Do the Oncological and Surgical Outcomes of Young and Older Women Differ in the Treatment of Colorectal Cancer?

Abstract

Background:

The present study aimed to compare the surgical and oncological outcomes between young and older women with colorectal cancer (CRC).

Materials and Methods:

This retrospective study included 1815 women with CRC between 2010 and 2014. Participants were divided into a young group (under the age of 65 years) and an old group (65 years and older). The surgical and oncological outcomes were compared between the two groups using univariate and multivariate analyses.

Results:

Around 45.1% (N = 819) patients were the older group. The old group had a higher comorbidity rate and a lower proportion of receiving postoperative chemotherapy. The old group also had a significantly higher blood loss (190 ± 611 mL vs. 145 ± 200 mL, p = 0.027) and a higher rate of intraoperative transfusion (5.4% vs. 3.0%, p = 0.011). They were found to develop more complications after surgery (11.7% vs. 7.8%, p = 0.015). The overall survival (OS) of the old group was lower than that of the young group (5-year OS rates: 72.8% vs. 83.8%, p < 0.001; adjusted hazard ratio: 1.86, 95% confidence interval: 1.49–2.33). However, the cancer-specific survival (CSS) was not significantly different between the old and young groups (5-year CSS rates: 84.7% vs. 84.9%, p = 0.076).

Conclusions:

Older women with CRC had poorer OS than young women with CRC, but had similar CSS. Therefore, the management of comorbidities along with cancer treatment may be important in older women with CRC.

Introduction

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of death worldwide.¹ The incidence of CRC has been increasing steadily owing to an increase in western eating habits, drinking, and smoking. Previous studies have reported that the incidence of and mortality associated with CRC are lower in women than in men,² possibly because of differential exposures to risk factors between the sexes.³ Guideline for colonoscopy surveillance after screening and surveillance in the United States were initially developed in 1997 and updated in 2012.⁴ This screening strategy has helped in lowering the age at which patients are diagnosed with CRC. However, with increasing life expectancy because of better health care and advances in medical science, the number of elderly patients with CRC is increasing. Studies on the treatment of CRC in elderly patients 80 years of age or older, with various comorbidities, have been reported.⁵ In particular, elderly individuals with lung and heart diseases are more likely to develop postoperative complications.⁶ Although there have been studies on the sex-specific differences in CRC, studies involving only women and reporting on age-specific oncological and surgical outcomes in this population are scarce.

The present study aimed to compare the surgical and oncological outcomes between young and older women with CRC.

Materials and Methods

Subjects

The study subjects were women who underwent surgery for CRC at the Seoul National University Hospital and Dongnam Institute of Radiological and Medical Sciences from January 2010 to December 2014. This study included patients with stage 0, I, II, III, and stage IV CRC, who underwent primary tumor resection. The stage group was divided into two groups (0, I, and II vs. III and IV). Patients with familial adenomatous polyposis or hereditary nonpolyposis CRC were excluded from the study. This study was reviewed and approved by the Institutional Review Board of the Seoul National University Hospital, and Dongnam Institute of Radiological and Medical Sciences, and this study was waived of the requirement for patient's informed consent. The study analyzed 1815 patients. Based on earlier studies, we used 65 years as the cutoff age and divided the participants of this study into two groups.^7,8 There were 996 subjects younger than 65 years (young group) and 819 subjects who were 65 years and older (old group) (Supplementary Fig. S1; Supplementary Data are available online at www.liebertpub.com/jwh). High ligation of vessels was performed as the surgical method for CRC, and patients with rectal cancer underwent total mesorectal excision. All the patients were followed up every 3 months for the first 2 years and every 6 months for 3 years thereafter. In this study, advanced CRC was defined as stage ≥III. Therefore, the stage group was divided into two groups as 0, I, and II and III and IV. Chemotherapy for CRC was performed at high-risk stage II, stage III, and stage IV. The high risk of stage II is defined by CRC as T4 lesions, obstruction or perforation, lymphovascular invasion, and poorly differentiated histology.

