer patients.
        Br J Cancer. 2004; 90: 2332-2337
        • Lykke J.
        • Nielsen H.J.
        Haemostatic alterations in colorectal cancer: perspectives for future treatment.
        J Surg Oncol. 2004; 88: 269-275
        • Alcalay A.
        • Wun T.
        • Khatri V.
        • et al.
        Venous thromboembolism in patients with colorectal cancer: incidence and effect on survival.
        J Clin Oncol. 2006; 24: 1112-1118
        • Lemmens V.E.
        • Janssen-Heijnen M.L.
        • Houterman S.
        • et al.
        Which comorbid conditions predict complications after surgery for colorectal cancer?.
        World J Surg. 2007; 31: 192-199
        • Chew H.K.
        • Wun T.
        • Harvey D.
        • Zhou H.
        • White R.H.
        Incidence of venous thromboembolism and its effect on survival among patients with common cancers.
        Arch Intern Med. 2006; 166: 458-464
        • Chessin D.B.
        • Enker W.
        • Cohen A.M.
        • et al.
        Complications after preoperative combined modality therapy and radical resection of locally advanced rectal cancer: a 14-year experience from a specialty service.
        J Am Coll Surg. 2005; 200 ([discussion 882–884]): 876-882
        • Longo W.E.
        • Virgo K.S.
        • Johnson F.E.
        • et al.
        Risk factors for morbidity and mortality after colectomy for colon cancer.
        Dis Colon Rectum. 2000; 43: 83-91
        • Alves A.
        • Panis Y.
        • Mathieu P.
        • Mantion G.
        • Kwiatkowski F.
        • Slim K.
        Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study.
        Arch Surg. 2005; 140 ([discussion 284]): 278-283
        • Longo W.E.
        • Virgo K.S.
        • Johnson F.E.
        • et al.
        Outcome after proctectomy for rectal cancer in Department of Veterans Affairs Hospitals: a report from the National Surgical Quality Improvement Program.
        Ann Surg. 1998; 228: 64-70
        • Bufalari A.
        • Giustozzi G.
        • Burattini M.F.
        • et al.
        Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors.
        J Surg Oncol. 2006; 93: 173-180
        • Marusch F.
        • Koch A.
        • Schmidt U.
        • et al.
        The impact of the risk factor ‘age’ on the early postoperative results of surgery for colorectal carcinoma and its significance for perioperative management.
        World J Surg. 2005; 29 ([discussion 1021–1022]): 1013-1021
        • Duque J.L.
        • Ramos G.
        • Castrodeza J.
        • et al.
        Early complications in surgical treatment of lung cancer: a prospective, multicenter study. Grupo Cooperativo de Carcinoma Broncogenico de la Sociedad Espanola de Neumologia y Cirugia Toracica.
        Ann Thorac Surg. 1997; 63: 944-950
        • Harpole Jr., D.H.
        • DeCamp Jr., M.M.
        • Daley J.
        • et al.
        Prognostic models of thirty-day mortality and morbidity after major pulmonary resection.
        J Thorac Cardiovasc Surg. 1999; 117: 969-979
        • Sekine Y.
        • Behnia M.
        • Fujisawa T.
        Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC.
        Lung Cancer. 2002; 37: 95-101
        • Varela G.
        • Brunelli A.
        • Rocco G.
        • et al.
        Measured FEV1 in the first postoperative day, and not ppoFEV1, is the best predictor of cardio-respiratory morbidity after lung resection.
        Eur J Cardiothorac Surg. 2007; 31: 518-521
        • Ambrogi V.
        • Pompeo E.
        • Elia S.
        • Pistolese G.R.
        • Mineo T.C.
        The impact of cardiovascular comorbidity on the outcome of surgery for stage I and II non-small-cell lung cancer.
        Eur J Cardiothorac Surg. 2003; 23: 811-817
        • Damhuis R.A.
        • Schutte P.R.
        • Varin O.C.
