Adjuvant chemotherapy in patients with colorectal cancer. Is there a role in the older adult?

Patient-Derived Tumor Organoids: A Platform for Precision Therapy of Colorectal Cancer

Colorectal cancer (CRC) represents a significant cause of cancer-related mortality on a global scale. It is a highly heterogeneous cancer, and the response of patients to homogeneous drug therapy varies considerably. Patient-derived tumor organoids (PDTOs) represent an optimal preclinical model for cancer research. A substantial body of evidence from numerous studies has demonstrated that PDTOs can accurately predict a patient's response to different drug treatments. This article outlines the utilization of PDTOs in the management of CRC across a range of therapeutic contexts, including postoperative adjuvant chemotherapy, palliative chemotherapy, neoadjuvant chemoradiotherapy, targeted therapy, third-line and follow-up treatment, and the treatment of elderly patients. This article delineates the manner in which PDTOs can inform therapeutic decisions at all stages of CRC, thereby assisting clinicians in selecting treatment options and reducing the risk of toxicity and resistance associated with clinical drugs. Moreover, it identifies shortcomings of existing PDTOs, including the absence of consistent criteria for assessing drug sensitivity tests, the lack of vascular and tumor microenvironment models, and the high cost of the technology. In conclusion, despite their inherent limitations, PDTOs offer several advantages, including rapid culture, a high success rate, high consistency, and high throughput, which can be employed as a personalized treatment option for CRC. The use of PDTOs in CRC allows for the prediction of responses to different treatment modalities at various stages of disease progression. This has the potential to reduce adverse drug reactions and the emergence of resistance associated with clinical drugs, facilitate evidence-based clinical decision-making, and guide CRC patients in the selection of personalized medications, thereby advancing the individualized treatment of CRC.

Unraveling the role of tumor sidedness in prognosis of stage II colon cancer

Background

Stage II colon cancer has varying risks for metastasis, and treatment strategies depend on molecular and clinicopathological features. While tumor-sidedness is a well-accepted prognostic factor for stage III/IV colon cancer, its role in stage II is controversial. Understanding its effect in stage II is crucial for improving treatment strategies.

Methods

We analyzed clinical and follow-up data of colon cancer from the Surveillance, Epidemiology, and End Results database (2004-2017). Patients were divided into a primary study cohort (2010-2017) and a validation cohort (2004-2009). The baseline characteristics between right-sided colon cancer (RCC) and left-sided colon cancer (LCC) groups were compared. Moreover, the effect of tumor size on cancer-specific survival (CSS) was evaluated using Kaplan-Meier analysis.

Results

The study involved 87,355 patients in the study cohort and 65,858 in the validation cohort. Of the study cohort, 52.3% were diagnosed with RCC. The median age was 64 years old, with 48.5% females and 76.8% of white people. In addition, stage II RCC showed better CSS compared with LCC (5-year CSS 88.0% vs 85.5%, P < 0.001), while stage III/IV RCC demonstrated poorer outcomes. Multivariate Cox regression analysis identified that the right-sidedness was a positive prognostic factor in stages I/II but negative in stages III (HR 1.10, P < 0.001) and IV (HR 1.26, P < 0.001). Chemotherapy rates decreased in RCC, particularly in stage II (RCC vs LCC: 16.2% vs 28.5%, P < 0.001). Subgroup analysis, stratified by T3/T4 stages and chemotherapy status, further highlighted better survival outcomes in RCC.

Conclusions

RCC is associated with a significantly better prognosis in stage II. The importance of considering tumor-sidedness in clinical decision-making and the design of future clinical trials should be emphasized.

Real-world analysis of survival benefit of surgery and adjuvant therapy in elderly patients with colorectal cancer

