Stage III colon cancers: why adjuvant chemotherapy is not offered to elderly patients

The Efficacy of Hemoglobin, Albumin, Lymphocytes, and Platelets as a Prognostic Marker for Survival in Octogenarians and Nonagenarians Undergoing Colorectal Cancer Surgery

Objectives: With the aging population worldwide, the octogenarians are becoming a substantial group and since cancer incidence increases by age, this group of patients is becoming more affected. However, no distinct treatment algorithm has been established for elderly patients with cancer. The present study aimed to determine the prognostic value of several inflammatory parameters by comparing octogenarian patients treated surgically for colorectal cancer with their younger counterparts, as well as to predict and prevent age-related complications in this frail group of patients. Methods: The demographic and clinical data were collected from octogenarians and older people as case group (51 patients) and from a nonelderly control group of patients 65 years old or younger (88 patients). Results: The results showed that Hemoglobin, Albumin, Lymphocytes, and Platelets (HALP) values were statistically different between case and control groups. Based on the results of the receiver operating characteristic analysis performed, there was a positive correlation between HALP and survival. HALP had a significant discrimination power at the good level [AUC = 0.775 (0.696-0.854); p < 0.001]. The multivariate model showed that age groups and HALP scores were significant factors for patient survival. Conclusions: HALP biomarker was associated with the prognosis of patients treated surgically for colorectal cancer with curative intent. Furthermore, HALP score was significantly different in octogenarians compared to their younger counterparts. The newly formulated Hemoglobin, Albumin, Lymphocytes, Platelets, and Age (HALPA) appeared to be a promising biomarker of survival for elderly patients scheduled for colorectal cancer surgery.

Surgical risk assessment for super-elderly patients

AIM

Super-elderly patients are often frail and the decision on surgical indications remains a difficult issue. The purpose of this study was to provide a certain preoperative surgical risk assessment tool for super-elderly people.

METHODS

We selected 112 individuals who were super-elderly patients aged >90 years who had surgeries under general anesthesia in our department. Based on the quality of the postoperative outcome of each case, we categorized these patients into two groups: good and poor groups. We evaluated the fundamental examination items, such as American Society of Anesthesiologists physical status, skeletal muscle mass index and so on, and a couple of the well-known risk score systems represented by Estimation of Physiology Ability and Surgical Stress.

RESULTS

A total of 85 of the 112 patients belonged to the good group and the rest belonged to the poor group. The quality of postoperative outcome is well characterized by Estimation of Physiology Ability and Surgical Stress (P = 0.001). Receiver operating characteristic analysis of Estimation of Physiology Ability and Surgical Stress for the quality of postoperative outcome shows sensitivity of 0.83 and specificity of 0.61. Multivariate logistic regression analysis showed that skeletal muscle mass index and American Society of Anesthesiologists physical status are prominent as the risk determinants affecting the quality of postoperative outcome. A scoring system based on the skeletal muscle mass index, which is a good index of sarcopenia, and American Society of Anesthesiologists physical status, named the "SAP score" has the following characteristics. P-value <0.001, sensitivity 0.76 and specificity 0.91.

CONCLUSIONS

Informed consent based on the risk score might be able to reduce the regrettable situation where it would have been better to have had surgery or not to have had surgery. Geriatr Gerontol Int 2022; ••: ••-••.

Neoadjuvant Therapy in Stage II/III Rectal Cancer: A Retrospective Study in a Disparate Population and the Effect on Survival

BACKGROUND

Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown.

OBJECTIVE

This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival.

DESIGN

This is a retrospective database review.

SETTINGS

This study was conducted by utilizing the Kentucky Cancer Registry at an academic center.

PATIENTS

All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival.

RESULTS

Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens.

LIMITATIONS

This study was limited by the retrospective nature of the review and by unmeasured confounders.

CONCLUSIONS

Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596.

TERAPIA NEOADYUVANTE EN EL MANEJO DEL CNCER DE RECTO EN ESTADIO II / III UN ESTUDIO RETROSPECTIVO EN UNA POBLACIN DISPAR Y EL EFECTO EN LA SUPERVIVENCIA

ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cáncer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la población que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atención de alto nivel es muy bajo. El tratamiento del cáncer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cáncer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISEÑO:Revisión retrospectiva de una base de datos.ESCENARIO:Este estudio se llevó a cabo utilizando el Registro de Cáncer de Kentucky en un centro académico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibió terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no académicos. El análisis de la supervivencia mostró una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparación con otros esquemas de tratamiento.LIMITACIONES:Revisión retrospectiva, factores de confusión no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cáncer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta población, por lo tanto se deben hacer esfuerzos en las políticas de salud, así como en educación, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no académicos. El centralizar la atención del cáncer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales económicamente, con acceso deficiente a la posibilidad de recibir atención de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

Associations between the Geriatric-8 and 4-meter gait speed test and subsequent delivery of adjuvant chemotherapy in older patients with colon cancer

OBJECTIVES

Feasible screening methods are important to identify older patients who might benefit from adjuvant chemotherapy. The aim of this study was to investigate the associations between the outcomes of screening for frailty with the Geriatric-8 questionnaire (G8) and the 4-meter gait speed test (4MGST) and subsequent delivery of adjuvant chemotherapy and treatment tolerance in older patients with colon cancer.

MATERIAL AND METHODS

This retrospective multicentre study included all patients aged ≥70 with primary colon carcinoma who underwent elective surgery between May 2016 and December 2018 and for whom adjuvant chemotherapy was indicated. Data were analysed using multivariate regression models.

RESULTS

97 (73.5%) of 132 eligible patients were screened by the G8 and 85 (64.4%) by the 4MGST. In univariate analyses, patients who scored indicative for frailty on both the G8 (≤14) and the 4MGST (>4 s) significantly more often did not proceed with adjuvant chemotherapy than patients who scored fit on both instruments (OR = 5.10, p = 0.01). After adjustment for gender, stage, and postoperative complications, the OR decreased to 4.22 (p = 0.04). Tolerance of treatment was very high (93%) and did not differ between screening groups.

CONCLUSION

Although patients who scored indicative for frailty on both the G8 and the 4MGST significantly more often did not proceed with adjuvant chemotherapy, it is still unknown whether the G8 and the 4MGST are reliable tools for identifying patients who are at high risk for severe chemotoxicity. Nonetheless, this study shows that current selection for adjuvant chemotherapy among older patients with colon cancer is safe with low rates of severe chemotoxicity.

Treatment patterns and primary reasons for adjusted treatment in older and younger patients with stage II or III colorectal cancer

OBJECTIVE

This study aims to assess age-related treatment patterns and primary reasons for adjusted treatment in patients with colorectal cancer.

