Colorectal cancer surgery in elderly and frail patients: Should we leave someone behind?

Frailty is a stronger determinant of surgical outcomes in colorectal cancer (CRC) than chronological age. Yet frail patients are often excluded from studies, and their long-term outcomes remain poorly defined. Most research dichotomizes patients as frail or non-frail, leaving the gradation of frailty (mild, moderate, severe) underexplored.

Prospective, single-center study (2017-2023) including 1028 consecutive CRC patients evaluated for curative treatment. Frailty was screened with PRISMA-7 and stratified using the IF-VIG index. Allocation to surgery or non-operative care followed multidisciplinary assessment. Primary outcomes were 30-day morbidity and mortality; secondary outcomes included length of stay, readmission, and survival.

Frailty was identified in 115 patients (11.2 %): 38 mild, 26 moderate, and 9 severe. Forty-one frail patients (mainly mild) underwent surgery, while 74 (mostly moderate-to-severe) received non-operative care. Compared with non-frail surgical patients (n = 913), frail patients had similar surgical complication rates (22.7 % vs 21.6 %) and no 30-day mortality, but longer stays (median 9.2 vs 6.8 days; p = 0.018), more medical complications (14.6 % vs 6.6 %; p < 0.001), and higher readmission (15.9 %). At 45 months, mortality was higher in frail surgical patients (69 % vs 19 %; HR 4.2, 95 % CI 2.8-6.3). Within the frail cohort, surgery improved survival over non-operative care (HR 0.62, 95 % CI 0.41-0.95).

Stratifying frailty into mild, moderate, and severe provides practical guidance for CRC management. Mildly frail patients, when optimized, can achieve outcomes comparable to non-frail individuals, while moderate-to-severe frailty often precludes surgery. Routine frailty stratification should inform individualized decisions and guide future trials in severely frail patients.