Chemotherapy in elderly patients with colorectal cancer

Delayed-Onset Organ/Space Surgical Site Infection Worsens Prognosis in High-Risk Stage II and III Colorectal Cancer

BACKGROUND

It is unclear how early- and delayed-onset organ/space surgical site infections (SSIs) affect the long-term prognosis of patients with colorectal cancer, who are potential candidates for adjuvant chemotherapy. This study aimed to investigate the association between the timing of SSI onset and clinical outcome.

METHODS

This retrospective, multicenter cohort study evaluated patients who were diagnosed with high-risk stage II or III colorectal cancer and underwent elective surgery between 2010 and 2020. Five-year recurrence-free survival (RFS) was the primary endpoint and was compared between early SSI, delayed SSI (divided based on the median date of SSI onset), and non-SSI groups.

RESULTS

A total of 2,065 patients were included. Organ/space SSI was diagnosed in 91 patients (4.4%), with a median onset of 6 days after surgery. The early-onset SSI group had a higher proportion of patients with Clavien-Dindo grade ≥IIIb SSI than the delayed-onset SSI. Patients who received adjuvant chemotherapy (AC) had earlier organ/space SSI onset than those who did not. The adjusted hazard ratio of 5-year RFS in the delayed-onset SSI was 2.58 (95% confidence interval: 1.43-4.65; p = 0.002): higher than that in the early-onset SSI, with the non-SSI as the reference.

CONCLUSIONS

Delayed-onset organ/space SSI worsened long-term prognosis compared to early-onset, and this may be due to delayed initiation of AC. Patients who are clinically suspected of having lymph node metastasis might need additional intervention to prevent delays in commencing AC due to the delayed SSI.

The Real-Life Impact of mFOLFIRI-Based Chemotherapies on Elderly Patients-Should We Let It or Leave It?

AIM

The oncologic treatment of elderly patients is going on with a lack of evidence due to their underrepresentation in clinical trials. Many data suggest that certain groups of elderly patients, like their younger counterparts, may benefit from the systemic treatment of their metastatic colorectal tumors (mCRC).

METHOD

We performed retrospective data analysis to investigate the clinical course of care and clinical outcomes of 515 patients who received first-line mFOLFIRI-based chemotherapy for mCRC between 1 January 2013 and 31 December 2018 at the Institute of Oncotherapy of the University of Pécs, focusing on a comparison of patients over and under 70 years of age, defined as the cut-off value.

RESULTS

28.7% of the 515 patients were 70 years old and older (median age 73.5 years). Compared to the data of the elderly patients, the younger group (median age 61.1 years) had a performance status that was significantly better (average ECOG 1.07 vs. 0.83, p < 0.0001), and significantly more patients received molecularly targeted agents (MTA) (21.6% vs. 51.8%, p < 0.0001); nevertheless, mPFS (241 vs. 285 days, p = 0.3960) and mOS (610 vs. 698 days, p = 0.6305) results did not differ significantly. Considering the 1y PFS OR and the 2ys OS OR values (0.94 [95%CI 0.63-1.41] and 0.72 [95%CI 0.47-1.09], respectively), only a non-significant trend was observed in OS favouring the younger population. Additional analysis of our data proved that the survival in patients over 70 years was positively affected by the addition of MTAs to the doublet chemotherapies, and the reasonable modifications/reductions in dose intensity and the addition of local interventions had similar positive effects as observed in the younger patients' group.

CONCLUSIONS

Age stratification of mCRC patients is not professionally justified. Patients over 70 years of age with good performance status and controlled co-morbidities benefit from systemic therapy, its modifications and local treatment to the same extent as younger patients. With the increasing incidence of age-related cancers due to the rising average lifespan, prospective randomised clinical trials are needed to determine the real value of systemic therapy in the elderly and the rational, objective methods of patient selection.

Prognostic impact of performance status on the outcomes of immune checkpoint inhibition strategies in patients with dMMR/MSI-H metastatic colorectal cancer

BACKGROUND

Immune checkpoint inhibitors yielded unprecedented outcomes in patients with mismatch repair deficient/ microsatellite instability-high (dMMR/MSI-H) metastatic colorectal cancer (mCRC), but clinical decision-making in this rapidly evolving treatment landscape is challenging. Since performance status (PS) represents a well-established prognostic factor in clinical practice, we investigated whether worse PS, overall or related to either patients' frailty or high tumour burden, could affect the outcomes in this whole patients' population and according to immune checkpoint inhibitor treatment type.

METHODS

We conducted a global study at Tertiary Cancer Centres and collected data of patients with dMMR/MSI-H mCRC treated with anti- programmed-death (ligand)-1 (PD(L)-1) monotherapy or anti-PD-1/anti- cytotoxic T-lymphocyte antigen 4 combination.

