agreement on what constitutes the elderly cancer patient is particularly vital since the community age structure is very dynamic ( taueber 1993 ) . functional deterioration is more frequently apparent beyond the age of 70 years ( yancik et al 1998 ) . no two elderly individuals are same : they differ in their physical fitness , cognitive level , and presence of co - morbidities , quality of life , and life expectations . surprisingly , few objective instruments have been made available to categorise age - related pre - existing chronic illness ; age related functional physical decline , or preoperative risk status ( copeland et al 1991 ; yancik et al 1998 ; ogle et al 2000 ) . ageism is defined as a  prejudice towards , stereotyping of and/or discrimination against any person or persons directly and solely as a function of their having attained a chronological age which the social group defines as old  ( apa 2005 ) . ageism attitudes are deep - rooted in mankind and are reflected in language , attitude , beliefs , behaviours , and policies ( penson et al 2004 ) . age frequently affects the overall cancer treatment plan , including the surgeon s view towards operative strategy and multi - modal treatment ( ogle et al 2000 ) . the majority of surgical oncologists seem to be aware of the burden of elderly patients affected by cancer and are not biased by an ageist approach . however there is disturbing evidence of a wide variety of treatment options offered , ranging from a minimalist approach to over - treatment ( audisio , osman , et al 2004 ) . solid tumors predominantly affect the aged and most cancer - related deaths occur within this age group ( brookes 1937 ; wallach and kurtz 1990 ; alexander et al 1991 ) . the elderly receive substandard cancer treatment in comparison with the young although the quoted reasons are many ( welch 1948 ; greenfield 1975 ; boyd et al 1980 ; greenburgh et al 1985 ; samet et al 1986 ; brow et al 1991 ; fallahzadeh and mays 1991 ; firat , bousamra , et al 2002 ; audisio , bozzetti , et al 2004 ) . outcomes of these are superimposable long - term cancer - related outcome across all age groups and short term complications and mortality which do not seem to differ in a highly selected patient group undergoing cancer surgery ( vercelli et al 1998 ; firat , byhardt , et al 2002 ) . surgery for elderly cardiac , orthopaedic , and vascular diseases is increasingly accepted . yet , the reluctance to offer optimal cancer surgery continues ( alexander et al 1991 ) although it remains the primary treatment for solid cancer ( wallach and kurtz 1990 ) . our limited knowledge of the elderly sub - population is due to the exclusion of onco - geriatric patients from clinical trials ( brow et al 1991 ; fallahzadeh and mays 1991 ; firat , bousamra , et al 2002 ) . there is an urgent need for expanding our understanding of cancer behavior and cancer management for this unique group . better understanding will come with elderly patients taking part in clinical research and by encouraging clinicians to take part in scientific meetings dedicated to onco - geriatrics . the median life expectancy of population among industrialized countries has dramatically expanded in recent years . an effect of an absolute rise in geriatric population among populous countries ( ie , china , india , and brazil ) despite smaller in proportion ( 11% to 15% ) , and a higher proportionate rise ( 20% ) in developed countries by 2020 , is likely to lead to geriatric population explosion ( day 1996 ; us census 1996 ; kalache and keller 2000 ) . at the end of the 19th century , the average life expectancy was 40 years , but has now doubled to 81 years of expected survival for females , and 76 years for males in the uk . a 60 year old subject is now expected to survive for 24 years and an 80 year old is expected to survive for 6 years in western europe ( lag et al 1999 ) . on the other hand , the risk of developing cancer increases with age . according to the cancer incidence , mortality and prevalence in the european union ( eucan ) 90 data , 58% of cancers , and 69% of cancer deaths , affect subjects aged 65 years or more . when all tumors are taken into account , the risk of developing cancer among persons older than 65 is 2.9-fold for males and 2.2-fold for females , in comparison with 55 to 64 year olds ( coeburgh 2001 ) . according to the seer ( surveillance epidemiology and end results ) data , the prevalence of cancer is 207.4 cases/100 000 in the < 65 year old subjects , and 2163.9/100 000 in 65 year old subjects in the us . this means cancer prevalence is 10 times , and mortality 15 times higher in the 65 year olds ( lag et al 1999 ) . le quintree et al ( 2005 ) concluded the methodological quality of randomized controlled trials ( rct ) in very elderly subjects is equivalent to that of rct in the general adult population . since only a small sub - setting of geriatric patients are being entered into clinical trials ( de rijke et al 1996 , 2000 , 2002 ; barchielli and balzi 2000 ) , elderly patients are still being managed on the assumptions and outcomes derived from a younger cancer patient . despite this epidemiological  time bomb  ( masoro 1997 ; redmond and aapro 1997 ) , there is concern that the scientific community has so far been unable to develop a significant amount of evidence - based knowledge . the increase in incidence of cancer