METHODS

Patients with colorectal cancer stage II or III diagnosed between 2015 and 2018 in the Netherlands were eligible for this study. Data were provided by the Netherlands Cancer Registry and included socio-demographics, clinical characteristics, treatment patterns and primary reasons for adjusted treatment. Treatment patterns and reasons for adjusted treatment were analysed according to age groups.

RESULTS

Of all 29,620 patients, 30% were aged <65 years (n = 8994), 34% between 65 and 75 years (n = 10,173), 27% between 75 and 85 years (n = 8102) and 8% were ≥85 years (n = 2349). Irrespective of cancer location or stage, older patients received less frequently a combination of surgery and (neo)adjuvant therapy compared to younger patients (decreasing from 55% to 1% in colon cancer patients, and from 71% to 23% in rectal cancer patients aged <65 years and ≥85 years respectively). Omission of surgical treatment increased with age in both patients with colon cancer (ranging from 1% in patients aged <65 years to 16% in those ≥85 years) and rectal cancer (ranging from 12% in patients aged <65 years to 56% in those ≥85 years). The most common reasons for adjusted treatment were patient preference (27%) and functional status (20%), both reasons increased with advancing age.

CONCLUSIONS

Guideline non-adherence increased with advancing age and omission of standard treatment was mainly based on patient preference and functional status. These findings provides insight in the treatment decision-making process in patients with colorectal cancer. Future research is necessary to further assess patient's role in the treatment decision-making process.

The efficacy of adjuvant chemotherapy for resected high-risk stage II and stage III colorectal cancer in frail patients

BACKGROUND

The number of frail patients with colorectal cancer (CRC) has increased. Despite evidence-based treatment guidelines, a large proportion of patients with resected CRC do not receive adjuvant chemotherapy in daily practice. This retrospective study aimed to examine the effect of adjuvant chemotherapy for CRC according to frailty.

METHODS

We retrospectively analyzed data from 507 consecutive patients with curatively resected high-risk stage II or stage III CRC between 2009 and 2016. Frailty was assessed using the Clinical Frailty Scale (CFS): 1 (very fit) to 9 (terminally ill), and frailty was defined as CFS ≥ 4. Recurrence-free survival (RFS) and overall survival (OS) were compared between surgery alone and adjuvant chemotherapy in frail and non-frail patients. A cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

Of the 507 patients, 194 (38%) were frail. There were no significant interactions between frailty and adjuvant chemotherapy regarding RFS (P_interaction = 0.59) and OS (P_interaction = 0.81). In multivariable analyses, associations of adjuvant chemotherapy with longer RFS and OS in frail patients (RFS, HR: 0.33, 95% CI 0.15-0.63; OS, HR: 0.23, 95% CI 0.08-0.54) were comparable to non-frail patients (RFS, HR: 0.36, 95% CI 0.22-0.58; OS, HR: 0.34, 95% CI 0.15-0.69). Frail patients receiving adjuvant chemotherapy were younger and had better nutritional status than those undergoing surgery alone (all P < 0.005).

CONCLUSION

Selected frail patients with CRC may experience a similar survival benefit from adjuvant chemotherapy as non-frail patients. Clinical trials are needed to establish adjuvant chemotherapy for CRC in frail patients.

Minimally invasive surgery in elderly patients with rectal cancer: An analysis of the Bi-National Colorectal Cancer Audit (BCCA)

BACKGROUND

Advanced age is associated with worse outcomes after open rectal cancer surgery. However, not much is known about outcomes of minimally invasive surgery (MIS) in the elderly. The aim of this study was to evaluate safety and efficacy of MIS in elderly rectal cancer patients using the Bi-national Colorectal Cancer Audit (BCCA) data from Australia and New Zealand (ANZ).

METHODS

3451 patients were included, divided into three groups: <50 years (n = 364), 50-74 years (n = 2157) and ≥75 years (n = 930). Propensity-score matching was performed for the elderly group analysis to correct for differences in baseline characteristics.

RESULTS

MIS was performed in 52.9% of elderly patients, slightly lower than rates in <50 year and 50-74 year old groups (61% and 55.5%, respectively, p = 0.022). Elderly patients had more postoperative complications (p < 0.0001) and had a longer length of hospital stay (LOS; median 11 vs. 8 days for both other groups; p < 0.0001). Elderly patients had higher (y)pT-stages compared to both other groups (p < 0.0001) and were less likely to receive adjuvant therapy (p < 0.0001). Propensity-score matched analysis of the elderly group showed a higher rate of superficial wound dehiscence and a longer LOS after open surgery compared to MIS (10.3% vs. 2.6%, p = 0.030; 12 days vs. 9.5 days, p = 0.001, respectively), with comparable short-term oncological outcomes.

CONCLUSIONS

MIS is performed in just over half of elderly rectal cancer patients who are selected for elective rectal resection surgery in ANZ. When performed in the elderly, MIS appears safe and is associated with fewer wound complications and a shorter LOS.

Colorectal cancer care in elderly patients: Unsolved issues

Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.

Oncologists’ End of Life Treatment Decisions

Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.

Chemotherapy use in stage III colon cancer: a National Cancer Database analysis

BACKGROUND

Although adjuvant chemotherapy in stage III colon cancer improves overall survival, prior studies have shown that it is underused. We analyzed different factors that may influence its use.

METHODS

This is a retrospective study of stage III colon cancer patients (n = 207,718) diagnosed between 2000 and 2011 in the National Cancer Data Base (NCDB). The NCDB contains ~70% of new cancer diagnosis from >1500 American College of Surgeons accredited cancer programs in the United States and Puerto Rico. The chi-squared test was used to determine any difference in characteristics of patients who did or did not receive chemotherapy.

RESULTS

A total of 35% of all stage III colon cancer patients, and 38% of stage III cases undergoing surgery, did not receive adjuvant chemotherapy. The use of chemotherapy had increased in recent years (64% in 2007-2011 versus 59% in 2000-2002; p < 0.0001). Its use was lower in whites (61%), females (60%), patients ⩾60 years (55%), patients with one or more comorbidities (55%), nonacademic centers (62%), those with medicare insurance (52%), lower education (61%) and income levels (59%, all p < 0.0001). The nonwhite and uninsured were more likely to be <60 years old.

CONCLUSION

More than one-third did not receive adjuvant chemotherapy, although its use has increased in more recent years. Age was one of the most important determinants of chemotherapy use, which may explain higher rates in nonwhite and uninsured. In addition to patient characteristics, race, gender and socioeconomic factors influence chemotherapy use. These findings have important implications for healthcare reform.