RESULTS

The cohort included 502 patients. At a median follow-up of 31.2 months, worse PFS and OS were reported in patients with patient-related PS ≥ 1 (adjusted-HRs: 1.73, 95%CI: 1.06-2.83, p = 0.004 and 2.06, 95%CI: 1.13-3.74, p = 0.001, respectively) and cancer-related PS ≥ 1 (adjusted-HRs: 1.61, 95%CI: 1.19-2.17, p = 0.004 and 1.87, 95%CI: 1.32-2.66, p = 0.001, respectively). Anti-PD-1/anti- cytotoxic T-lymphocyte antigen 4 combination did not provide significantly better survival compared to anti-PD(L)-1 monotherapy in PS 0 subgroup (PFS HR = 0.62, 95%CI: 0.37-1.02, p = 0.059; OS HR = 0.59, 95%CI: 0.32-1.11, p = 0.100) and in patient-related PS ≥ 1 (PFS HR 0.93, 95%CI: 0.31-2.83, p = 0.899; OS HR 1.22, 95%CI: 0.34-4.37, p = 0.760), but the difference was significant and clinically meaningful in the subgroup with cancer-related PS ≥ 1 (PFS HR = 0.32, 95%CI: 0.19-0.53, p < 0.001; OS HR = 0.26, 95%CI: 0.14-0.48, p < 0.001).

CONCLUSIONS

In patients with dMMR/MSI-H mCRC, an extensive evaluation of clinical variables including PS may be implemented in the therapy decision-making.

Oxaliplatin plus fluoropyrimidines as adjuvant therapy for colon cancer in older patients: A subgroup analysis from the TOSCA trial

BACKGROUND

Previous studies on oxaliplatin and fluoropyrimidines as adjuvant therapy in older patients with stage III colon cancer (CC) produced conflicting results.

PATIENTS AND METHODS

We assessed the impact of age on time to tumour recurrence (TTR), disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) in 2360 patients with stage III CC (1667 aged <70 years and 693 ≥ 70 years) randomised to receive 3 or 6 months of FOLFOX or CAPOX within the frame of the phase III, TOSCA study.

RESULTS

Older patients compared with younger ones presented more frequently an Eastern Cooperative Oncology Group performance status equal to 1 (10.5% vs 3.3%, p < 0.001), a greater number of right-sided tumours (40.9% vs 26.6%, p < 0.001), and were at higher clinical risk (37.2% vs 33.2%, p = 0.062). The treatments were almost identical in the two cohorts (p = 0.965). We found a greater proportion of dose reductions (46.7% vs 41.4%, p = 0.018), treatment interruptions (26.1% vs 19.3%, p < 0.001) and a higher proportion of recurrences (24.2% vs 20.3%, p = 0.033) in the older patients. The multivariable analysis of the TTR did not indicate a statistically significant effect of age (hazard ratio [HR]: 1.19; 95% confidence interval [CI]: 0.98-1.44; p = 0.082). The HR comparing older with younger patients was 1.34 (95% CI: 1.12-1.59; p = 0.001) for DFS, 1.58 (95% CI: 1.26-1.99; p < 0.001) for OS, and 1.28 (95% CI: 0.96-1.70; p = 0.089) for CSS.

CONCLUSIONS

Worse prognostic factors and reduced treatment compliance have a negative impact on the efficacy of oxaliplatin-based adjuvant therapy in older patients.

Chemotherapy for elderly colorectal cancer patients at a tertiary hospital in South Africa

Introduction

surgical treatment of colorectal cancer (CRC) in elderly patients has improved, but data on the tolerability and benefits of adjuvant and palliative chemotherapy in this growing population remains scarce.

Methods

we conducted a retrospective study to compare chemotherapy-associated toxicities in CRC patients aged < 70 years and ≥ 70 years at Tygerberg Hospital (South Africa). We also assessed tumor-related mortality, progression free survival (PFS), and overall survival (OS) including predictive factors of OS.

Results

a total of 50 patients received either adjuvant or palliative chemotherapy. There was no difference in overall toxicity between the two groups. Out of the 50 patients, 8 (16%) had Grade 3-4 toxicity. 4 of these patients made up 15% of the < 70 years age group, whereas the other 4 made up 17% of the ≥ 70 years age group. The mean follow-up time was 47.5 months (95% CI 41.5 - 53.5 months). The 5-year over-all survival rate for stage II and III patients < 70 years and ≥ 70 years were 80.9% and 69.5%, respectively, and not significantly different (P = 0.52). Furthermore, the 5-year progression-free survival rates of the < 70 and ≥ 70 age groups were 70.7% and 58.8%, respectively, and also not statistically significantly different (P = 0.49). For stage IV patients, there were no significant differences in survival between the two age groups.

