Colorectal cancer treatment in an ageing world - Technical advances, treatment decisions and multidisciplinary care

The incidence of colorectal cancer has risen in recent years and currently over 50% of patients are over 70 years of age. Many questions regarding the optimal management of the growing group of elderly colorectal cancer patients are still unanswered. The research presented in this thesis focuses on several components of the treatment of colorectal cancer in an ageing world and comprises three parts. Part 1 describes technological developments in the treatment of colorectal cancer. A major advancement in recent years has been the introduction of laparoscopic colorectal surgery. Our research showed that for low rectal cancer, the advantages of laparoscopic surgery are reduced blood loss, faster recovery and shorter hospitalization. A study on the functional outcome after transanal resection of rectal tumours, using flexible portals, showed excellent functional results and an significant improvement of continence for patients with reduced preoperative function. A systematic literature review showed that laparoscopic resection leads to reduced cardiac complications compared to conventional resection for colorectal cancer. There was insufficient data on the outcome for elderly patients. Part 2 focusses on treatment decisions for elderly colorectal cancer patients. A retrospective study of patients diagnosed with low rectal cancer demonstrated that oncologic decision-making is still largely based on age and that guideline adherence is significantly reduced with increasing age. Population-based data showed improved survival after surgery for colorectal cancer between 2008 and 2011, concurrent with a rise in the use of laparoscopic techniques. The elderly seem to profit most of this improved postoperative survival. Participation of elderly in clinical trials on laparoscopic surgery for colorectal cancer was investigated and it was shown that 44% of trial protocols exclude elderly from participation and their inclusion has lagged behind. Part 3 investigates the role of a geriatrician in the multidisciplinary care of elderly cancer patients. A systematic review studied the effect of a geriatric evaluation on treatment decision-making for elderly cancer patients. A geriatric evaluation has significant impact on oncologic and non-oncologic treatment decisions in older cancer patients and deserves consideration in the work-up for these patients. Through a national survey of cancer specialists and geriatricians it was shown that a geriatric oncology program has been initiated by half of respondents, while others are interested in doing so. However, many obstacles still remain. Finally, an observational study demonstrated the value of a geriatric consultation in oncologic treatment decision-making and in optimizing elderly prior or during oncologic therapy