Incidence and patterns of late recurrences in colon cancer patients

Long-term recurrences of colon cancer raised questions about the possible benefit of prolonging the recommended active 5-year surveillance. The aim of this study was to determine, for the first time, the incidence and patterns of late 10-year recurrence following curative resection of colon cancer. Data were obtained from two French digestive cancer registries. A total of 3,622 patients under 85 years resected for cure for colon cancer diagnosed between 1985 and 2000 were included. Information regarding recurrences was actively collected. Cumulative failure rates at 10 years were estimated using Kaplan-Meier estimates corrected by cause-specific hazards, and multivariable analysis was performed using a model for the subdistribution of a competing risk proposed by Fine and Gray. The overall cumulative recurrence rate between 5 and 10 years after initial surgery was 2.9% for local recurrence and 4.3% for distant metastasis. Among men with no recurrence 5 years after diagnosis of colon cancer, 1 in 12 developed a recurrence between 5 and 10 years, and the corresponding cumulative rate was 7.8%. The frequency was 1 in 19 for women, corresponding to a cumulative rate of 5.2%. In the multivariate analysis, non-emergency diagnostic feature, female sex and age under 75 were associated with a lower risk of recurrence. Stage at diagnosis was not a predictor of late recurrence. Late recurrence after colon cancer resection with curative intent can occur. A regular clinical follow-up is necessary to detect early signs of possible recurrence.

Age-related guideline adherence and outcome in low rectal cancer

BACKGROUND

Care for elderly patients with low rectal cancer can pose dilemmas, because radical total mesorectal excision surgery comes with high morbidity and mortality rates.

OBJECTIVE

The purpose of this study was to analyze the treatment of patients with low rectal cancer, comparing treatment choices, guideline adherence, and outcomes for elderly patients (≥75 years) with younger patients (<75 years).

DESIGN

Patient data were retrieved from the hospital pathology database and from the hospital prospective colorectal surgery database for surgically treated patients. Records were reviewed for nonadherence to treatment guidelines. Delivered treatment modalities for patients with stage I to III rectal cancer were compared with treatment advised by national guidelines, and reasons stated by the treating physician for nonadherence to guidelines were subsequently collected.

SETTINGS

This study was performed at a high-volume teaching hospital.

PATIENTS

Patients included were those with newly diagnosed rectal cancer (≤10 cm from the anal verge).

MAIN OUTCOME MEASURES

Treatment decisions, guideline adherence, and outcome of surgical treatment were the main outcome parameters.

RESULTS

Of 218 included patients, 75 (34%) were aged ≥75 years. Guideline adherence for all of the treatment modalities in stage I to III rectal cancer was significantly lower in elderly patients (62% versus 87% for aged <75 years; p < 0.001), and age was the primary reason mentioned for withholding treatment. Palliative anticancer treatment for stage IV disease was also initiated significantly less frequently in elderly patients (60% versus 97%; p = 0.002). Overall rates of treatment complications were similar for both patient groups (p = 0.71), but the impact of complications on survival was much greater for elderly patients (p = 0.002).

LIMITATIONS

Data on outcome of other treatment modalities, such as chemotherapy and radiotherapy, are lacking.

CONCLUSIONS

Guideline adherence for all of the treatment modalities in stage I to III rectal cancer declines significantly with increasing age. Future research should focus on strategies of treatment tailored to patient health status rather than chronological age.

Geriatric assessment is associated with completion of chemotherapy, toxicity, and survival in older adults with cancer

OBJECTIVES

Our purpose was to determine whether geriatric assessments are associated with completion of a chemotherapy course, grade III/IV toxicity or survival in older adults with cancer.

MATERIALS AND METHODS

In this prospective cohort study, patients aged 65 years and older with colorectal, lung, or breast cancer or lymphoma completed a brief geriatric assessment prior to chemotherapy. Endpoints included completion of the planned number of chemotherapy cycles, grade III/IV toxicity and survival. Multivariate logistic regression determined which factors were independently associated with completion of therapy, grade III/IV toxicity or death.

RESULTS

Sixty-five patients were enrolled in the study. The median age was 73 years (range 65–89). Geriatric syndromes were common, including depression (21.5%), dependence on others to carry out instrumental activities of daily living (38.5%) and activities of daily living (10.8%), and comorbidities (mild 47.7%, moderate 20%, severe 15.4%). Of the 65 participants, 67.6%completed the planned number of chemotherapy cycles. Curative intent therapy [OR 4.97 (95% CI 1.21–18.81)], Eastern Cooperative Oncology Group (ECOG) performance status 2–3 [OR 0.089 (0.015–0.53)] and renal function [OR 1.03 (1.00–1.06) per ml/min] were significantly associated with therapy completion. Furthermore, 31.1% experienced grade III/IV nonhematologic toxicity. Moderate to severe comorbidities significantly increased the risk of grade III/IV non-hematologic toxicity [OR 6.13 (1.65–22.74)]. Patients who received chemotherapy with curative intent had lower mortality [HR 0.15 (0.06–0.42)], while patients who reported a fall in themonth prior to chemotherapy had an increased risk of death [HR 3.20 (1.13–9.11)].

CONCLUSIONS

Geriatric assessment is associatedwith completion of a planned number of cycles of chemotherapy, grade III/IV non-hematologic toxicity, and mortality.

Association between the availability of medical oncologists and initiation of chemotherapy for patients with stage III colon cancer

PURPOSE

Although the number of medical oncologists (MOs) has steadily increased over time, and adjuvant chemotherapy provides significant survival benefit for patients with stage III colon cancer, many patients still do not receive chemotherapy. Uneven geographic distribution of MOs may contribute to decreasing access to cancer care. This study explored the association of MO availability by hospital service area (HSA) of patient residence and access to chemotherapy treatment.

METHODS

Using the linked SEER-Medicare database, the study identified 9,262 patients who were age ≥66 years and underwent colectomy for stage III colon cancer diagnosed from 2000 to 2005. MOs were identified by physician specialty codes. HSAs are geographic areas that are relatively self-contained with respect to routine hospital care. Multivariate logistic regression was used to investigate the association between MO availability by HSA of patient residence and initiation of chemotherapy.

RESULTS

Within 3 months after colectomy, 5,622 patients (60.7%) initiated chemotherapy. Adjusting for clinical and patient characteristics, patients residing in an HSA with ≥ one MO had an increased likelihood of initiating chemotherapy within 3 months after colectomy compared with those living in areas with no MOs (one to two MOs: OR, 1.451 [P < .01]; three to eight MOs: OR, 1.497 [P < .01]; ≥ nine MOs: OR, 1.322 [P < .01]).