Treatment guidelines for colorectal cancer (CRC) in elderly patients remain unclear. This study aimed to investigate whether elderly patients (≥ 70 years) with CRC benefit from surgery and adjuvant therapy. A total of 90,347 eligible CRC patients older than 70 years were collected from the Surveillance, Epidemiology, and End Results (SEER) database and divided into a surgery group and a no-surgery group. After being matched by propensity score matching at a 1:1 ratio, 23,930 patients were included in our analysis. The Kaplan‒Meier method and log-rank test were applied to compare overall survival (OS) and cancer-specific survival (CSS). Univariate and multivariate Cox regression analyses were utilized to confirm independent prognostic factors for OS and CSS. In age-stratified analysis (70-74; 75-79; 80-84; ≥ 85), the OS and CSS rates of patients in the surgery group were significantly higher than those of patients in the no-surgery group (all P < 0.001). Adjuvant therapy was an independent prognostic factor for OS and CSS in elderly patients with CRC (all P < 0.001). Further analysis showed that elderly colon cancer patients with stage III and stage IV disease gained a survival benefit from adjuvant chemotherapy. Adjuvant chemoradiotherapy can significantly improve OS and CSS in elderly rectal cancer patients with stage II, III, and IV disease. In conclusion, among CRC patients aged ≥ 70 years reported in the SEER database, treatment with surgical resection is significantly associated with improved OS and CSS. Moreover, adjuvant therapy led to a significant prognostic advantage for elderly advanced CRC patients who underwent surgery.

Factors Associated With Adjuvant Chemotherapy Noncompliance and Survival in Older Adults With Stage III Colon Cancer

BACKGROUND

Standard management of stage III colon cancer includes surgical resection and adjuvant chemotherapy. Despite improved overall survival with adjuvant chemotherapy in stage III colon cancer, it is reportedly underused in older adults. To date, no contemporary national analysis of adjuvant chemotherapy use and its impact on older adults with stage III colon cancer exists.

OBJECTIVE

This study aimed to assess the current use of adjuvant chemotherapy in older adults with stage III colon cancer and determine factors associated with noncompliance.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted using the National Cancer Database.

PATIENTS

This study included patients aged 65 years and older undergoing curative resection for stage III colon adenocarcinomas, 2010-2017.

MAIN OUTCOME MEASURES

Adjuvant chemotherapy use, factors associated with adjuvant chemotherapy use, and overall survival with and without adjuvant chemotherapy in older adults with pathologic stage III disease.

RESULTS

Of 64,608 patients included, 64.3% received adjuvant chemotherapy. Adjuvant chemotherapy was significantly independently associated with improved 1-, 3-, and 5-year overall survival vs no adjuvant chemotherapy (92.8%, 75.3%, 62.4% vs 70.8%, 46.6%, 32.7%; HR 0.475; 95% CI, 0.459-0.492; p <0.001). Compared with the no adjuvant chemotherapy cohort, patients who received adjuvant chemotherapy were younger, female, and less comorbid ( p < 0.001). Factors associated with adjuvant chemotherapy noncompliance included advancing age, lower annual income, open approach, longer length of stay, pathologic stage IIIA, and fewer than 12 lymph nodes.

LIMITATIONS

Administrative data source with inherent risks of bias, coding errors, and limitations in the fields available for analysis.

CONCLUSIONS

Adjuvant chemotherapy significantly improved overall survival but was only used in 64.3% of older adults with stage III colon cancer. Adjuvant chemotherapy noncompliance was seen in the most vulnerable and highest-risk patients, including those with greater comorbidity, lower income, and patients who received open surgery. See Video Abstract at http://links.lww.com/DCR/C125 .

FACTORES ASOCIADOS CON EL INCUMPLIMIENTO DE LA QUIMIOTERAPIA ADYUVANTE Y LA SUPERVIVENCIA EN ADULTOS MAYORES CON CNCER DE COLON EN ESTADIO III