with age is related to a number of biologic factors . age - related etiological factors includes decreased immune surveillance , longer duration of carcinogenic exposure , increased susceptibility of cells to carcinogens , decreased dna repair , oncogene activation or amplification , and defects in tumor - suppressor genes . the biological behaviour of neoplasm , once initiated , may vary in different age groups depending on tumour type , immune system status , and alterations in other regulatory factors such as angiogenesis . attention to age - related biological changes are essential to the designing of successful therapy ( cohen 1994 ) . the biology of cancers differs in various age groups , with variations in growth patterns , and doubling times , intrinsic hormonal receptor expression , dna ploidy , tumor angiogenesis , percentage of cells in s - phase , p53 expression , and extracellular matrix protein expression ( piantanelli 1988 ; cutler and sensei 1989 ; cristofalo et al 1994 ; osiewicz and hamann 1997 ) . histologically identical tumor in older patients may behave differently ( olshansky et al 1990 ; holmes et al 1991 ; eppenberger - castori et al 2002 ; anisimov 2003 ) . the subcellular changes involved in the aging process and the effect of particular aging  phenotype has on cancer susceptibility is ill - understood ( thigpen 1998 ; ling et al 2000 ) . the correlation between immune system and cancer development / progression are currently poorly understood ( ling et al 2000 ; schindowski et al 2002 ; zhang et al 2002 ) . prolonged tumor - associated antigen exposure associated with immune exhaustion and absence of repair genes is the predominance of a  frail gene variant ( baramiya 2000 ; franceschi et al 2000 ; ling et al 2000 ) . age influences the predilection of cancer for disease site and histology type , ie , higher incidence of adeno - carcinoma of the distal esophagus , well - differentiated gastric tumors , right - sided colonic cancer , and low - grade lobular or mucinous type breast tumors in the elderly population have been reported ( audisio , veronesi , et al 1997 ) . similarly a higher incidence of larger thyroidal tumour with hrthle cell variant , extra - thyroidal growth and metastases at presentation are noted in elderly ( audisio and zbar 2002 ) . elderly patients have greater frequency of tumors with more indolent histology and an overall favorable tumor profile ( hayman and muss 2003 ) : older women with breast cancer tend to have more estrogen receptor - positive tumors ( wyld and reed 2003 ) . for most types of solid epithelial tumors , old age itself does not appear to function as an independently negative prognostic variable for cancer - specific survival ; a finding evident in recent studies assessing colorectal cancer ( audisio , cazzaniga , et al 1997 ; staudacher et al 2000 ; chiappa et al 2001 ) , gastric cancer ( lo et al 1996 ; kitamura et al 1999 ) , esophageal carcinoma ( jougon et al 1997 ; poon et al 1998 ) , liver ( chiappa et al 1999 ) , head & neck ( robinson 1994 ; rapidis et al 1998 ) and breast cancers ( veronesi et al 1988 ; desch et al 1993 ; newschaffer et al 1996 ; siliman 1996 ) . more complex issues , however , impact on different age groups and affect their overall and disease - free survival . the most important responsibility a surgeon is asked to take is to decide whether to operate or not ( jones and de cossart 1999 ; de cossart 2001 ) . the decision - making process is complex in a poor surgical candidate or frail and elderly : on one side , a nihilistic approach has been repeatedly reported , which results in intolerably poor cancer management and outcomes ; on the other , the surgical oncologist must balance the operative risk against benefits . a number of factors , including a greater need for information , a more effective utilization of available resources , and advances in peri - operative management and surgical techniques , demand an improved risk definition to be shared between the surgeon and the patient . unfortunately there seems to be no laboratory test capable of predicting postoperative adverse outcomes ( balducci et al 2001 ) . none of the risk classifications aimed at predicting outcomes in specific conditions used by surgeons are completely reliable . more importantly , no scoring method has ever been attempted specifically in the elderly population and a  cga - snap - shot  of senior patients undergoing surgery has never been attempted . the recommendations of the consensus meeting held during the 6th international conference on geriatric oncology ( balducci et al 2001 ) was that any elderly cancer patient should firstly be assessed on his / her frailty , and then considered for appropriate cancer management . currently available risk assessment tools include american society of anesthesiologists ( asa ) scoring system . the asa scoring system does not measure operative risk , rather it globally assess the degree of sickness or physical state prior to anesthesia and surgery . sensitivity of asa scoring to differentiate the proportion of patients belonging to asa ii vs iii ( leung and dzankic 2001 ) , where both groups show a similar mortality under elective conditions ( 15% ) is poor . the assessment of cardiac risk is addressed by the goldman cardiac risk index ( cri ) ( goldman et al 1977 ) ; an instrument designed to assess cardiac risk in noncardiac