TO THE EDITOR
Colorectal cancer (CRC) remains one of the most formidable global health challenges, ranking as the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related deaths worldwide[1,2]. Its incidence has surged in aging populations, with individuals aged 65 years and older accounting for over 60% of newly diagnosed cases[3]. This demographic shift underscores the urgent need to refine surgical strategies tailored to elderly patients, who often present with unique physiological vulnerabilities, including diminished functional reserves, multimorbidity, and heightened susceptibility to postoperative complication[4]. Following World Health Organization criteria[5] and China's Law on the Protection of the Rights and Interests of the Elderly[6], we define elderly patients as those aged 60 years or older. While surgical resection remains the cornerstone of curative treatment for localized CRC, the conventional open approach—long regarded as the gold standard—faces growing scrutiny due to its association with prolonged recovery, significant tissue trauma, and systemic inflammatory cascades that disproportionately impact older adults. In this context, minimally invasive techniques, particularly laparoscopic radical resection of colorectal cancer (LRRCC), have emerged as a transformative paradigm, promising reduced physiological stress and accelerated rehabilitation[7,8]. The recent study by Min et al[9] provides timely insights into the efficacy and safety of LRRCC in elderly patients, yet it also invites a broader discourse on the integration of minimally invasive surgery into geriatric oncology care, the biological implications of surgical stress, and the systemic barriers to equitable access.
The global burden of CRC and the aging population
The rising incidence of CRC in low- and middle-income countries, coupled with aging populations in high-income nations, has created a dual burden. By 2040, the global number of CRC cases is projected to exceed 3.2 million annually, with elderly patients constituting the majority[10,11]. Aging itself is a cardinal risk factor for CRC, driven by cumulative DNA damage, epigenetic alterations, and chronic inflammation. However, elderly patients are frequently excluded from clinical trials due to concerns over comorbidities or functional decline, resulting in a paucity of evidence-based guidelines for this demographic[12]. Compounding this issue, older adults undergoing open surgery face elevated risks of postoperative ileus, cardiopulmonary complications, and prolonged hospitalization—factors that not only impair quality of life but also escalate healthcare costs[13]. These challenges necessitate a surgical approach that balances radical oncological resection with minimal physiological disruption—a balance that LRRCC appears poised to achieve.
The evolution of minimally invasive surgery in CRC
Since its introduction in the 1990s, laparoscopic surgery has revolutionized CRC treatment by offering smaller incisions, enhanced visualization, and reduced intraoperative blood loss. Early skepticism regarding its oncological adequacy—particularly in achieving clear margins and adequate lymph node harvest—has been dispelled by landmark trials, which demonstrated non-inferiority of laparoscopic vs open resection in terms of survival and recurrence rates[14,15]. For elderly patients, the benefits extend beyond oncological efficacy. Reduced surgical stress, as quantified by lower levels of interleukin-6 (IL-6) and C-reactive protein, correlates with faster recovery of gut motility and shorter hospital stays[16]. Several studies have shown a significant reduction in median length of stay for LRRCC in patients over 75 years of age and comparable 30-day mortality rates compared with open surgery[17,18]. Despite these advances, adoption remains uneven, particularly in resource-limited settings where laparoscopic expertise and infrastructure are scarce.
The immunological and inflammatory nexus
Surgical trauma triggers a systemic inflammatory response characterized by cytokine release, neutrophil activation, and oxidative stress—a phenomenon exacerbated in elderly patients with preexisting immunosenescence[19]. Elevated postoperative levels of tumor necrosis factor-alpha and IL-6 are not merely biomarkers of inflammation but active contributors to muscle catabolism, cognitive dysfunction, and delayed recovery[20,21]. Min et al’s observation of significantly attenuated inflammatory markers post-LRRCC aligns with mechanistic studies showing that laparoscopic techniques minimize peritoneal handling and preserve mesothelial integrity, thereby reducing cytokine spillage into systemic circulation[9]. This immunomodulatory effect may have far-reaching implications beyond recovery. Chronic inflammation is a recognized driver of cancer recurrence and chemotherapy resistance[22]. By mitigating surgical stress, LRRCC could theoretically enhance long-term survival—a hypothesis warranting validation in prospective cohorts.
Persistent challenges and unmet needs
While Min et al's findings are encouraging, they also expose critical gaps in the current evidence base[9]. First, the single-center, retrospective design limits generalizability, as outcomes may reflect institutional expertise rather than the broader feasibility of LRRCC. Future studies should prioritize multicenter designs to account for variability in surgical expertise, institutional resources, and patient demographics, ensuring broader applicability of LRRCC outcomes. Second, the study’s 12-month follow-up precludes assessment of long-term endpoints such as disease-free survival, functional independence, and quality of life—metrics of paramount importance to elderly patients. Prospective trials with extended follow-up periods are urgently needed to evaluate long-term oncological outcomes (such as recurrence rates, disease-free survival, and overall survival) and functional independence. These endpoints are particularly significant for elderly patients who prioritize not only the quantity but also the quality of their remaining years. In addition, inclusive recruitment strategies targeting frail subgroups, such as patients with cognitive impairment or severe cardiopulmonary comorbidities, would improve practical applicability, as the exclusion of these individuals raises questions about the applicability of LRRCC to the most vulnerable subgroups.