Clinicopathological characteristics

The carcinoembryonic antigen levels were measured preoperatively, and each subject's age and body mass index were recorded at the time of surgery. Location of the primary tumor, blood loss, operating time, and length of stay were also evaluated. Preoperative albumin level and preoperative hemoglobin level were investigated. Postoperative complications were evaluated using the Clavien–Dindo classification scale,⁹ and major complications were defined as those requiring surgical, endoscopic, or radiological intervention (Clavien–Dindo classification ≥3). The use or nonuse of postoperative chemotherapy was investigated. The histopathological findings were reviewed to determine the histological grade, T stage, number of harvested lymph nodes, number of metastatic lymph nodes, angiolymphatic invasion (ALI), venous invasion (VI), and perineural invasion (PNI).

Comorbidities

Comorbidities were examined and classified as heart disease (hypertension, myocardial infarction, valvular heart disease, and heart failure), lung disease (chronic obstructive pulmonary disease [COPD], asthma, interstitial lung disease, emphysema, and tuberculosis infection), liver disease (hepatitis and liver cirrhosis), and diabetes.

Statistical analyses

Statistical analyses were performed using SPSS version 21.0 (IBM Corporation, Armonk, NY). Categorical variables of the two groups were compared using Pearson's chi-squared test or Fisher's exact test. Continuous variables were compared using Student's t-test. All tests were performed as two-sided. Overall survival (OS) was defined as the time from operation to death. We defined cancer-specific survival (CSS) as the time from operation to death caused by the same cancer, CRC.¹⁰ Deaths from other cancers, noncancer-related deaths, treatment-related deaths, and loss to follow-up are censored. The OS and CSS were assessed using the Kaplan–Meier method, and the two groups were compared using the log-rank test. Multivariate analysis was performed on significant factors found in the univariate analysis using the Cox proportional hazards regression model. p-Values ≤0.05 were considered statistically significant.

Results

Clinicopathological characteristics

The old group had a statistically higher comorbidity rate, particularly heart disease and diabetes (Table 1). On the other hand, the young group had a significantly higher proportion of well-differentiated CRC and rectal cancer. The proportion of patients who did not receive postoperative chemotherapy was significantly higher in the old group compared with the young group. There was no difference between two groups in terms of stage, ALI, VI, and PNI invasion (Supplementary Table S1).

Table 1.

Demographic Data and Clinical Characteristics

	Young group (<65 years), (N = 996)	Old group (≥65 years), (N = 819)	p
Age (years)	53.3 ± 7.5	72.8 ± 5.5
BMI (kg/m²)	23.2 ± 3.4	23.4 ± 3.5	0.295
Comorbidity, n (%)
No	718 (72.1)	279 (34.1)	<0.001
Yes	278 (27.9)	540 (65.9)
Heart disease	217 (21.8)	489 (59.7)	<0.001
Lung disease	27 (2.7)	29 (3.5)	0.309
Liver disease	20 (2.0)	20 (2.4)	0.531
Diabetes	67 (6.7)	146 (17.8)	<0.001
Comorbidity ≥2	57 (5.7)	167 (20.4)	<0.001
Tumor location with stage, n (%)
Location
Colon	653 (65.6)	591 (72.2)	0.003
Rectum	343 (34.4)	228 (27.8)
Stage			0.538
0, I, and II	507 (50.9)	405 (49.5)
III and IV	489 (49.1)	414 (50.5)
Colon			0.633
Stage 0, I, and II	337 (51.6)	297 (50.3)
Stage III and IV	316 (48.4)	294 (49.7)
Rectum			0.607
Stage 0, I, and II	170 (49.6)	108 (47.4)
Stage III and IV	173 (50.4)	120 (52.6)
Preoperative anemia (hemoglobin <12 g/dL), n (%)			0.644
No	617 (61.9)	516 (63.0)
Yes	379 (38.1)	303 (37.0)
Preoperative hypoalbuminemia (albumin <3.5 g/dL), n (%)			0.466
No	897 (90.1)	729 (89.0)
Yes	99 (9.9)	90 (11.0)
Histology, n (%)			<0.001
Well differentiated	330 (33.1)	133 (16.2)
Moderately differentiated	642 (64.5)	578 (70.6)
Poorly differentiated	23 (2.3)	104 (12.7)
Mucinous adenocarcinoma	1 (0.1)	4 (0.5)
ALI, n (%)			0.229
No	720 (72.3)	571 (69.7)
Yes	276 (27.7)	248 (30.3)
VI, n (%)			0.258
No	851 (85.4)	684 (83.5)
Yes	145 (14.6)	135 (16.5)
PNI, n (%)			0.391
No	672 (67.5)	568 (69.4)
Yes	324 (32.5)	251 (30.6)
Harvested lymph node	24.7 ± 12.7	23.6 ± 12.2
Preoperative CEA (ng/mL)	33.1 ± 199.2	35.1 ± 221.9	0.051
< 5, n (%)	727 (73.0)	575 (70.2)	0.841
≥5, n (%)	241 (24.2)	215 (26.3)	0.367
Unknown, n (%)	28 (2.8)	29 (3.5)
Surgical approach, n (%)			0.315
Open	692 (69.5)	551 (67.3)
Laparoscopy	304 (30.5)	268 (32.7)
Chemotherapy, n (%)			<0.001
No	303 (30.4)	351 (42.9)
Yes	693 (69.6)	468 (57.1)
Radiotherapy, n (%)			0.314
No	776 (77.9)	654 (79.9)
Yes	220 (22.1)	165 (20.1)