CONCLUSION

Results suggest that the availability of ≥ one MO within the HSA in which a patient resides was associated with greater access to chemotherapy after surgery.

Differences between referred and nonreferred patients in cancer research

BACKGROUND

In Canada, provincial cancer registries have been established to provide rigorous population-based data for patients with colorectal cancer. Databases maintained by regional cancer agencies contain a broader scope of information and have been used as a surrogate source of information for colorectal cancer research. It is unclear whether these data can be reliably extrapolated to all patients affected by colorectal cancer. We sought to determine whether patients included in a referral-based database are systematically different from patients who are not included.

METHODS

We conducted a retrospective cohort study to compare patients referred to the British Columbia Cancer Agency with those who were not referred. Comparison was based on age, sex and geographic location. We used univariate and logistic regression analysis to identify significant differences between the cohorts.

RESULTS

Univariate analysis demonstrated that the referral and nonreferral cohorts differed in sex, age and geographic location. For patients with rectal cancer, the referral and nonreferral cohorts varied in age and geographic location. Multivariate analysis demonstrated significant differences in age and geographic location but not sex for patients with colon and rectal cancer.

CONCLUSION

Patients included in the referral database differed in age and geographic location from those included only in the provincial database. Studies using large data sets from referral centres must be interpreted with caution and may not be representative of the entire patient population.

Patterns of adjuvant chemotherapy for stage II and III colon cancer in France and Italy

BACKGROUND

European guidelines recommend adjuvant chemotherapy for stage III colon cancer but not for stage II.

AIM

To determine the extent to which adjuvant chemotherapy was used in Italy and France.

METHODS

A common retrospective database of 2186 colon cancers diagnosed between 2003 and 2005 was analysed according to age, stage and presenting features.

RESULTS

38.9% of patients with stage II and 64.6% with stage III received chemotherapy in Italy, 21.7% and 65.1% in France. For stage II, the association between country and chemotherapy was only significant in patients diagnosed out of emergency (ORItaly/France: 3.05 [2.12-4.37], p<0.001) whereas patients diagnosed in emergency were as likely to receive chemotherapy in both countries. For stage III, there was a trend to a higher administration of chemotherapy for elderly patients in France compared to Italy. French patients were more likely than Italian to receive chemotherapy (OR: 1.91[1.32-2.78], p=0.001).

CONCLUSION

Chemotherapy for stage III colon cancer was as extensively used in Italy as in France for young patients. Its administration could be increased in patients over 75. Stage II patients with a lower risk of relapse received chemotherapy more often in Italy than in France.

The effect of age and comorbidity on patient-centered health outcomes in patients receiving adjuvant chemotherapy for colon cancer

OBJECTIVES

While the impact of age, comorbidity and receipt of adjuvant chemotherapy on survival are known, less is known about their effect on patient-centered outcomes including living situation and unplanned health care services. The current study describes the impact of age and comorbidity on patient-centered outcomes in patients with colon cancer.

MATERIALS AND METHODS

Patients with resected stage III colon cancer and high risk stage II colon cancer were identified from a colorectal cancer center database. Using data collected from chart abstraction, we describe unplanned health care utilization and trajectories of living situation (use of home health, skilled nursing facility, etc.) among high-risk stage II and III colon cancer patients with regard to age categories and receipt of adjuvant chemotherapy.

RESULTS

Among 126 eligible patients, 66% received adjuvant chemotherapy and 34% did not. Older patients receiving chemotherapy were more likely to be living independently (81%) compared to those older patients who did not receive chemotherapy (63%). Older patients receiving chemotherapy were less likely to be started on an oxaliplatin-containing regimen compared to younger patients (54% vs. 81%, p=0.02). On multivariate analysis, both diabetes mellitus (OR 3.70 [95% CI 1.3-10.2]) and chronic obstructive pulmonary disease (OR 4.26 [95% CI 1.1-16.0]) were significantly associated with unplanned health care service use.

CONCLUSION

Medical oncologists appear to factor clinical and sociodemographic variables when making recommendations for adjuvant chemotherapy. Older patients deemed eligible for chemotherapy did not experience significant changes in living situation. Among patients with colon cancer receiving adjuvant chemotherapy, diabetes mellitus and COPD are associated with emergency visits and hospital admissions.

Efficacy, compliance and reasons for refusal of postoperative chemotherapy for elderly patients with colorectal cancer: a retrospective chart review and telephone patient questionnaire

BACKGROUND

Numerous clinical trials have demonstrated that elderly patients with colorectal cancer (CRC) can benefit from chemotherapy, yet compliance in real-world practice is low. The purpose of this study is to investigate the efficacy, compliance and reasons for refusal of postoperative chemotherapy for elderly patients with CRC and to provide corresponding strategies.

PATIENTS AND METHODS

The clinico-pathological and biochemical data of the chemotherapy group and chemo-refusing group were compared among 386 elderly patients (>70 years old) with CRC who underwent surgery. 226 patients received chemotherapy and 160 patients refused. Follow-up of the subjective reasons for refusal was investigated using the elderly caner patients' chemo-refusal reason questionnaire (ECPCRRQ) prepared by the authors and a group of psychologists. The questionnaire is administrated by telephone. A predictive model for 5-year disease-free survival (DFS) and 5-year overall survival (OS) was constructed by using Kaplan-Meier analysis, logistic and Cox regression.

RESULTS

Among stage III patients, receiving chemotherapy was associated with a significantly higher OS (68%) compared to those who refused ( OS 50%) (HR: 2.05, 95%CI: 1.12-3.77, P = 0.02). The Chemo-refusal group had more female and elderly patients, significantly higher rate of severe complications, and lower body mass index (BMI). Follow-up phone questionnaire analysis showed the doctors' uncertainty of chemotherapy benefit, economic difficulties, uncomfortable feeling, superstition of Traditional Chinese Medicine, concealing information and lack of social support were the main factors for elderly CRC patients to decline chemotherapy.

CONCLUSION

The receipt of post-operative chemotherapy in elderly patients with resected stage III CRC was associated with a more favorable survival. The low compliance rate (160/386) of postoperative chemotherapy was influenced by various subjective and objective factors.

Postoperative adjuvant chemotherapy use in patients with stage II/III rectal cancer treated with neoadjuvant therapy: a national comprehensive cancer network analysis

PURPOSE

Practice guidelines recommend that patients who receive neoadjuvant chemotherapy and radiation for locally advanced rectal cancer complete postoperative adjuvant systemic chemotherapy, irrespective of tumor downstaging.