ANTECEDENTES: El tratamiento estándar de oro del cáncer de colon en estadio III incluye la resección quirúrgica y la quimioterapia adyuvante. A pesar de la mejora de la supervivencia general con la quimioterapia adyuvante en el cáncer de colon en estadio III, se reporta que se utiliza poco en los adultos mayores. Hasta la fecha, no existe ningún análisis nacional actual, sobre el uso de quimioterapia adyuvante y su impacto en adultos mayores con cáncer de colon en etapa III.OBJETIVO: Evaluar el uso actual de quimioterapia adyuvante en adultos mayores con cáncer de colon en estadio III y determinar los factores asociados con el incumplimiento.DISEÑO: Estudio de cohorte retrospectivo.AJUSTES: Realizado y utilizando la Base de Datos Nacional de Cáncer.PACIENTES: Pacientes de 65 años o más sometidos a resección curativa por adenocarcinomas de colon en estadio III de 2010-2017.PRINCIPALES MEDIDAS DE RESULTADO: Uso de quimioterapia adyuvante, factores asociados con el uso de quimioterapia adyuvante y supervivencia general con y sin quimioterapia adyuvante en adultos mayores con enfermedad en estadio patológico III.RESULTADOS: De 64.608 pacientes incluidos, el 64,3% recibió quimioterapia adyuvante. La quimioterapia adyuvante se asoció de forma significativa e independiente con una mejor supervivencia general a 1, 3 y 5 años frente a ninguna quimioterapia adyuvante (92,8 %, 75,3 %, 62,4 % frente a 70,8 %, 46,6 %, 32,7 %; respectivamente, HR 0,475, 95 % IC 0,459-0,492, p < 0,001). En comparación con la cohorte sin quimioterapia adyuvante, los pacientes que recibieron quimioterapia adyuvante eran más jóvenes, mujeres y con menos comorbilidad. (p < 0,001). Los factores asociados con el incumplimiento de la quimioterapia adyuvante incluyeron edad avanzada (OR 0,857, IC del 95 % 0,854-0,861), ingresos anuales más bajos (OR 0,891, IC del 95 % 0,844-0,940), abordaje abierto (0,730, IC del 95 % 0,633-0,842), mayor duración de la estancia (OR 0,949, IC 95% 0,949-0,954) y estadio patológico IIIA (0,547, IC 95% 0,458-0,652) y <12.LIMITACIONES: Fuente de datos administrativos con riesgos inherentes de sesgo, errores de codificación y limitaciones en los campos disponibles para el análisis.CONCLUSIONES: La quimioterapia adyuvante mejoró significativamente la supervivencia general, pero solo se utilizó en el 64,3 % de los adultos mayores con cáncer de colon en estadio III. El incumplimiento de la quimioterapia adyuvante se observó en los pacientes más vulnerables y de mayor riesgo, incluidos aquellos con mayor comorbilidad, menores ingresos y pacientes que recibieron cirugía abierta. Consulte Video Resumen en http://links.lww.com/DCR/C125 . (Traducción-Dr. Fidel Ruiz Healy ).

Shikonin potentiates therapeutic efficacy of oxaliplatin through reactive oxygen species-mediated intrinsic apoptosis and endoplasmic reticulum stress in oxaliplatin-resistant colorectal cancer cells

Oxaliplatin (OXA) has been recognized as a third-generation platinum-based chemotherapeutic agent with stellar therapeutic efficacy in managing colorectal cancer (CRC). Nevertheless, resistance to OXA in CRC patients hinders its effectiveness. Shikonin (SHI), a natural naphthoquinone derived from Arnebia euchroma (Royle) Johnst., features a broad pharmacological profile and minimal toxicities. To assess the synergism of SHI and OXA towards OXA-resistant CRC cells (HCT116^R ), we employed in vitro and in vivo pharmacological assays. Our experiments provided evidence that SHI, either alone or in combination with OXA, considerably reduced cell proliferation, triggered apoptosis, and induced the generation of reactive oxygen species (ROS) in HCT116^R cells. Furthermore, the combination of SHI and OXA dramatically curbed the extent of HCT116^R -initiated xenograft growth in mouse models. Bioinformatics, western blot, and ROS assays highlighted that the mechanisms of SHI against OXA-resistant CRC cells may involve the induction of cellular responses to chemical stress, intrinsic apoptosis, as well as endoplasmic reticulum stress pathways mediated by ROS. Notably, the synergism of SHI+OXA was partially abrogated by an ROS inhibitor N-acetyl cysteine. Our findings imply the potential of SHI to boost the sensitivity of OXA to CRC, offering promising benefits for clinical strategies to combat OXA resistance.

Prognostic value of the geriatric nutritional index in colorectal cancer patients undergoing surgical intervention: A systematic review and meta-analysis

BACKGROUND

We reviewed the literature to assess the prognostic ability of the geriatric nutritional risk index (GNRI) for patients with colorectal cancer (CRC) undergoing curative surgery.

METHODS

The online databases of PubMed, CENTRAL, ScienceDirect, Embase, and Google Scholar were searched for articles reporting the relationship between GNRI and outcomes in CRC patients. English language studies were searched up to 28th April 2022.