ALI, angiolymphatic invasion; BMI, body mass index; CEA, carcinoembryonic antigen; PNI, perineural invasion; VI, venous invasion.

Surgical outcomes

No significant difference was found in operating time between the two groups (Table 2). However, there was significantly more blood loss and a higher rate of intraoperative transfusion in the old group. Compared with the young group, the old group stayed 2 days longer in the hospital, which was a significant difference. In addition, there were a significantly higher number of minor and major complications in the old group.

Table 2.

Comparison of Surgical Outcomes and Complications Between the Young and Old Groups

	Young group (<65 years), (N = 996)	Old group (≥65 years), (N = 819)	p
Open/laparoscopy, n (%)			0.315
Open	692 (69.5)	551 (67.3)
Laparoscopy	304 (30.5)	268 (32.7)
Operation time (minutes)	127 ± 74	132 ± 76.8	0.154
Blood loss (mL)	145 ± 200	190 ± 611	0.027
Intraoperative transfusion, n (%)			0.011
No	966 (97.0)	775 (94.6)
Yes	30 (3.0)	44 (5.4)
Length of stay (days)	7.0 ± 3.6	9.1 ± 5.4	<0.001
Postoperative complication, n (%)			0.015
No complication	917 (92.2)	723 (88.3)
Minor complication	66 (6.6)	77 (9.4)
Major complication	12 (1.2)	19 (2.3)

Oncological outcomes

The median follow-up period was 56.4 months (interquartile range: 40.6–72.3 months). The OS of the old group was lower than that of the young group (5-year OS: 72.8% vs. 83.8%, p < 0.001; Fig. 1). In each stage, the OS of the young group were significantly higher than those of the old group (5-year OS in stage 0, I: 99.0% vs. 89.9%, p < 0.001; stage II: 95.3% vs. 85.8%, p = 0.001; stage III: 87.3% vs. 77.7%, p = 0.001; and stage IV: 36.0% vs. 18.4%, p < 0.001).

FIG. 1.

Kaplan–Meier plots comparing overall survival between women in the young (under 65 years of age) and old (65 years and older) groups with different stages of colorectal cancer. (a) Overall, (b) stage 0 and I, (c) stage II, (d) stage III, and (e) stage IV. Color images available online at www.liebertpub.com/jwh

However, the CSS was not significantly different between the old and young groups (5-year CSS rates: 84.7% vs. 84.9%, p = 0.076; Fig. 2). There was also no statistical difference between the two groups in each stage (5-year CSS in stage 0, I: 99.4% vs. 97.9%, p = 0.125; stage II: 96.2% vs. 91.2%, p = 0.105; stage III: 88.6% vs. 83.9%, p = 0.094; and stage IV: 36.0% vs. 31.2%, p = 0.159).

FIG. 2.

Kaplan–Meier plots comparing the cancer-specific survival between women in the young (under 65 years of age) and old (65 years and older) groups with different stages of colorectal cancer. (a) Overall, (b) stage 0 and I, (c) stage II, (d) stage III, and (e) stage IV. Color images available online at www.liebertpub.com/jwh

Univariate analysis indicated that age of 65 years and older, heart disease, lung disease, cancer stage ≥III, intraoperative transfusion, ALI, VI, PNI, postsurgical complications, and no chemotherapy were poor prognostic factors for OS (Table 3). Multivariate analysis showed that patients with age of 65 years and older had significantly poor survival than younger patients (adjusted hazard ratio [HR]: 1.86, 95% confidence interval [CI]: 1.49–2.33, p < 0.001).