Furthermore, the economic dimensions of minimally invasive surgery remain underexplored. The economic considerations of LRRCC are indeed multifaceted and warrant careful examination. From the healthcare system’s perspective, the implementation of LRRCC involves significant upfront investments, including the procurement and maintenance of specialized laparoscopic equipment, as well as the potential for increased operating room time, which can lead to higher immediate costs compared to conventional open surgery. These financial demands may pose challenges, particularly in settings with limited resources, where healthcare facilities might struggle to allocate sufficient funds for advanced surgical technologies. However, it is crucial to consider the long-term economic benefits that LRRCC can offer. The reduction in postoperative complications and faster recovery times can lead to decreased hospitalization durations, which in turn can enhance hospital bed turnover rates and operational efficiency. This can result in substantial cost savings over time, potentially offsetting the initial financial outlay. Moreover, the decreased incidence of complications may also lower the risk of readmissions, further reducing the overall healthcare expenditure associated with treating CRC in elderly patients.
From the patient’s standpoint, while LRRCC may involve higher direct costs due to the advanced technology employed, the long-term economic advantages are significant. The accelerated recovery and reduced likelihood of complications mean that patients can return to their normal activities and work sooner, thereby minimizing income loss. Additionally, the lower risk of postoperative issues can reduce the need for extended treatments and rehabilitation, leading to decreased out-of-pocket expenses for patients in the long run. On a societal level, the broader adoption of LRRCC can contribute to improved public health outcomes and enhanced productivity levels, especially as the global population continues to age. By enabling elderly patients to recover more quickly and maintain their independence for longer periods, LRRCC can alleviate some of the caregiving and economic burdens associated with aging populations. Furthermore, the efficient utilization of healthcare resources through LRRCC can help optimize the allocation of medical services, ensuring that more patients have access to effective and innovative treatments within the constraints of available resources.
Toward a geriatric-centric surgical paradigm
The management of elderly CRC patients demands a paradigm shift from disease-centered to patient-centered care. This entails preoperative geriatric assessments (e.g., G8 screening tool, comprehensive geriatric assessment) to identify vulnerabilities and tailor interventions[23]. Nutritional optimization, preoperative rehabilitation programs, and multidisciplinary team (MDT) involvement have shown promise in reducing the incidence of serious postoperative complications[24]. However, implementing these approaches requires careful planning and coordination. Healthcare systems must invest in training healthcare professionals to conduct geriatric assessments and design individualized care plans. Additionally, integrating prehabilitation programs into existing clinical workflows may necessitate adjustments in scheduling and resource allocation to accommodate these services. MDT collaboration also requires effective communication channels and shared decision-making processes among surgeons, geriatricians, nutritionists, and physiotherapists.
Additionally, emerging technologies such as robotic-assisted surgery and enhanced recovery after surgery protocols may further optimize outcomes[25], though their cost-effectiveness in geriatric populations requires rigorous evaluation. Robotic-assisted surgery could potentially offer even greater precision and control during complex colorectal procedures, potentially reducing surgical trauma and improving recovery times. However, the acquisition of robotic surgical systems represents a significant financial investment for healthcare institutions. The cost of maintaining and updating this technology, along with the need for specialized training for surgical teams, may pose substantial barriers to widespread adoption. Additionally, the learning curve associated with mastering robotic-assisted techniques must be considered, as it may initially impact surgical efficiency and outcomes. Future research should explore not only the clinical benefits of these technologies but also conduct thorough cost-benefit analyses to determine their value in the context of elderly CRC patient care. This will help healthcare systems make informed decisions about investing in and integrating these advanced approaches into their clinical practices, ultimately aiming to enhance the quality of care for elderly CRC patients while considering the economic implications for all stakeholders involved.
CONCLUSION
The study by Min et al[9] underscores the pivotal role of LRRCC in elderly patients, demonstrating its dual capacity to enhance oncological outcomes and mitigate systemic inflammatory burden. To translate these findings into clinical practice, it is imperative to prioritize structured training programs utilizing laparoscopic simulation platforms, thereby addressing the steep learning curve and improving procedural safety. Simultaneously, integrating multidisciplinary care models—incorporating geriatricians, nutritionists, and physiotherapists—can address age-specific vulnerabilities and optimize postoperative recovery. Expanding insurance coverage for minimally invasive techniques and rehabilitation services will further ensure equitable access to advanced surgical care. Future research should focus on long-term outcomes, including cancer recurrence and functional independence, alongside cost-effectiveness analyses and comparative trials against emerging robotic-assisted approaches. To advance the field, there is a pressing need for well-designed studies such as randomized controlled trials and longitudinal cohort studies that can provide robust evidence on the efficacy and safety of LRRCC in elderly populations. These studies should not only assess clinical outcomes but also address the implementation challenges and ethical considerations associated with surgical innovation in this vulnerable group. Ethical issues, such as ensuring informed consent and protecting the welfare of elderly patients during experimental procedures, must be carefully managed. This includes conducting thorough risk-benefit analyses and establishing clear protocols for patient selection and surgical intervention. As the global population ages, these strategies will be critical in advancing personalized, high-quality surgical care for elderly CRC patients. By integrating rigorous research with thoughtful ethical oversight, we can ultimately bridge the gap between evidence-based innovation and real-world clinical implementation, ensuring that the benefits of LRRCC and future technologies are equitably available to all elderly patients in need.