RESULTS

Ten studies with 3802 patients were included. Meta-analysis indicated that patients with low GNRI had significantly poor overall survival (HR: 2.41 95% CI: 1.72, 3.41 I2 = 68%) and disease-free survival (HR: 1.92 95% CI: 1.47, 2.49 I2 = 49%) as compared to those with high GNRI. The meta-analysis also indicated a significantly higher risk of complications with low GNRI as compared to high GNRI (HR: 1.98 95% CI: 1.40, 2.82 I2 = 0%). The results did not change on subgroup analysis based on study location, age group, GNRI cut-off, and sample size.

CONCLUSION

Current evidence indicates that GNRI can be a valuable prognostic indicator for CRC patients undergoing surgical intervention. Patients with low GNRI have poor overall and disease-free survival and a higher incidence of complications. Clinicians could use this simple indicator to stratify patients and formulate personalized treatment plans.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier (CRD42022328374).

Long-term outcomes of elderly patients with peritoneal metastases of colorectal origin after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

INTRODUCTION

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) were reportedly safe for the elderly. However, long-term survival data in this subgroup of patients are scarce. Our aim was to evaluate the peri-operative and long-term outcomes of CRS + HIPEC in colorectal peritoneal metastases (CRC-PM) in patients ≥70 years of age.

MATERIAL AND METHODS

We retrospectively analyzed our combined institutional databases for patients who underwent CRS + HIPEC for CRC-PM. Clinical and pathological characteristics, as well as overall survival (OS) and progression-free survival (PFS) were compared between the groups. Tumor extent was measured by the peritoneal carcinomatosis index (PCI) and completeness of cytoreduction by the CCR score. Major morbidity was defined according to Clavien-Dindo classification.

RESULTS

The dataset of 159 patients included 33 elderly and 126 non-elderly patients. Clinical characteristics between the groups differed only in medical comorbidities (Charlson comorbidity index 10 vs. 7, P < 0.001) and delivery of post-HIPEC adjuvant treatment (12.5% vs. 43.8%, P = 0.004). Overall PCI and CCR0 rates were similar between the groups, as were length of stay and major morbidity and mortality rates. Long-term outcomes in the elderly group were lower than those of the non-elderly (median OS: 21.8 vs. 40.5 months, P < 0.001; median PFS: 6 vs. 8 months, P = 0.02, respectively).

CONCLUSIONS

CRS + HIPEC in selected elderly patients can be safe in terms of postoperative morbidity and mortality. However, despite the same surgical extents and radicality, their long-term outcomes are inferior, possibly due to under-usage of systemic chemotherapy.

The impact of hepatic steatosis on outcomes of colorectal cancer patients with liver metastases: A systematic review and meta-analysis

Background

It is unclear how hepatic steatosis impacts patient prognosis in the case of colorectal cancer with liver metastases (CRLM). The purpose of this review was to assess the effect of hepatic steatosis on patient survival and disease-free survival (DFS) in the case of CRLM.

Methods

We examined the databases of PubMed, CENTRAL, Embase, Google Scholar, and ScienceDirect for studies reporting outcomes of CRLM patients with and without hepatic steatosis. We performed a random-effects meta-analysis using multivariable adjusted hazard ratios (HR).

Results

Nine studies reporting data of a total of 14,197 patients were included. All patients had undergone surgical intervention. Pooled analysis of seven studies indicated that hepatic steatosis had no statistically significant impact on patient survival in CRLM (HR: 0.92 95% CI: 0.82, 1.04, I² = 82%, p = 0.18). Specifically, we noted that there was a statistically significant improvement in cancer-specific survival amongst patients with hepatic steatosis (two studies; HR: 0.85 95% CI: 0.76, 0.95, I² = 41%, p = 0.005) while there was no difference in overall survival (five studies; HR: 0.97 95% CI: 0.83, 1.13, I² = 78%, p = 0.68). On meta-analysis of four studies, we noted that the presence of hepatic steatosis resulted in statistically significant reduced DFS in patients with CRLM (HR: 1.32 95% CI: 1.08, 1.62, I² = 67%, p = 0.007).

Conclusion

The presence of hepatic steatosis may not influence patient survival in CRLM. However, scarce data is suggestive of poor DFS in CRLM patients with hepatic steatosis. Further prospective studies taking into account different confounding variables are needed to better assess the effect of hepatic steatosis on outcomes of CRLM.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/#searchadvanced], identifier [CRD42022320665].