Table 3.

Prognostic Factors for Overall Survival in All Patients After Univariate and Multivariate Analyses

	Total
	Univariate analysis ^a		Multivariate analysis ^a
	HR (95% CI)	p	Adjusted HR (95% CI)	p
Age		<0.00		<0.00
<65 years	1		1
≥65 years	1.81 (1.48–2.22)		1.86 (1.49–2.33)
Heart disease		0.045		0.132
No	1		1
Yes	1.23 (1.01–1.50)		1.18 (0.95–1.48)
Lung disease		0.022		0.004
No	1		1
Yes	1.73 (1.08–2.78)		2.01 (1.25–3.23)
Liver disease		0.263
No	1
Yes	1.40 (0.77–2.56)
Diabetes		0.606
No	1
Yes	1.08 (0.79–1.47)
Cancer stage		<0.001		<0.001
0, I, and II	1		1
III and IV	5.39 (4.17–6.97)		4.21 (3.10–5.74)
Cancer location		0.769
Colon	1
Rectum	0.97 (0.78–1.20)
Intraoperative transfusion		<0.001		<0.001
No	1		1
Yes	3.95 (2.85–5.49)		2.37 (1.66–3.38)
ALI		<0.001		<0.001
No	1		1
Yes	3.63 (2.97–4.43)		1.74 (1.40–2.17)
VI		<0.001		<0.001
No	1		1
Yes	4.35 (3.53–5.35)		2.08 (1.65–2.62)
PNI		<0.001		<0.001
No	1		1
Yes	3.08 (2.51–3.76)		1.67 (1.34–2.07)
Complication		0.001		<0.001
No	1		1
Yes	2.38 (1.83–3.10)		1.95 (1.46–2.61)
Chemotherapy		<0.001		<0.001
No	1		1
Yes	0.66 (0.53–0.83)		0.56 (0.43–0.73)
Radiation therapy
No	1
Yes	0.91 (0.71–1.16)

Cox proportional hazards regression model.

CI, confidence interval; HR, hazard ratio.

In multivariate analysis for CSS, lung disease, cancer stage, intraoperative transfusion, ALI, VI, PNI, complication, and chemotherapy were significant prognostic factors (Table 4). However, age was not a significant factor after being adjusted with significant factors (adjusted HR: 1.19, 95% CI: 0.94–1.50, p = 0.143).

Table 4.

Prognostic Factors for Cancer-Specific Survival in All Patients After Univariate and Multivariate Analyses

	Total
	Univariate analysis ^a		Multivariate analysis ^a
	HR (95% CI)	p	Adjusted HR (95% CI)	p
Age		0.076		0.126
<65 years	1		1
≥65 years	1.23 (0.98–1.54)		1.20 (0.95–1.52)
Heart disease		0.836
No	1
Yes	1.02 (0.81–1.29)
Lung disease		0.041		0.008
No	1		1
Yes	1.75 (1.02–2.99)		2.07 (1.21–3.55)
Liver disease		0.954
No	1
Yes	1.02 (0.46–2.29)
Diabetes		0.750
No	1
Yes	1.06 (0.73–1.53)
Cancer stage		<0.00		<0.001
0, I, and II	1	1	1
III and IV	8.29 (5.89–11.65)		6.13 (4.13–9.11)
Cancer location		0.847
Colon	1
Rectum	1.02 (0.80–1.30)
Intraoperative transfusion		<0.001		0.001
No	1		1
Yes	3.66 (2.45–5.38)		2.05 (1.34–3.10)
ALI		<0.001		<0.001
No	1		1
Yes	3.94 (3.14–4.96)		1.68 (1.31–2.15)
VI		<0.001		<0.001
No	1		1
Yes	4.53 (3.58–5.73)		1.96 (1.51–2.54)
PNI		<0.001		<0.001
No	1		1
Yes	3.71 (2.94–4.68)		1.84 (1.43–2.36)
Complication		<0.001		<0.001
No	1		1
Yes	2.51 (1.87–3.37)		2.19 (1.59–3.04)
Chemotherapy		<0.001		0.002
No	1		1
Yes	0.49 (0.36–0.65)		0.64 (0.43–0.84)
Radiation therapy		0.765
No	1
Yes	0.96 (0.73–1.27)

Cox proportional hazards regression model.

