Surgical treatment options for colorectal cancer

The aging of our national population is recognized as a major achievement of modern society. The National Institutes of Health have recently redefined "old" as beginning at age 70. This segment of our population lead active and productive lives. An unfortunate association of aging is the development of neoplasia. The incidence of colorectal cancer continues to escalate, with 150,000 cases expected each year, representing 15% of all cancer, two thirds of which are found in patients older than age 65. Forty percent of these patients present with advanced disease. Little change in survival by stage has been noted in the last 30 years. Surgical resection offers the only opportunity for cure as well as affording significant palliation in patients with advanced disease. Although age alone does not increase operative risks, comorbidity and emergency surgery are confounding factors. Repeated studies have shown that acceptable mortality and morbidity may be achieved by surgical resection for cure and for palliation in the elderly, thus age alone should not be a limiting factor. Key elements in management are early detection with surgical intervention before stage advancement or before complications occur (i.e., obstruction, perforation). When possible, comorbid factors, such as nutritional deficits, cardiovascular decompensation, and pulmonary insufficiency should be corrected. The appropriate use of mechanical bowel preparation and perioperative antibiotics should be emphasized. Surgical management should encourage adequate resection for cure or palliation rather than bypass or diversion. Proximal shifts in colon cancer location and improved technology frequently make resection with anastomosis possible rather than end colostomy. Multidisciplinary approaches to rectal cancer offer significant opportunities for sphincter preservation. Local excision with or without radiation therapy offers an occasional opportunity for treatment of rectal cancer in highly selective cases, also with sphincter preservation.