The major difference between this study and the study which was reported from Birmingham in 1986 is in the incidence of emergency presentation of the disease, both in the under 70 and in the over 70 age group. In the Birmingham series, 58 per cent of the elderly patients were admitted as an emergency and 43 per cent of the younger age group; whereas, in Mr Irvin's study corresponding figures are 18 and 11 per cent. It was the high incidence of emergency presentation and its serious consequences, particularly in the elderly, which was highlighted in the Birmingham paper. The authors did not suggest that the pathology of tumours in the elderly was unfavourable per se, as was suggested in the discussion in Mr Irvin's paper, but that the staging in both emergency groups, whether over or under 70, was unfavourable in comparison with the elective cases as approximately 30 per cent of all emergencies were stage 'D'. Disseminated disease was the cause of death in one quarter of the deaths in the emergency groups. The vast majority of the remainder were due to cardio-respiratory complications, and indeed severe preexisting disease other than malignancy was considered to render the patients unfit in 11 per cent of the emergencies over the age of 70 compared with only 2 per cent under the age of 70.
I would agree with Mr Irvin's comments that differences in public awareness and standards of primary care are probably very important in influencing the timing of presentation of this disease. Dudley Road Hospital serves a predominantly poor area of inner Birmingham with many elderly people living alone. The concluding paragraph emphasized the belief that early diagnosis is very important, particularly in the elderly patients as they do especially badly if the primary disease is allowed to progress to produce obstruction or perforation. I agree with Mr Irvin that elderly patients with large bowel malignancy should be treated by surgical resection whenever possible, and should not be denied treatment that would be offered to younger patients.