Conclusion

the benefits from adjuvant and palliative chemotherapy for elderly CRC patients are similar to that of younger patients. Therefore, standardized adjuvant and palliative chemotherapy is recommended for elderly patients.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

Background

Many older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.

Methods

A prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.

Results

In colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ²_trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ²_trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.

Conclusions

The probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5910-z) contains supplementary material, which is available to authorized users.

Cost-effectiveness analysis of capecitabine plus bevacizumab versus capecitabine alone in elderly patients with previously untreated metastatic colorectal cancer from Chinese societal perspective

PURPOSE

The aim of the study was to evaluate the cost-effectiveness of capecitabine plus bevacizumab compared with capecitabine alone in elderly patients with metastatic colorectal cancer (CRC) from a Chinese societal perspective.

METHODS

A decision-analytic Markov model was conducted to simulate the process of metastatic CRC. Three distinct health states: progression-free survival (PFS), progressive disease and death were included. Clinical data were derived from the AVEX trial. Health effectiveness was denoted in quality-adjusted life years (QALYs) and health utilities were derived from previously published studies. Incremental cost-effectiveness ratio (ICER) was regarded as the primary endpoint and willingness-to-pay (WTP) threshold was set at $26,753.37/QALY (3 × per capita GDP of China, 2017). One-way sensitivity analyses and probabilistic sensitivity analysis were also performed to explore the parameters uncertainty in the study.

RESULTS

Over a 10-year life horizon, capecitabine plus bevacizumab gained 1.14 QALYs at an average cost of $21,609.48, while the effectiveness and cost of capecitabine group were 0.99 QALYs and $7274.83, respectively. The ICER between the two groups was $95,564.33/QALY. Parameters that mostly influenced the results of the model were utility of PFS state, duration of PFS state for capecitabine plus bevacizumab, total cost of PFS state for capecitabine plus bevacizumab and price of bevacizumab. The probabilities of capecitabine plus bevacizumab and capecitabine as the dominant option were 0% and 100% at the WTP threshold of $26,753.37/QALY.

CONCLUSIONS

The results of the study showed that capecitabine plus bevacizumab is unlikely to be a cost-effective treatment option for elderly patients with metastatic CRC.

Long-term survival of an elderly female with metastatic colon cancer after treated with capecitabine monotherapy: A case report

RATIONALE

Colorectal cancer (CRC) is one of the most common cancers all over the world, and approximately 70% of the newly diagnosed patients are over 65 years old. Due to the aging of society, there will be more and more elderly patients of CRC in the future. Treatment of CRC in elderly patients is much more challenging thanks to multiple factors including disabling comorbidities as well as declines in organs function, especially in advanced or metastatic settings.

PATIENT CONCERNS

An 82-year-old female without history of disease was admitted to the emergency room because of abdominal pain in December 2009. A computed tomography (CT) scan of the abdomen was performed immediately, which revealed bowel obstruction.

DIAGNOSES

The histopathological examination of the resected specimen confirmed well-to-moderately differentiated colonic adenocarcinoma with a stage of IIIB (T3N1M0) based on the NCCN tumor-node-metastasis (TNM) classification system.

INTERVENTIONS

The patient underwent emergency surgery and rejected adjuvant chemotherapy, but was diagnosed with multiple liver metastases 3 months later. Then she received capecitabine monotherapy as first-line treatment.

OUTCOMES

The efficacy achieved complete response (CR) when 8 cycles were completed and the agent was continued as maintenance treatment until totally 16 cycles were completed. Up to the latest follow-up, the disease remained CR and the progression-free survival (PFS) has achieved approximately 87 months. She is still alive and has good quality of life.

LESSONS

Capecitabine monotherapy may be an effective treatment in advanced or metastatic colorectal cancer (mCRC) for elderly patients.

Treatment of patients with metastatic colorectal cancer and poor performance status: current evidence and challenges

Patients with unresectable metastatic colorectal cancer live for a median of three years when treated with standard therapies. While the evidence guiding cancer-directed treatment of this disease comes from phase III trials that have mostly enrolled patients with good performance status, some patients present with poor clinical conditions. The best treatment for these patients remains to be determined. We performed a systematic review of the treatment outcomes of patients with metastatic colorectal cancer and poor performance status, defined as Eastern Cooperative Oncology Group performance status ≥2. Eligible articles were prospective or retrospective studies or case reports published in English, Portuguese or Spanish. We searched PubMed, EMBASE, LILACS and the Cochrane Library from onset until October 2017 using specific keywords for each search. We found a total of 18 publications, mostly case reports and retrospective studies (14 articles). One was an uncontrolled prospective trial, two were observational studies and one was an individual patient meta-analysis. Although some studies suggested benefits in terms of symptomatic response with standard chemotherapy, with good safety profiles when dose-reduced regimens were administered, a true survival gain could not be demonstrated. The scientific evidence for treating metastatic colorectal cancer patients with poor performance status is scarce, and more studies evaluating treatment for this population are necessary since this condition is not uncommon in clinical practice, particularly in the public healthcare system and developing countries and among destitute populations.