PATIENTS AND METHODS

The National Comprehensive Cancer Network (NCCN) Colorectal Cancer Database tracks longitudinal care for patients treated at eight specialty cancer centers across the United States and was used to evaluate how frequently patients with rectal cancer who were treated with neoadjuvant chemotherapy also received postoperative systemic chemotherapy. Patient and tumor characteristics were examined in a multivariable logistic regression model.

RESULTS

Between September 2005 and December 2010, 2,073 patients with stage II/III rectal cancer were enrolled in the database. Of these, 1,193 patients receiving neoadjuvant chemoradiotherapy were in the analysis, including 203 patients not receiving any adjuvant chemotherapy. For those seen by a medical oncologist, the most frequent reason chemotherapy was not recommended was comorbid illness (25 of 50, 50%); the most frequent reason chemotherapy was not received even though it was recommended or discussed was patient refusal (54 of 74, 73%). After controlling for NCCN Cancer Center and clinical TNM stage in a multivariable logistic model, factors significantly associated with not receiving adjuvant chemotherapy were age, Eastern Cooperative Oncology Group performance status ≥ 1, on Medicaid or indigent compared with private insurance, complete pathologic response, presence of re-operation/wound infection, and no closure of ileostomy/colostomy.

CONCLUSION

Even at specialty cancer centers, a sizeable minority of patients with rectal cancer treated with curative-intent neoadjuvant chemoradiotherapy do not complete postoperative chemotherapy. Strategies to facilitate the ability to complete this third and final component of curative intent treatment are necessary.

Patient and physician characteristics associated with erythropoiesis-stimulating agent use in patients with myelodysplastic syndromes

Patient and physician characteristics associated with use of erythropoiesis-stimulating agents in myelodysplastic syndrome patients have not yet been described. Myelodysplastic syndrome patients diagnosed from 2001 to 2005 were identified from the Surveillance Epidemiology and End Results-Medicare database. Multivariate regressions examined the association between patient and physician characteristics and the probability of receiving any erythropoiesis-stimulating agents, and of receiving therapeutic-length (≥ 8 week) treatment episodes. Among the 6,588 myelodysplastic syndrome patients studied, 65% received erythropoiesis-stimulating agents. Use of erythropoiesis-stimulating agents was lower for blacks compared to whites (OR 0.78; 95% CI:0.61-0.99), single persons compared to married (OR 0.77; 95% CI:0.62-0.97), Medicaid recipients (OR 0.66; 95% CI:0.55-0.79), and those living in census tracts with lower educational attainment. Patients who did not consult a hematology-oncology specialist were less likely to receive erythropoiesis-stimulating agents. Specialist access, financial resources and mobility are key determinants of receipt of erythropoiesis-stimulating agents among myelodysplastic syndrome patients.

Evaluation of efficacy and safety of FOLFIRI for elderly patients with gastric cancer: a first-line phase II study

OBJECTIVE

Current chemotherapy protocols for gastric cancer present high toxicity. The FOLFIRI regimen has shown promising results with elderly colorectal cancer patients and for gastric cancer patients but this is the first report on elderly gastric cancer patients.

DESIGN

In this multicenter non-randomized phase II trial, we administered the FOLFIRI chemotherapy protocol (irinotecan [180 mg/m(2)], fluorouracil [5-FU] [400 mg/m(2)] and folinic acid 400 mg/m(2) or 200mg/m(2) of l-folinic acid) to patients aged over 70 years with locally-advanced or metastatic gastric cancer combined with Comprehensive Geriatric Assessment (CGA). Responses were assessed at 2 months.

RESULTS

Forty-two patients received eight cycles of the FOLFIRI regimen, with 82.5% of patients showing disease control: 10 patients (26%) showing objective (partial or complete) responses and 23 (57.5%) showing stable disease. One-year overall survival (OS) was 41.5% [95%CI 26.5-56.0] and one-year progression-free survival (PFS) was 31.8% [95%CI 18.4-46.1%]. We observed 10 Grade 3/4 hematologic toxicities with one febrile neutropenia. CGA data demonstrated that geriatric functions were not altered by treatment and that nutritional status improved over treatment.

CONCLUSIONS

Results show excellent disease control and relatively high survival rates with limited toxicity similar to younger patients indicating that this regimen should be considered as a possible treatment in advanced gastric cancer of the elderly.

Reasons for underuse of recommended therapies for colorectal and lung cancer in the Veterans Health Administration

BACKGROUND

Many studies have documented low rates of effective cancer therapies, particularly in older or minority populations. However, little is known about why effective therapies are underused in these populations.

METHODS

The authors examined medical records of 584 patients with cancer diagnosed or treated in Department of Veterans Affairs facilities to assess reasons for lack of 1) surgery for stage I/II nonsmall cell lung cancer, 2) surgery for stage I/II/III rectal cancer, 3) adjuvant radiation therapy for stage II/III rectal cancer, and 4) adjuvant chemotherapy for stage III colon cancer. They also assessed differences in reasons for underuse by patient age and race.

RESULTS

Across the 4 guideline-recommended treatments, 92% to 99% of eligible patients were referred to the appropriate cancer specialist; however, therapy was recommended in only 74% to 92% of eligible cases. Poor health was cited in the medical record as the reason for lack of therapy in 15% to 61% of underuse cases; patient refusal explained 26% to 58% of underuse cases. African American patients were more likely to refuse surgery. Older patients were more likely to refuse treatments.

CONCLUSIONS

Recommendation against therapy was a primary factor in underuse of effective therapies in older and sicker patients. Patients' refusal of therapy contributed to age and racial disparities in care. Improved data on the effectiveness of cancer therapies in community populations and interventions aimed at improved communication of known risks and benefits of therapy to cancer patients could be effective tools to reduce underuse and lingering disparities in care.

Oxaliplatin-based chemotherapy in the treatment of elderly patients with metastatic colorectal cancer (CRC)

Elderly patients constitute a subpopulation with special clinical features that differ from those of the general population and are under-represented in clinical trials. We retrospectively analyzed the toxicity and efficacy of oxaliplatin-based chemotherapy in the treatment of elderly patients affected by metastatic (m) CRC. Seventy-five consecutive patients aged 65-75 years (median age 71 years), 51 males and 24 females, with mCRC and measurable disease, were analyzed. The primary site of metastases was the liver (38.6% of patients). The majority of patients had a performance status (PS) according to the Eastern Cooperative Oncology Group (ECOG) PS before treatment of 0-1 (96%). The overall response rate was 57.3%, median progression-free survival was 7 months and median overall survival was 27 months. The main hematological and extra-hematological toxicities (grade 3 or 4) were neutropenia (20.0%), and neurological toxicity or diarrhea (6.7%), respectively. No toxic death occurred. Oxaliplatin-based chemotherapy maintains its efficacy, and safety in elderly patients with mCRC and good PS. This regimen should be considered in the treatment of this particular setting of patients.