Prognostic factors for each group were also evaluated separately (Table 5). In the young group, multivariate analysis revealed that cancer stage ≥III, intraoperative transfusion, ALI, VI, PNI, complications, and no chemotherapy were significantly poor prognostic factors. On the other hand, in the old group, lung disease was one of the poor independent prognostic factors.

Table 5.

Prognostic Factors for Overall Survival in the Young and Old Groups After Univariate and Multivariate Analyses

	Young group				Old group
	Univariate analysis ^a		Multivariate analysis ^a		Univariate analysis ^a		Multivariate analysis ^a
	HR (95% CI)	p	Adjusted HR (95% CI)	p	HR (95% CI)	p	Adjusted HR (95% CI)	p
Heart disease		0.340				0.675
No	1				1
Yes	1.21 (0.82–1.79)				1.06 (0.81–1.38)
Lung disease		0.479				<0.001		<0.001
No	1				1		1
Yes	1.51 (0.48–4.73)				2.56 (1.52–4.33)		2.61 (1.53–4.42)
Liver disease		0.492				0.474
No	1				1
Yes	1.41 (0.52–3.82)				1.32 (0.62–2.79)
Diabetes		0.319				0.926
No	1				1
Yes	1.43 (0.71–2.92)				1.02 (0.72–1.43)
Cancer stage		<0.001		<0.001		<0.001		<0.001
0, I, and II	1		1		1		1
III and IV	9.78 (5.91–16.1)		6.04 (3.30–11.0)		4.22 (3.11–5.73)		2.58 (1.84–3.61)
Cancer location		0.218				0.319
Colon	1				1
Rectum	1.21 (0.89–1.66)				1.16 (0.86–1.57)
Intraoperative transfusion		<0.001		0.101		<0.001		<0.001
No	1		1		1		1
Yes	3.47 (1.97–6.13)		1.68 (0.90–3.14)		3.93 (2.63–5.89)		2.79 (1.79–4.33)
Angiolymphatic invasion		<0.001		0.001		<0.001		<0.001
No	1		1		1		1
Yes	4.69 (3.43–6.42)		1.79 (1.27–2.54)		2.97 (2.28–3.86)		1.69 (1.27–2.24)
VI		<0.001		<0.001		<0.001		<0.001
No	1		1		1		1
Yes	4.58 (3.33–6.29)		1.92 (1.35–2.74)		4.20 (3.19–5.53)		1.94 (1.42–2.63)
PNI		<0.001		0.002		<0.001		0.001
No	1		1		1		1
Yes	3.78 (2.76–5.18)		1.72 (1.22–2.42)		2.78 (2.13–3.62)		1.61 (1.21–2.13)
Complication		<0.001		0.001		<0.001		0.003
No	1		1		1		1
Yes	2.21 (1.43–3.41)		2.16 (1.35–3.47)		2.35 (1.68–3.27)		1.73 (1.20–2.50)
Chemotherapy		<0.001		0.671		0.387
No	1		1		1
Yes	0.23 (0.13–0.39)		0.87 (0.46–1.64)		0.89 (0.67–1.16)
Radiation therapy		0.994				0.375
No	1				1
Yes	1.00 (0.69–1.45)				0.86 (0.61–1.20)

Cox proportional hazards regression model.

Discussion

The present study was conducted only in women with CRC to investigate differences in the oncological and surgical outcomes between those who were 65 years of age or above and those under 65 years. There are only a few studies on women with CRC, and age-specific studies are even fewer. The present study found that 20.4% of the old group had more than two comorbidities, which was higher than that in the young group. In the old group, 29.6% did not receive chemotherapy, which is important for advanced CRC for various reasons. Patients in the old group lost significantly more blood and received more intraoperative transfusions. They were also found to develop more minor and major complications after surgery, and their OS was significantly lower compared with that of the young group. However, CSS was comparable between the two groups. Lung disease was found to affect OS in the old group but not in the young group.

