Muir et al. estimated that as many as 24% of head and neck cancers are found in patients older than 70 years [18], and this was supported by our study. A higher female proportion, as in the present study, was also confirmed by Sarini et al. [19].
Furthermore, in the present study the rate of patients with alcohol abuse or smoking risk factors was found to be lower than that in younger patient groups. This finding follows the logic that malignant tumors occur earlier under the influence of risk factors, but are also likely to occur without them as time passes by. Malignancy may interfere with accumulation of mutations, decreased efficiency in DNA repair, and reduced immune surveillance.
Concerning the higher portion of maxillary carcinomas in elderly patients, similar results can be shown in other studies [20, 21]. These findings are also important with regard to therapy planning because performing elective neck dissections for maxillary carcinoma is still controversial. It is also striking that, particularly in maxillary carcinoma, the proportion of females is higher than that of males [21].
Four patients had a verrucous form; this type of well-differentiated squamous cell carcinoma is well known in elderly patients [22].
In deciding which treatment strategy would be suitable for an individual elderly patient, a comprehensive geriatric assessment seems to be the essential step, because age by itself is an unreliable parameter for decision making. In the present study, only 3 patients had an ASA status of 1, and the predominant therapy was primary closure.
Due to changed renal function (reduced glomerular filtration rate, decreased renal blood flow) and changed hepatic metabolism (reduced hepatic blood flow and reduced activity of the microsomal oxidizing system), drug distribution is also changed in elderly patients. Moreover, increased myocardial stiffness, increased aortic impedance, increased left atrium size, and increased vascular stiffness, in addition to decreased β-adrenoceptor responsiveness, must be considered before a surgical treatment is planned for elderly patients (Table 1).
Though our population is becoming older and, therefore, the risk of developing cancer is also increasing, little research evaluating age-related toxicities has been conducted, and age-related guidelines for chemotherapy administration are often missing. The therapy decision should be based on the patient's wishes, ASA score, and combined quality of life and function, instead of being based on the patient's age and years of life expectancy.
Perioperative mortality
In 810 patients older than 65 years who had undergone major head and neck resections under general anaesthesia, Morgan et al. reported a mortality rate as low as 3.5% [23]. In addition, Jones et al. reported no significant differences in perioperative or postoperative complications between head and neck cancer patients older than 70 years and patients younger than 66 years, although the older group had a higher frequency of morbid preoperative conditions [24]. In the present study the ASA score was applied preoperatively in order to evaluate the individual surgical risk, and none of the patients died perioperatively.
Microvascular
Controversy still surrounds microvascular free tissue transfer. Studies dealing with free tissue in the elderly have been done for those aged 50 years [3, 25], 60 years[14], 65 years[2, 15], and 70 years [16]. The flap loss rate in these studies ranged from 1% out of 92 patients [25] to 16.7% out of 47 patients [14, 24].
Blackwell et al. reported that microvascular reconstructions in elderly patients are reliable, but the incidence of medical complications and costs has significantly increased [25]. The success rate of free flaps seems no different from that for other age groups, but postoperative medical complications seem to be directly related to the presence of concurrent illness [3]. In the current study a microvascular reconstruction was performed in only 13 patients; in all cases it was for mandible/mouth floor or tongue reconstruction. For maxilla, the most common closure was performed by an obturator prosthesis, followed by primary closure or temporal/nasolabial flaps.