FOLFOX4 in the treatment of metastatic colorectal cancer in elderly patients: a prospective study

Elderly patients constitute a subpopulation with special characteristics that differ from those of the general population and have been under-represented in clinical trials. We, prospectively, analyzed the toxicity and efficacy of the original FOLFOX4-regimen in the treatment of elderly patients affected by metastatic (m) colorectal cancer (CRC). Thirty-six consecutive patients aged 67-82 years (median age 72 years), 22 males and 14 females, with mCRC and measurable disease, were enrolled in the study. The primary site of metastases was the liver (36.1% of patients). The median ECOG Performance Status (PS) was 1. The main hematological and extra-hematological (grade 3 or 4) toxicities were neutropenia (38.9%) and neurological (13.9%), respectively. A total of 36 patients, aged 67-82 years were included. Twenty-two and 14 patients were male and female, respectively. The median age was 72 years (range 67-82). The primary site of metastases was the liver (36.1% of patients). The median ECOG Performance Status (PS) was 1. The overall response rate (ORR) was 44.4% and similar to original study. Median progression-free survival (PFS) was 7.5 months and median overall survival (OS) was 16 months. The main hematological and extra-hematological (grade 3 or 4) toxicities were neutropenia (38.9%) and neurological (13.9%), respectively. Tolerability, however, was manageable and no toxic death occurred. FOLFOX4-regimen maintains its efficacy, and safety ratio in elderly patients with mCRC and good performance status. It would be considered the treatment of choice in the treatment of this particular setting of patients.

Factors influencing medical oncology referral in Dukes' C colonic cancer

AIM

Colorectal cancer (CRC) is one of the most common malignancies worldwide and adjuvant chemotherapy is proven to improve survival in patients with Dukes' C CRC. The purpose of this study was to analyze factors influencing referral to medical oncology in patients with Dukes' C colonic cancer in our institutions.

METHODS

Patients who underwent resection for Dukes' C colonic cancer were assessed for factors that influence the pattern of postoperative referral to the medical oncology department, including demographic and perioperative data.

RESULTS

Overall, 466 patients were identified to have Dukes' C colonic cancer, with 53.9% of these being female. Referral to medical oncology occurred for 58.4% patients. Multivariable logistic regression modeling identified age, elective admission and resection in private hospitals as factors. The likelihood of medical oncology referral in patients who had elective resection was 63% versus 41% in those who had emergency resection and resection in private hospitals was 69% versus 50% in public hospitals.

CONCLUSION

Referral to a postoperative medical oncology clinic for adjuvant chemotherapy in Dukes' C colonic cancer was more likely in younger patients, those who underwent elective resection and those treated in private hospitals.

The Benefit of Adjuvant Chemotherapy in Elderly Patients with Stage III Colorectal Cancer is Independent of Age and Comorbidity

OBJECTIVES: To determine the combined effect of age and comorbidity on receipt of chemotherapy and its impact on survival in elderly patients with stage III colorectal cancer (CRC). MATERIALS AND METHODS: All patients over age 65 with Stage III CRC diagnosed 1996-2006 were identified from the Barnes-Jewish Hospital Oncology Data Services registry. An age/comorbidity staging system was created using the ACE-27 comorbidity index and data from both Stage II and III CRC. The staging system was then applied to patients with Stage III CRC. Odds of receiving chemotherapy were calculated, and survival analyses determined the impact of chemotherapy on overall survival in each age/comorbidity stage. RESULTS: 435 patients with Stage III CRC were evaluated [median age 75 years (range 65-99)]. Advancing age/comorbidity stage (Alpha, Beta, Gamma) was associated with decreasing odds of receiving chemotherapy for Stage III CRC [Odds Ratio 0.83 (95% CI, 0.51-1.35) for Beta and 0.14 (95% CI, 0.08-0.24) for Gamma, compared to Alpha]. Chemotherapy was associated with lower risk of death in each of the age/comorbidity stages, compared to those who underwent surgery only. The hazard ratio for death in patients who did not receive chemotherapy, relative to those who did, within each age/comorbidity stage was 1.8 [95%CI 1.06-3.06] for Alpha, 2.24 [95%CI 1.38-3.63] for Beta and 2.10 [95% CI 1.23-3.57] for Gamma. CONCLUSION: While stage III CRC patients with increasing age and comorbidity are less likely to receive chemotherapy, receipt of chemotherapy is associated with a lower risk of death.

[Geriatrics and radiation oncology. Part 1: How to identify high-risk patients and basic treatment principles]

BACKGROUND

Until the mid of this century, 33% of the Western population will be > or = 65 years old. The percentage of patients being > or = 80 years old with today 5% will triple until 2050. Therefore, radiation oncologists must be familiar with special geriatric issues to meet the increasing demand for multidisciplinary cooperation and to offer useful and individual treatment concepts.

PATIENTS AND METHODS

This review article will provide basic data on the definition, identification and treatment of geriatric cancer patients.

RESULTS

The geriatric patient is defined by typical multimorbidity (15 items) and by age-related increased vulnerability. Best initial identification of geriatric patients will be provided by assessment including the Barthel Index evaluating self-care and activity in daily life, by the Mini-Mental Status Test that will address cognitive pattern, and by the Timed "Up&Go" Test for evaluation of mobility. As for chemotherapy, standard treatment was associated with increased toxicity, consequently, dose modifications and supportive treatment are of special importance.

CONCLUSION

Geriatric cancer patients need to be identified by special assessment instruments. Due to increased toxicity following chemotherapy, supportive measures seem important. Radiation treatment as a noninvasive and outpatient-based treatment remains an important and preferable option.

The adverse prognostic impact of advanced age in multiple myeloma

The adverse prognostic impact of advanced age in multiple myeloma is multi-factorial. In this review we explore the various contributory factors to this phenomenon. These include general biological and psychosocial factors, which impact on cancer in the elderly population such as the presence of multiple co morbidities and poor performance status at diagnosis and variation in patient's expectations of treatment. Factors specific to myeloma include the ability to deliver optimum therapy in older patients and the impact of this on disease response, possible biological differences of myeloma in older patients, and how these various factors impact on the efficacy of conventional-dose, high-dose (HDT) and newer disease modifying therapies. Selected elderly patients can gain equal benefit to younger patients from effective therapies such as HDT. However, the use of specific assessment tools for the elderly, apart from chronological age, should be used to select elderly patients who will benefit. Future testing of newer therapies in patients with myeloma must include older patients, who will make up an increasing proportion of the myeloma population in the future and should incorporate assessment of effect of these therapies on quality of life.