Clinical spectrum of rectal cancer identifies hallmarks of early-onset patients and next-generation treatment strategies

BACKGROUND

The incidence of colorectal cancer is increasing among young adults and more rectal cancers are reported. This study aimed to identify the clinical features specific for early-onset rectal cancer and provide insights on cancer management.

METHODS

Early-onset (<50 years) and late-onset (≥50 years) rectal cancer patients from a referral tertiary care center (SYSU cohort) and Surveillance Epidemiology and End Results database (SEER cohort) were included to perform a comprehensive comparison on clinical information.

RESULTS

A total of 552 and 80,341 patients with stages I-III rectal cancer were included in the SYSU and SEER cohorts, respectively. In the SYSU cohort, early-onset diseases had significantly higher prevalence of family history of cancer and history of HBV infection and lower incidence of comorbidities (p < 0.05). In addition, early-onset patients presented more frequently with advanced node stage (N2 stage: 16.9 vs. 9.3%, p = 0.017) and high-risk features, including mucinous or signet cell carcinomas (21.8 vs. 12.9%, p = 0.014), poorly differentiated tumors (28.8 vs. 15.4%, p = 0.002), and perineural invasion (14.5 vs. 7.9%, p = 0.027) compared with late-onset patients. However, early-onset patients received more neoadjuvant (18.5 vs. 11.2%, p = 0.032) and adjuvant treatments (71.0 vs. 45.8%, p < 0.001), and they had better overall survival in both SYSU (HR 0.57, 95% CI: 0.34-0.95; p = 0.029) and SEER (HR 0.38, 95% CI: 0.37-0.40; p < 0.001) cohorts.

CONCLUSION

Early-onset rectal cancers are distinct from late-onset cases in clinicopathological features, treatment modalities, and outcomes. The clinical trials and studies that are specific for young populations are needed to develop optimal strategies for cancer screening, treatment, and surveillance.

Does adjuvant chemotherapy improve outcomes in elderly patients with colorectal cancer? A systematic review and meta-analysis of real-world studies

BACKGROUND

Elderly patients are frequently excluded from randomized trials. It is unclear if adjuvant chemotherapy improves outcomes of colorectal cancer in such patients. The current study aimed to review evidence on the impact of adjuvant chemotherapy on overall survival (OS) and disease-free survival (DFS) in elderly patients with stage II/III colorectal cancer by pooling data from real-world studies.

METHODS

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for observational studies reporting adjusted data on OS and DFS in elderly (≥70 years) colorectal cancer patients based on receipt of adjuvant chemotherapy.

RESULTS

Thirteen studies included. The meta-analysis demonstrated statistically significant improved OS in elderly patients receiving adjuvant chemotherapy (p < 0.00001). Results were similar for sub-group analysis based on cancer stage and definition of elderly. Improvement in OS was noted in only Western population studies with no difference in Asian patients. The meta-analysis also revealed no statistically significant difference in DFS in elderly patients receiving adjuvant chemotherapy vs surgery alone (p = 0.14).

CONCLUSION

Real-world evidence indicates that adjuvant chemotherapy significantly improved OS but not DFS in elderly colorectal cancer patients. Scarce evidence suggests a limited role of adjuvant chemotherapy in Asian patients which needs confirmation by further studies.

Changes of proportions of circulating lymphocyte subsets in cancer patients after chemotherapy

BACKGROUND

It remains unknown how chemotherapy affects circulating lymphocyte subsets and whether the pattern of change is related to prognosis in cancer patients.

METHODS

Cancer patients who received chemotherapy between 2018/03/01 and 2019/12/31 were enrolled from the Hefei Cancer Hospital, Chinese Academy of Sciences. Peripheral blood samples were collected before and 3 weeks after the start of chemotherapy, and the proportions of T cells (CD3+), helper T cells (CD3+CD4+), cytotoxic T cells (CD3+CD8+), B cells (CD19+), and Natural killer (NK) cells (CD3-CD56+) were examined by flow cytometry. Multivariable logistic regression analysis was employed to explore risk factors associated with overall survival within 12 months after the start of chemotherapy.