A previous study has reported that among the various predictors of OS, a high-impact heart problem and COPD increased the risk ratio to 1.48 and 1.67, respectively, when compared with CRC patients without these comorbidities.¹¹ However, the present study showed that lung disease, but not heart disease, was a significant prognostic factor for OS in the old group. In particular, COPD is known to increase intensive care unit admissions, in-hospital morbidity, and mortality among patients with CRC and should therefore be aggressively treated before and after CRC surgery.^12,13 The 5-year OS was significantly lower in the old group, but the 5-year CSS showed no significant difference between the two groups. In addition, age of 65 years and older was not a significant factor for CSS. Despite the difference in OS, no difference was seen in the rate of mortality from CRC between the two groups, pointing to the significant effects of the comorbidities on survival. These results are in line with those of other studies showing that although death rates from cancer are decreasing, higher age is associated with higher mortality caused by diseases other than cancer.¹⁴ Our findings, therefore, suggest that elderly patients with comorbidities should be treated for both CRC and the comorbidities, applying the principles of individualized medicine.¹⁵

The results of the present study confirmed that more blood loss occurs during surgery in the old group and 59.7% of the subjects in this group were found to have heart disease as a comorbidity. The use of aspirin or other antithrombotic agents was, therefore, more common, and discontinuing its use often caused hemorrhage. In addition, intraoperative transfusion, which was a poor prognostic factor in both the young and old groups, was performed more frequently in the old group. Our findings are consistent with those from other studies showing that intraoperative transfusion affects morbidity and mortality after surgery.^16
–18 Although the underlying cause has not yet been clarified, it is believed that transfusion-related immunomodulation stimulates immunity when transfusion is performed and then induces alloimmunization of the host.^19,20 In addition, it has been reported that in old age, blood loss and subsequent anemia can be risk factors associated with mortality.^21
–23 A way to prevent complications due to intraoperative transfusion or blood loss is to diagnose preoperative anemia and proactively use intravenous iron for its treatment.²⁴

Our results show that the incidences of minor and major complications were higher in women 65 years of age and older. Among the minor complications, wound complication was the most common in the young group, whereas ileus was the most common problem in the old group. The most common major complication was the intra-abdominal fluid collection, in both groups. In addition, postoperative complications were prognostic factors for OS and are known to affect long-term quality of life, social functioning, body image, and self-care.²⁵ These findings are consistent with those in an earlier report showing that complications, specially infections after CRC surgery, are associated with decreased long-term survival.²⁶ Therefore, efforts should be made to minimize the occurrence of postoperative complications. According to the results of recent randomized trials, laparoscopic surgery is reported to be associated with a lower incidence of complications compared with open surgery, but the differences are not statistically significant.^27,28 In line with these results, we also found that the incidence of complications was 8.6% in the laparoscopic surgery group and 10.1% in the open surgery group, which was not significantly different. It was recently reported that laparoscopic surgeries for CRC in patients 80 years of age and older produced better short-term outcomes.⁵ However, laparoscopic surgery in elderly patients should be planned after sufficient discussion with the patient regarding other comorbidities.

Adjuvant chemotherapy is routinely recommended for stage III and stage II CRC with high-risk features after surgical resection.^29

–32 In the case of stage IV CRC, patients with resectable metastatic CRC should undergo surgery if complete resection is possible, followed by postoperative chemotherapy. On the other hand, patients with an unresectable metastatic CRC should undergo palliative resection if a symptom such as bleeding or obstruction is present, followed by postoperative chemotherapy; otherwise, they should be considered for chemotherapy as the initial treatment.^33
–35 The present study found that the number of patients with stage II or higher CRC who did not receive chemotherapy was significantly higher in the old group (29.6%) compared with the young group (8.3%). A previous study has reported that physicians did not recommend adjuvant chemotherapy for elderly CRC patients with and without other comorbidities.³⁶ On the basis of our findings, the reasons for the older patients (65 years and older) not receiving chemotherapy included old age, difficulty in undergoing chemotherapy because of comorbidities, and refusal of chemotherapy. If chemotherapy is carefully administered to elderly patients in consideration of their performance status and comorbidities, they may have similar oncological outcomes to those in younger patients.^37
–39 Therefore, elderly patients should be actively treated using a multidisciplinary approach.

The limitation of this study is that it may have the selection bias between the young groups and the old group from a retrospective analysis.

In conclusion, older women with CRC had poorer OS than young women with CRC but had similar CSS. Therefore, the management of comorbidities along with cancer treatment may be important in older women with CRC.

Footnotes

Acknowledgments

This study was partly funded by the Priority Research Center Program (2009-0093820) through a National Research Foundation of Korea (NRF) grant funded by the MSIP and partly funded by the Basic Science Research Program through the NRF funded by the Ministry of Education (No. NRF-2017R1D-1A1B03036191).

Author Disclosure Statement

No competing financial interests exist.

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