Disparities in the treatment of colon cancer in octogenarians

BACKGROUND

Disparities in healthcare for the elderly are understudied, despite the increasing proportion of patients over 80 years of age. Advanced age is a principal risk factor for colorectal adenocarcinoma, but there are few data to guide treatment in the elderly patient population.

METHODS

We performed a retrospective review of prospectively gathered data on 10,433 patients diagnosed with primary colon tumors between 1998 and 2004. We compared demographics, stage at diagnosis, and initial treatment between patients younger than 80 years and those age 80 years or older.

RESULTS

Patients who were >or=80 years old made up 30% of the database. Older patients were less likely to have colectomy for advanced or metastatic disease than younger patients. Patients who were >or=80 years of age had fewer lymph nodes removed than younger patients (11 vs 10, P <.01). Older patients were significantly less likely to receive chemotherapy for every stage of colon cancer than younger patients. When older patients did get chemotherapy, it was more likely to be with a single agent. Multivariate analysis revealed that predictors of receiving chemotherapy for patients >or=80 years of age include living in an urban county, younger age, and worse stage at diagnosis.

CONCLUSIONS

Older patients make up a large portion of the patients treated for colon cancer and are treated less aggressively. While some of the treatment difference may be explained by medical factors, demographic factors affect treatment decisions as well.

Half of elderly patients routinely treated for colorectal cancer receive a sub-standard treatment

BACKGROUND

Several database studies report a lack of care in elderly patients with colorectal cancer.

PURPOSE

To describe the management of elderly patients admitted for colorectal cancer; to identify factors associated with standard management according to recommendations and to study factors influencing the survival.

PATIENTS AND METHODS

All consecutive patients over 75 years managed for a colorectal adenocarcinoma in our hospital from 1995 to 2000 and followed until 2006 were retrospectively included. The appropriateness of the management of their disease according to the recommendations available at that time was assessed. Several risk factors in receiving the standard cancer treatment were tested using univariate and then multivariate logistic regression. Risk factors of survival were studied using univariate and then multivariate survival analysis.

RESULTS

One hundred and ten patients were included. Median age was 82 years (range: 75-96). A surgical treatment was performed in 96 patients. The median overall survival was 32 (1-108) months. A standard cancer treatment according to recommendations was performed in 53 (48%) patients: adjuvant chemotherapy in 6/23 patients with stage III tumour, palliative chemotherapy in 3/18 patients with stage IV tumour and adjuvant radiotherapy in 4/14 patients who had a rectal tumour resection. Multivariate analysis retains tumour stage I or II (OR=7.6, 95% C.I.=[2.9-19.9], p<0.0001) as the only factor associated with standard treatment and presence of metastasis (HR=3.9, 95% C.I. [1.4-10.8], p=0.005), and Charlson's score >3 (HR=28.9, 95% C.I. [2.5-335.6], p=0.001) as independent risk factors of poor survival.

CONCLUSIONS

Fifty two percent of elderly patients have had a sub-standard cancer treatment. The majority had a surgical treatment, but only a few received chemotherapy or radiotherapy. Metastasis, older age and Charlson's comorbidity score are the main prognosis factors of poor survival.

Impact of patient age and comorbidity on surgeon versus oncologist preferences for adjuvant chemotherapy for stage III colon cancer

BACKGROUND

To study surgeons' versus oncologists' preferences for adjuvant chemotherapy for elderly patients with stage III colon cancer, as population studies indicate that such patients are less likely to receive treatment.

STUDY DESIGN

A vignette-based survey was mailed to a nationally representative sample of 1,000 general surgeons and 1,000 oncologists in the United States. Patient age, comorbidity level, and preference were varied across eight vignettes. Physician preference for referral (surgeons) or treatment (oncologists) was measured using a 7-point Likert scale. Mixed-effects linear regression was used to evaluate the results.

RESULTS

One thousand twenty-nine surveys were returned (response rate of 54%). Among surgeons, increasing age and more severe comorbidity resulted in lower likelihood of referral to oncologist: mean difference in preference scores for vignettes describing a 61-year-old versus an 83-year-old patient (adjusted for comorbidity) was 0.77 (p < 0.0001); mean difference in scores between vignettes describing a patient with none versus severe comorbidity, adjusted for age, was 1.94 (p < 0.0001). Among oncologists, patient age and comorbidity interacted significantly (p < 0.0001) to affect oncologists' preferences: both increasing age and more severe comorbidity resulted in decreased preference for recommending adjuvant chemotherapy, but oncologists were more heavily influenced by comorbidity at younger patient age. Patient preference against therapy also affected physicians' recommendations (p < 0.0001), but the magnitude of effect was small relative to age and comorbidity.

CONCLUSION

Patient age and comorbidity level influence both types of physicians' preferences about adjuvant chemotherapy for colon cancer and might explain some of the patterns of care seen for this disease in population-based studies.

Residual treatment disparities after oncology referral for rectal cancer

BACKGROUND

Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.

METHODS

We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.

RESULTS

There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.

CONCLUSION

Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

FOLFOX in patients aged between 76 and 80 years with metastatic colorectal cancer: an exploratory cohort of the OPTIMOX1 study

BACKGROUND

Patients older than 75 years of age are usually excluded from metastatic colorectal cancer randomized studies. The OPTIMOX1 study evaluated FOLFOX7, a simplified (s) leucovorin (LV) and 5-fluorouracil (5FU) regimen (sLV5FU2) with high-dose oxaliplatin, in a new oxaliplatin stop-and-go strategy. An exploratory cohort of patients aged 76 to 80 years was included in the study.

METHODS

In all, 620 previously untreated patients were randomized between FOLFOX4 until progression (arm A), or FOLFOX7 for 6 cycles, maintenance without oxaliplatin for 12 cycles, and reintroduction of FOLFOX7 (arm B).

RESULTS

A total of 37 patients aged 76 to 80 years were included, 20 in arm A and 17 in arm B. The overall response rate (ORR) was 59.4%, comparable to younger patients (59%). Median progression-free survival (PFS) was 9.0 months and median overall survival (OS) was 20.7 months. These results did not differ from that in younger patients < or =75 years in the OPTIMOX1 study with PFS 9.0 months (P = .63) and OS 20.2 months (P = .57). They experienced slightly more grade 3 of 4 toxicity than younger patients: 65% versus 48% (P = .06), mainly with more neutropenia (41% vs 24%, P = .03) and neurotoxicity (22% vs 11%, P = .06). Tolerability, however, was manageable and no toxic death occurred in this elderly population.

