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[Gastric cancer in the elderly]
Literatures about the surgical experience are always excellent. This report from Kangbuk Samsung Hospital can be a good example. Authors divided the elderly patients into two groups - younger elderlies, who are less than 75 years old, and very elderlies, who are more than 75 years old. As you can guess, the very elderly patients have underlying diseases more often. However, the rate of curative resection is also very good in the very elderly patients - more than 90 percent.
Regarding surgery for very elderly patients, there is a concern about postoperative morbidity and mortality. However, in this series, the rate of postoperative complication and one-month mortality was not different between the two age groups.
The overall survival was slightly better in the young elderly patients, but it may be related with more advanced stages in the very elderly patients.
Actually, the overall survival for stage I, II, and IIIa did not differ significantly between the two age groups.
This is a rare example of early gastric cancer without significant interval change for a long time.
There are two important biases in the cancer screening. The first one is very famous, the lead time bias. I think all individuals in this hall already understand this type of bias. Even if we may detect cancers earlier, the overall survival gain is another issue due to the lead time bias.
The second bias is the length-time bias. It means cancers detected in the screening program may be less aggressive. This bias is especially important for the elderly population. If some cancers in the elderly people are very slow-growing, is there any reason that we need to find them?
Survival gain by the cancer screening is usually like this. At some age, the survival gain can be zero. After that point, screening can actually decrease the individual’s survival. We need to stop before that age. But, the problem here is that we don’t know exactly when to stop.
In terms of screening for cancers, we need to consider the life expectancy. Screening tests are usually recommended when the expected survival is longer than 10 years. In this regard, screening at the age of 80 is usually not recommended.
Do you know the Hoerr’s law? It means it is difficult to make the asymptomatic patient feel better. Regarding the screening in the elderly population, we need to ask to ourselves. We are really making the elderly people feel better, be happier by all the screening and aggressive treatment?
A few years ago, US preventive services task force recommended against routine colonoscopy for adults with ages 76 to 85.
This is one of many evidences supporting the US preventive services task force recommendations. After 75 years, screening colonoscopy showed no more benefit. Actually, screening colonoscopy after 75 years makes more and more complications. 75 is a good age for stopping screening colonoscopy.
As a box summary, I can say that more is not always better, especially in the cancer screening in the elderly. Sometimes, less may be better. We need to stop at some point.