RESULTS

A total of 167 patients with cancer were included in the analysis, including 14 cases of cervical cancer, 18 cases of breast cancer, 33 cases of gastric cancer, 48 cases of lung cancer, 21 cases of colorectal cancer, and 33 cases of esophageal cancer. The proportion of T cells (72.58%±10.44% vs. 80.67%±11.63%, P<0.001) and cytotoxic T cells (25.38%±8.87% vs. 39.20%±12.26%, P<0.001) significantly increased, while the proportion of helper T cells (45.58%±10.19% vs. 41.98%±10.47%, P<0.001), B cells (15.10%±5.23% vs. 11.29%±5.60%, P<0.001), and NK cells (19.33%±7.54% vs. 18.28%±7.62%, P<0.001) significantly decreased at 3 weeks after chemotherapy when compared to baseline levels. The overall mortality rate was 14.97% (25/167) within 1 year after the start of chemotherapy. Patients who survived showed a significantly less increase in cytotoxic T cells (13.38%±8.28% vs. 17.28%±7.97%, P=0.030) and less decrease in B cells (-3.58%±2.81% vs. -5.29%±3.03%, P=0.006) when compared to non-survivors. Greater decreases in helper T cells (OR 0.81, 95% CI, 0.68-0.96) and B cells (OR 0.72, 95% CI, 0.59-0.87), and a greater increase in cytotoxic T cells (OR 1.09, 95% CI, 1.03-1.16) were risk factors for poor overall survival.

CONCLUSIONS

Circulating lymphocyte subsets of cancer patients presented characteristic changes after chemotherapy. Patients with a greater decrease in helper T cells and B cells, or greater increase in cytotoxic T cells, may have worse survival.

Isoflurane Suppresses Proliferation, Migration, and Invasion and Facilitates Apoptosis in Colorectal Cancer Cells Through Targeting miR-216

Objective: Surgery is the first line treatment of colorectal cancer (CRC). Anesthetic isoflurane may improve outcomes of cancer surgery. Herein, we investigated the effects of isoflurane on malignant behaviors of CRC cells and its underlying therapeutic target.

Methods: SW620 and HCT116 CRC cells were exposed to a series of concentrations of isoflurane. CCK-8 assay was utilized for determination of the optimal concentration of isoflurane. Under treatment with isoflurane, proliferation, migration, and invasion were separately assessed via clone formation and transwell assays. Apoptotic levels were observed via flow cytometry and expression of Bax, Bcl-2, and Caspase3 proteins was quantified through western blot. MiR-216 expression was detected in isoflurane-induced SW620 and HCT116 cells by RT-qPCR. Following transfection with miR-216 mimic, malignant biological behaviors were examined in isoflurane-treated SW620 and HCT116 cells.

Results: 40 μM isoflurane distinctly restrained proliferative, migrated, and invasive capacities and elevated apoptotic levels in SW620 and HCT116 cells. Up-regulation of miR-216 was found in CRC cells. Its expression was suppressed by isoflurane. MiR-216 mimic ameliorated the reduction in proliferation, migration, and invasion and the increase in apoptosis for 40 μM isoflurane-induced SW620 and HCT116 cells.

Conclusion: Isoflurane, a promising drug of CRC, may suppress malignant biological behaviors of tumor cells. Furthermore, miR-216 is an underlying target of isoflurane. Thus, isoflurane could be adopted for CRC treatment.

Prognostic factors for stage III colon cancer in patients 80 years of age and older

PURPOSE

Oncological strategies in the elderly population are debated. The objective of this study was to assess the factors predictive of poor prognosis in elderly patients with stage III colon cancer.

METHODS

A retrospective review of demographic, pathologic, treatment, and outcome data from 308 patients with stage III colon adenocarcinoma who had undergone surgery between 2007 and 2014 was conducted. A proportional hazards model was used to assess the association of prognostic factors with disease-free survival (DFS) and overall survival (OS).

RESULTS

The 5-year survival rate was 34.4% (95% CI 27.1-39.8%) and Charlson comorbidity index was a significant predictor of death (p < 0.01). The presence of perineural invasion (p = 0.03) and incomplete resection (p < 0.001) were significantly correlated with OS. The postoperative (30 days) mortality rate was 11.7%. Adjuvant chemotherapy was significantly associated with better OS (p < 0.001) independently of the regimens. Disease-free survival was significantly correlated with adjuvant chemotherapy (HR 0.63, 95% CI: 0.42-0.97, p = 0.034), Charlson comorbidity index (CCI 5; HR 1.61, 95% CI: 1.05-2.48, p = 0.029), and venous and/or perineural invasion (HR 1.54, 95% CI: 1.03-2.29, p = 0.035).