surgery but is rarely used by surgeons ( michaels et al 1996 ) . respiratory complications were analyzed by kroenke and colleagues ( 1993 ) who identified the following as associated with postoperative respiratory complications : 1 ) age over 70 ; 2 ) peri - operative broncho - dilator use ; 3 ) abnormal chest x - ray ; and 4 ) high asa grade . lawrence et al ( 1994 ) identified four preoperative variables that were associated with postoperative respiratory complications : 1 ) abnormal respiratory examination ; 2 ) abnormal chest x - ray ; 3 ) goldman cri ; and 4 ) the charlson co - morbidity index ( charlson et al 1987 ) . these have not been formalized as a score or validated . the acute physiological and chronic health evaluation ( apache ) it is based on 34 physiological variables taking the worst values in the first 24 hours from the patient s admission to an intensive care unit ( icu ) . various modifications of this apache system are now available : apache ii ( knaus et al 1985 ) uses 12 physiological variables ; it is currently being used in general and surgical intensive care patients . its application in the icu seems very appropriate , but its utility to general surgical patients who may not require respiratory support in the icu is limited . a relatively popular risk assessment tool especially in uk is possum ( physiological and operative severity score for enumaration of mortality and morbidity ) as well as portsmouth modification ( p - possum ) ( prytherch et al 1998 ) . the weakness of the tool is to overestimate mortality rate for low risk procedures , inability to predict postoperative outcome in preoperative setting and is affected by surgeon dependent factors rather than intrinsic difficulty of the case ( bann and sarin 2001 ; sutton et al 2002 ) . pace is a prospective multicenter , international cooperative investigation which aims at defining the general health condition of onco - geriatric surgical candidates . pace is designed to assess the functional activities of geriatric patient and hence to assess the functional life of an onco - geriatric patient . the pilot study has proven pace is feasible , inexpensive and well accepted by the patient ( warner 1998 ) . our study population constituted of 70 years age patients undergoing moderate , major and major + elective cancer surgery whose mini mental score is 18 ( ability to give written informed consent ) . the end points of the study are 30 days morbidity , 30 days mortality , and hospital bed days . the aim is to predict preoperatively the probable outcome of cancer surgery treatment in elderly . the interim analysis results ( table 3 ) show median age was 76 years ( 70100 years ) . the median number of co - morbidity was 2 in complications group and 1 in complications - free group . functional assessment using performance status ( ps ) , ( p<0.0001 ) and activities of daily living ( adl ) ( p<0.005 ) achieved statistical significance in predicting postoperative morbidity . aspects of pace relating to psychological well being ( geriatric depression score , mini mental state ) do not appear to be significantly associated with post operative morbidity . the number of co - morbidities , asa , instrumental activities of daily living ( iadl ) which failed to achieve statistical significance will be a reassessed on a larger sample . recruitment to the study is currently ongoing and full results will be revealed on completion . it is estimated that up to a third of cancer deaths is preventable by the promotion of education . an emphasis should be on the dangers of a delayed diagnosis , as well as the erroneous interpretation of misleading symptoms in the presence of co - morbidities ( audisio et al 2003 ) . this could be achieved by encouraging elderly to take part into clinical trials specifically developed for onco - geriatric series . elderly cancer patients should be encouraged to enroll with the same vigor as their younger counterpart . elderly wish to participate in trials in contrast to present perceptions ( silliman et al 1993 ) . it is also desirable to make cancer management decision within a dedicated multidisciplinary ( mdt ) meeting , comprising of onco - surgeon , oncologist , radiation therapist , geriatricians , anesthesiologists with interest in geriatric surgery , and other support staff involved in elderly patient care . educational opportunities like international society of geriatrics oncology ( siog 2006 ) conferences and the european school of oncology ( eso 2004 ) courses should be utilized to enhance our knowledge and to discuss issues pertaining to management of elderly cancer . further learning modules should be included in the medical curriculum in order to learn to look beyond age . the special needs of elderly cancer patient should be taken into consideration prior to treatment planning . more progress in optimization of surgery for cancer in elderly could be achieved with the availability of validated tools capable of predicting postoperative outcomes . clinical trials should be specifically developed for onco - geriatric series and elderly cancer patients should be encouraged to enroll . educational opportunities like siog and eso should be utilized to enhance our understanding of this unique subgroup . developments in the surgery and expansion of our elderly cancer knowledge base are the way forward to optimize cancer surgery for elderly .