Treatment options for a 95 year old with rectal cancer
Dear OncoLink "Ask The Experts,"
My mother is a very youthful 95 year old who lives independently. She was diagnosed last week with rectal cancer, an adenocarcinoma within 6 inches of the anus. Surgery with the possibility of a colostomy is the option of choice by her surgeon. She indeed has atherosclerotic cardiovascular disease, and had a total gastrectomy when she was 80 years old. Please tell me if there are any alternatives to surgery. She absolutely does not want surgery and yet she is too "well" to allow her to suffer the consequences of doing "nothing!" As a family, we all agree that she is "not up for a possible colostomy." She and our family are not looking for quantity of years but rather quality of time.
Thank you so very much.
Timothy C. Hoops, MD, Clinical Assistant Professor of Medicine in the Gastroenterology Division at the University of Pennsylvania and Director of Gastroenterology at Penn Medicine at Radnor, responds:
I am sorry to hear about your mother. There are several things I might say. First, if the cancer is truly 6 inches from the anus, it may be possible to operate and not have a colostomy. If the cancer is not extensively advanced into the area around the anus, resection is possible and a 6-inch margin is sufficient to allow a primary anastomosis. Doing this in a 95 year old may cause some problems such as incontinence and that would need to be discussed prior to any surgery. If the cancer were too low to allow a primary anastomosis, I would not let the possibility of a colostomy be the sole factor in the decision. I would encourage you and her to talk to someone with a colostomy. Life can be very normal with a colostomy and many people may have these devices without anyone knowing about them. If the cancer is localized, it may be possible to remove the cancer transrectally. That would again be determined by the depth of invasion. An accurate assessment of the stage of the cancer can be made with an endoscopic ultrasound. This would allow the endoscopist to "see" how deep the tumor is and whether there are any lymph nodes with metastases. Finally, surgery may not be curative, but may be very good palliative treatment.
Her heart condition may make her a poor surgical candidate but that affects only whether surgery could be done and not what surgery might be done. If surgery is not an option (locally extensive or distal disease, or an inability to operate for medical reasons or personal preferences) she can be treated with systemic and local therapy. This could include chemotherapy and/or radiation therapy. An Oncologist should be the physician advising and coordinating this decision process. Others can speak more cogently regarding these treatment options.
Lastly, as a generalization, rectal cancers tend to grow very slowly and usually remain localized to the rectal area. No treatment is always an option, with the understanding that this means that one will wait to see what happens as the disease progresses.
I wish your mother the best of luck in this difficult time. While 95 years old is arbitrarily "old", age is a very individual characteristic and cannot be an absolute criterion in making these decisions. Being "youthful" is very important to the decision and the outcome.