CONCLUSION

Age, comorbidities, tumor histology, and adjuvant chemotherapy were independent predictors of prognosis in patients with stage III colon cancer. These data can be used to identify elderly patients with poor prognosis and to design future tailored randomized clinical trials.

TRIAL REGISTRATION

ClinicalTrial.gov No. NCT04526314. Date of registration 25 August 2020.

N1c colon cancer and the use of adjuvant chemotherapy: a current audit of the National Cancer Database

AIM

Colorectal cancer staging has evolved to define N1c as the presence of tumour deposits without concurrent positive lymph nodes. Work to date reports poor prognosis in N1c colon cancer, with Stage III categorization and adjuvant chemotherapy (AC) recommended. No study has yet evaluated the prevalence, treatment compliance or treatment-related outcomes on a national scale. We aimed to evaluate the prevalence of N1c colon cancer, use, outcomes and factors associated with AC in the USA.

METHOD

The National Cancer Database was reviewed for N1cM0 colon adenocarcinomas that underwent resection from 2010 to 2016. Cases were stratified into 'AC' or 'no AC' cohorts. The Kaplan-Meier method was used to estimate overall survival (OS) and compare the AC and no AC cohorts using the log-rank test. Multivariable logistic regression identified factors associated with AC. The main outcome measures were the prevalence and factors associated with AC use and its impact in N1c disease.

RESULTS

Of the 5684 (1.59% of 357 752) colon adenocarcinomas that were N1c, 55% (n = 3071) received AC. AC significantly improved 1-, 3- and 5-year OS compared with no AC (96.2%, 80%, 67.4% and 72.9%, 48.5%, 33.8%, respectively; P < 0.001). Compared with the no AC group, AC patients were younger, had less comorbidity, were of the male gender and received minimally invasive surgery at an academic treatment centre (all P < 0.05). Socioeconomic and procedural factors significantly impacted the use of AC.

CONCLUSION

In the USA, AC is underutilized in N1c colon cancer despite significantly improved OS. Socioeconomic and procedural factors associated with AC were identified, highlighting disparities in AC use and opportunities to improve oncological outcomes and survival.

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.

Older cancer patients and COVID-19 outbreak: Practical considerations and recommendations

Since the COVID-19 outbreak started, it has been affecting mainly older individuals. Among the most vulnerable older individuals are those with cancer. Many published guidelines and consensus papers deal with prioritizing cancer care. Given the lack of high-quality evidence for management of cancer in older patients also in normal times, it is even more stringent to provide some resources on how to avoid both undertreatment and overtreatment in this population, who as of now is twice challenged to death, due to both a greater risk of getting infected with COVID-19 as well as from cancer not adequately addressed and treated. We hereby discuss some general recommendations (implement triage procedures; perform geriatric assessment; carefully assess comorbidity; promote early integration of palliative care in oncology; acknowledge the role of caregivers; maintain active take in charge to avoid feeling of abandonment; mandate seasonal flu vaccination) and discuss practical suggestions for specific disease settings (early-stage and advanced-stage disease for solid tumors, and hematological malignancies). The manuscript provides resources on how to avoid both undertreatment and overtreatment in older patients with cancer, who as of now is twice challenged to death, due to both a greater risk of getting infected with COVID-19 as well as from cancer not adequately addressed and treated.

Adjuvant Chemotherapy in Elderly Colorectal Cancer Patients

The value of adjuvant chemotherapy in elderly patients has been the subject of many overviews, with opinions varying from “not effective”, since randomized trials have not been performed, to “as effective as in young individuals”, based upon many retrospective analyses of randomized trials that have included patients of all ages. In the absence of randomized trials performed specifically with elderly patients, retrospective analyses demonstrate that the influence on the time to tumour recurrence (TTR) may be the same as in young individuals, but that endpoints that include death for any reason, such as recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS), are poorer in the elderly. This is particularly true if oxaliplatin has been part of the treatment. The need for adjuvant chemotherapy after colorectal cancer surgery in elderly patients is basically the same as that in younger patients. The reduction in recurrence risks may be similar, provided the chosen treatment is tolerated but survival gains are less. Adding oxaliplatin to a fluoropyrimidine is probably not beneficial in individuals above a biological age of approximately 70 years. If an oxaliplatin combination is administered to elderly patients, three months of therapy is in all probability the most realistic goal.