CONCLUSIONS

The efficacy of FOLFOX-based treatment was maintained in patients >75 years with both FOLFOX regimens. The oxaliplatin stop-and-go management strategy performed well in this population.

Assessing the quality of colorectal cancer care: do we have appropriate quality measures? (A systematic review of literature)

RATIONALE, AIMS AND OBJECTIVES

The burden of illness from colorectal cancer (CRC) can be reduced by improving the quality of care. Identifying appropriate quality measures is the first step in this direction. We identified process measures currently available to assess the quality of diagnosis and management of CRC. We also evaluated the extent to which these measures are ready to be implemented in clinical practice, and identified areas for future research.

METHODS

We searched MEDLINE, Cochrane Database of Systematic Reviews, and relevant grey literature. We identified 3771 abstracts and reviewed 74 articles that included quality measures for diagnosis or management of CRC. Measures from traditional quality improvement literature, and from epidemiological and other studies that included quality measures as part of their research agenda, were considered. In addition, we devised a summary rating scale (IST) to appraise the extent of a measure's importance and usability, scientific acceptability and extent of testing.

RESULTS

The coverage of general process measures in CRC is extensive. Most measures are important, but need to be developed and field-tested. The best available measures relate to pathology and chemotherapy. No measures are available for assessing quality of management of stage IV rectal cancer and hepatic metastasis; chemotherapy for stage II colon cancer; and procedure notes.

CONCLUSIONS

There is an urgent need to refine existing measures and to develop scientifically accurate quality measures for a comprehensive assessment of the quality of CRC care. The role of the federal government and professional societies is critical in pursuing this goal.

First-line treatment strategies for elderly patients with metastatic colorectal cancer

Colorectal cancer ranks third in incidence in both men and women after lung, breast and prostate cancer. The prevalence of colorectal cancer increases significantly with age, with 40% of patients in Europe being >75 years of age at the time of initial diagnosis. Furthermore, the number of elderly patients with colorectal cancer is expected to increase significantly over the next two decades. Treatment of advanced colorectal cancer has evolved dramatically over the last decade. Advances in surgery and chemotherapy are effective in prolonging time to disease progression and survival in patients with advanced colorectal cancer. For >40 years, fluorouracil has been the mainstay of chemotherapy for advanced colorectal cancer. Recently, however, newer cytotoxic chemotherapies and biological agents effective against colorectal cancer have been shown to improve overall survival in metastatic disease. Thus, a patient with metastatic colorectal cancer today has an expected median survival of 20 months compared with 10 months only a few years ago. There is evidence that elderly individuals derive as much survival benefit from standard chemotherapy approaches in metastatic colorectal cancer as younger patients. Unfortunately, most older patients who might benefit from chemotherapy are not offered this treatment, and the fraction who are not offered it increases with increasing age. Treatment decisions should not be made on the basis of age. Rather, they should be based on functional status, the presence of co-morbidities, and consideration of drug-specific toxicities that can be aggravated in older individuals because of decreased functional reserve. Although the elderly have been under-represented in clinical trials, studies also support the effectiveness of combination chemotherapy in elderly patients with advanced colorectal cancer. This article reviews current optimal first-line treatment strategies for elderly patients with metastatic colorectal cancer.

Referral to medical oncology: a crucial step in the treatment of older patients with stage III colon cancer

PURPOSE

Adjuvant chemotherapy for stage III colon cancer produces a substantial survival benefit, but many older patients do not receive chemotherapy. This study examines factors associated with medical oncology consultation and evaluates the impact of such consultation on chemotherapy use.

PATIENTS AND METHODS

We used the Surveillance Epidemiology and End Results-Medicare linked database and identified 7,569 patients, aged 66-99, with stage III colon cancer diagnosed from 1992-1999. Modified Poisson regression was used to assess the relative risk for seeing a medical oncologist and for receiving chemotherapy as a function of individual characteristics.

RESULTS

78.08% of patients saw a medical oncologist within 6 months of diagnosis. Patients who were female, white, married, had low comorbidity scores, were diagnosed in more recent years, or had four or more positive lymph nodes were more likely to see a medical oncologist. Patients seeing a medical oncologist were 10 times more likely to receive chemotherapy (odds ratio, 9.98; 95% confidence interval, 8.21-12.14), after controlling for demographic and tumor characteristics. Chemotherapy use increased over time, but was substantially lower among older, black, and unmarried patients.

CONCLUSIONS

Referral to medical oncology is one of the most important factors associated with receipt of chemotherapy among older patients with stage III colon cancer. Comorbidity decreases the likelihood of receiving chemotherapy, but its effect is the same for those who see a medical oncologist and all patients combined. Ensuring that high-risk patients are referred to medical oncology is a crucial step in quality care for patients with colon cancer.

Radical prostatectomy for octogenarians: How old is too old?

OBJECTIVES

As the population ages, healthy octogenarians are increasingly diagnosed with prostate cancer. Some of these patients will request radical prostatectomy (RP), although outcome data in this population group are lacking. We report our experience with patients undergoing RP during their ninth decade of age.

METHODS

From 1986 to 2003, 13,154 patients underwent RP at our institution. Of these patients, 19 (0.14%) were 80 years old or older at surgery and were included in this analysis. Patient survival and quality-of-life measures were retrospectively obtained from the Mayo Clinic Prostatectomy Registry.

RESULTS

The reasons for RP varied, but usually patients requested or demanded operative intervention. At surgery, the mean patient age was 81 years (range 80 to 84), the median prostate-specific antigen level was 10.2 ng/mL (range 1.3 to 45.9), and the mean American Society of Anesthesiologists score was 2.4 (range 2 to 3). Of the 19 patients, 13 (68%) had Stage pT3 disease or a Gleason score of 7 or more. The median follow-up was 10.5 years (range 1.2 to 14.2). At the last follow-up visit, 10 patients had survived more than a decade after RP and 3 patients had died within 10 years of surgery. The remaining 6 patients were alive at less than 10 years of follow-up. Of the 19 patients, 14 (74%) were continent; 1 patient required an artificial sphincter. No patient had died of prostate cancer, and the 10-year all-cause survival rate was similar to that observed in healthy patients 60 to 79 years old undergoing RP.

CONCLUSIONS

On rare occasions, healthy and well-informed octogenarians will request RP for prostate cancer treatment. Our data suggest that select patients can achieve satisfactory oncologic and functional outcomes after surgery, although the rate of urinary incontinence is increased compared with that in younger counterparts.