In a Canadian population-based cohort study reported in JAMA Surgery, Chesney et al found that the 5-year rate of cancer-related deaths exceeded that of non–cancer-related deaths among patients aged 70 or older undergoing surgery for cancer.
The study used data from ICES (formerly Institute for Clinical Evaluative Sciences) on all patients aged 70 and older who underwent resection for a new diagnosis of cancer in Ontario between January 2007 and December 2017. Patients were followed until death or censored at date of last contact of December 2018.
At the population level, the relative burden of cancer deaths exceeds noncancer deaths for older adults selected for surgery. No subgroup had a higher burden of noncancer death early after surgery, even in more vulnerable patients.— Chesney et al
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Among a total of 82,037 patients who underwent surgery, 34,044 died over a median follow-up of 46 months (interquartile range = 23–80 months); of these, 16,900 (49.6%) were cancer-related deaths. Postoperative mortality within 90 days of surgery accounted for 11.2% (n = 3,831) of all deaths.
At 5 years after surgery, the estimated cumulative incidence of cancer death across all cancers was 20.7% (95% confidence interval [CI] = 20.4%–21.0%), as compared with an incidence of noncancer death of 16.5% (95% CI = 16.2%–16.8%).
Across all cancer types, the cumulative incidence of all-cause mortality ranged from 22.0% to 50.8% at 5 years. The lowest 5-year cumulative incidence of cancer death was in breast cancer (9.1%) and was the highest in oropharyngeal cancers (29.1%). The incidence of cancer-related death was greater than that of non–cancer-related death across most cancer types at 5 years, with the exceptions being breast cancer and melanoma.
Overall, the incidence of noncancer deaths exceeded cancer deaths beginning at 3 years after surgery in patients with breast cancer, prostate cancer, and melanoma, and among patients aged > 85 years and those with preoperative frailty across all cancers.
On multivariate analyses, cancer type, increasing age, and preoperative frailty were independently associated with cause-specific death.
The investigators stated, “Our results indicate that the incidence of death from cancer was greater than death from noncancer causes overall. Thus, even with cancer surgery, cancer remains the major driver of death, and there is no evidence of overtreatment. In certain circumstances, cancer death did not exceed noncancer death, such as with breast, melanoma, and prostate cancers. If treated with surgery, patients with those cancers are less likely to die of cancer than from other causes. Similarly, the risk of noncancer death was greater in patients 85 years and older and in those with preoperative frailty but only starting at 3 years after surgery. This suggests that cancer surgery is not overtreatment in older adults selected for surgery, even in vulnerable subgroups, because cancer death still represents an immediate greater threat of mortality.”
They concluded, “At the population level, the relative burden of cancer deaths exceeds noncancer deaths for older adults selected for surgery. No subgroup had a higher burden of noncancer death early after surgery, even in more vulnerable patients. This cause-specific overall prognosis information should be used for patient counseling, to assess patterns of over- or under-treatment in older adults with cancer at the system level, and to guide targets for system-level improvements to refine selection criteria and perioperative care pathways for older adults with cancer.”
Tyler R. Chesney, MD, MSc, of St. Michael’s Hospital, Department of Surgery, University of Toronto, is the corresponding author for the JAMA Surgery article.
Disclosure: This study was supported by ICES, which is funded by the Ontario Ministry of Health and Long-Term Care. For full disclosures of the study authors, visit jamanetwork.com.