        • van den Berg P.M.
        • Heinhuis R.
        • Plaisier P.W.
        Poor results after surgery for bronchioloalveolar carcinoma.
        Eur J Surg Oncol. 2006; 32: 573-576
        • Brock M.V.
        • Kim M.P.
        • Hooker C.M.
        • et al.
        Pulmonary resection in octogenarians with stage I non-small cell lung cancer: a 22-year experience.
        Ann Thorac Surg. 2004; 77: 271-277
        • Battafarano R.J.
        • Piccirillo J.F.
        • Meyers B.F.
        • et al.
        Impact of comorbidity on survival after surgical resection in patients with stage I non-small cell lung cancer.
        J Thorac Cardiovasc Surg. 2002; 123: 280-287
        • Yancik R.
        • Wesley M.N.
        • Ries L.A.
        • et al.
        Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study.
        Cancer. 1998; 82: 2123-2134
        • Piccirillo J.F.
        • Tierney R.M.
        • Costas I.
        • Grove L.
        • Spitznagel Jr., E.L.
        Prognostic importance of comorbidity in a hospital-based cancer registry.
        JAMA. 2004; 291: 2441-2447
        • Read W.L.
        • Tierney R.M.
        • Page N.C.
        • et al.
        Differential prognostic impact of comorbidity.
        J Clin Oncol. 2004; 22: 3099-3103
        • Shahir M.A.
        • Lemmens V.E.
        • van de Poll-Franse L.V.
        • Voogd A.C.
        • Martijn H.
        • Janssen-Heijnen M.L.
        Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study.
        Eur J Cancer. 2006; 42: 3015-3021
        • Sorensen H.T.
        • Mellemkjaer L.
        • Olsen J.H.
        • Baron J.A.
        Prognosis of cancers associated with venous thromboembolism.
        N Engl J Med. 2000; 343: 1846-1850
        • Lee A.Y.
        • Levine M.N.
        Venous thromboembolism and cancer: risks and outcomes.
        Circulation. 2003; 107: I17-I21
        • Latkauskas T.
        • Rudinskaite G.
        • Kurtinaitis J.
        • et al.
        The impact of age on post-operative outcomes of colorectal cancer patients undergoing surgical treatment.
        BMC Cancer. 2005; 5: 153
        • Firat S.
        • Bousamra M.
        • Gore E.
        • Byhardt R.W.
        Comorbidity and KPS are independent prognostic factors in stage I non-small-cell lung cancer.
        Int J Radiat Oncol Biol Phys. 2002; 52: 1047-1057
        • Kaplan M.H.
        • Feinstein A.R.
        The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus.
        J Chronic Dis. 1974; 27: 387-404
        • Tammemagi C.M.
        • Neslund-Dudas C.
        • Simoff M.
        • Kvale P.
        Impact of comorbidity on lung cancer survival.
        Int J Cancer. 2003; 103: 792-802
        • Miller M.D.
        • Paradis C.F.
        • Houck P.R.
        • et al.
        Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale.
        Psychiatry Res. 1992; 41: 237-248
        • Monfardini S.
        • Balducci L.
        A comprehensive geriatric assessment (CGA) is necessary for the study and the management of cancer in the elderly.
        Eur J Cancer. 1999; 35: 1771-1772
        • Hurria A.
        • Gupta S.
        • Zauderer M.
        • et al.
        Developing a cancer-specific geriatric assessment: a feasibility study.
        Cancer. 2005; 104: 1998-2005
        • Freeman C.
        • Todd C.
        • Camilleri-Ferrante C.
        • et al.
        Quality improvement for patients with hip fracture: experience from a multi-site audit.
        Qual Saf Health Care. 2002; 11: 239-245
        • Todd C.J.
        • Freeman C.J.
        • Camilleri-Ferrante C.
        • et al.
        Differences in mortality after fracture of hip: the east Anglian audit.
        BMJ. 1995; 310: 904-908