When 95-year-old Ramesh Sharma (name changed) was brought to Delhi’s Maulana Azad Medical College (MAMC) with stomach cancer and a severe underlying health condition, doctors faced a difficult question: was the elderly patient fit enough to withstand the treatment, could his existing health problems be brought under control, and would removing the cancer give him a meaningful chance of recovery?
In fact, it was not simply a question of age for the doctors investigating his case. Sharma had stomach adenocarcinoma, had presented with vomiting of blood and also suffered from chronic obstructive pulmonary disease (COPD), making both anaesthesia and recovery particularly challenging.
However, instead of considering 95 years as an automatic reason to rule out surgery, the MAMC team first worked on making Sharma fit for the procedure. His respiratory condition was assessed and optimised with spirometry, steam inhalation and chest physiotherapy.
The family was also counselled about the substantial risks involved in undertaking major cancer surgery at such an advanced age.
After detailed assessment and preparation, doctors decided to proceed. Sharma underwent a total gastrectomy, in which the entire stomach was removed. To restore the food passage, doctors created a J-pouch from the small intestine and performed a jejuno-oesophageal anastomosis. The operation was carried out under combined general and epidural anaesthesia and lasted around three hours and 20 minutes.
The surgical team was led by Prof (Dr) Anurag Mishra and Prof (Dr) Pawan Lal of the Surgery Department, with Dr Megha, Dr Rahul and Dr Pooja as members. The anaesthesia and critical-care team was led by Dr Muneesha, supported by Dr Gunjan, Dr Kapil, Dr Divya and Dr Khushboo.
For the team, however, removing the tumour was only one part of the challenge. At 95, with an underlying lung condition, Sharma required careful anaesthesia planning, respiratory optimisation, pain management and close postoperative monitoring.
His early recovery was encouraging. By the fourth day after surgery, his bowel function had returned, he was passing gas, had started feeling hungry and was able to walk on his own. Chest physiotherapy was continued, and his condition was closely monitored.
“95 years of age in itself should not be a reason to deny a patient major surgery. With proper patient selection, careful preoperative preparation, an experienced surgical and anaesthesia team and good postoperative care, even complex surgeries can be performed safely. This achievement is not of one individual but a victory of the entire MAMC team and its collective teamwork,” said Dr Mishra.
The case brings into focus an increasingly important issue in Indian cancer care. As life expectancy rises, hospitals are likely to see more elderly patients diagnosed with cancer, many of whom will also have conditions such as heart disease, lung disease, diabetes or other age-related illnesses.
The challenge is to avoid two extremes — denying treatment simply because a patient is old or subjecting a frail patient to an aggressive treatment from which he or she may not benefit.
In Sharma's case, doctors chose not to ask simply, “How old is the patient?” The more important question was, “Can this patient safely undergo the treatment, and can the treatment give him a meaningful benefit?”
Functional ability, nutritional status, frailty, existing illnesses, cardiac and respiratory reserve, cognitive status and the patient's ability to recover after treatment can all influence the risk-benefit assessment.
Two people of the same age can therefore have completely different treatment prospects. A physically active 90-year-old with well-controlled medical conditions may tolerate cancer treatment better than a younger but severely frail patient with multiple uncontrolled illnesses, the doctors pointed out.