Impact of the addition of bevacizumab, oxaliplatin, or irinotecan to fluoropyrimidin in the first-line treatment of metastatic colorectal cancer in elderly patients

INTRODUCTION

The clinical benefit of double-front-line therapy (including oxaliplatin or irinotecan or bevacizumab plus 5-fluorouracil (5FU) or capecitabine) compared to monotherapy (5FU or capecitabine) in elderly (> 70 years) patients with metastatic colorectal cancer (MCRC) is controversial. We performed a meta-analysis of published randomized studies.

MATERIALS AND METHODS

The selection of the studies was carried out using PubMed with the following keywords: "metastatic colorectal cancer," "elderly," "oxaliplatin," "irinotecan," "bevacizumab," "survival." The efficacy endpoints were overall survival (OS) and progression-free survival (PFS). Hazard ratios (HRs) with their 95% confidence intervals (CIs) were collected from the studies and pooled. By convention, an HR < 1 was a result in favor of biotherapy.

RESULTS

This meta-analysis (MA) included ten studies: three assessing irinotecan (FFCD 2001-02, CAIRO, and an already published MA by Folprecht), three assessing oxaliplatin (FOCUS2, FFCD 2000-05, and a published study by De Gramont), and four assessing bevacizumab (PRODIGE-20, AVEX, AGITG-MAX, and "AVF2192g" by Kabbinavar). Our MA included 1652 patients (62% of men). Concerning age, we chose a cut-off of 70 years or a cut-off of 75 years, corresponding to the available data for each study. The performance index (PS) was 0-1 for about 90% of patients, with the exception of FFCD 2001-02 and FOCUS2 which included 30% of patients with PS2. Overall, the addition of bevacizumab to fluoropyrimidin statistically improves both OS and PFS (HR = 0.78; CI 0.63-0.96 and HR = 0.55; CI 0.44-0.67, respectively). The addition of oxaliplatin did not statistically improve OS (= 0.99; CI 0.85-1.17) but improves PFS (HR = 0.81; CI 0.67-0.97) as well as the addition of irinotecan (HR = 1.01; CI 0.84-1.22 and HR = 0.82; CI 0.68-1.00, respectively).

CONCLUSION

In previously untreated elderly patients with MCRC, the addition of bevacizumab to fluoropyrimidin appears more effective in terms of OS or PFS than the addition of oxaliplatin or irinotecan.

Causes of mortality in older patients with stage 3 colon cancer

OBJECTIVES

Life expectancy plays a key role in the selection of patients with stage III colon cancer for adjuvant chemotherapy, but little is known about causes of mortality in older patients with colon cancer. We aimed to examine causes of death in this population and compare these causes between patients who received chemotherapy and those who did not. Specifically, we chose to examine the rates of death related to recurrent colon cancer versus non colon cancer.

MATERIALS AND METHODS

Patients aged 50 and older diagnosed with stage III colon cancer between 2005 and 2009 were included. Patients were divided into "younger" (aged 50-69) and "older" (aged 70+). Causes of death, which were categorized into colon cancer versus non-colon cancer related.

RESULTS

1361 patients were included, 50% of whom were 70 or older. Younger patients were more likely to receive adjuvant chemotherapy (90% vs. 60%). 601 patients died in the follow up period. Deceased patients in the younger group were more likely to die from colon cancer (81% vs. 62%). The most common cause of non-colon cancer death was other primary malignancies in younger patients and cardiovascular diseases in older patients. In older patients who received chemotherapy, 41% died; 89% of these deaths were related to colon cancer. In older patients who did not receive chemotherapy 72% died, with 38% of patients ultimately dying from colon cancer.

CONCLUSIONS

Older patients remain under-treated with chemotherapy. Although non-colon cancer deaths were more frequent in older patients with cancer, colon cancer was a still a significant cause of mortality. These deaths may be preventable with adjuvant chemotherapy.

Competing nomograms help in the selection of elderly patients with colon cancer for adjuvant chemotherapy

PURPOSE

The extent to which ≥ 70 year patients with colon cancer benefit from adjuvant chemotherapy in the presence of competing risks remains controversial.

METHODS

18,937 patients ≥ 70 years with high-risk stage II and stage III colon cancer were retrospectively reviewed from SEER database. Propensity score matching (PSM) was used to adjust for potential baseline confounding. The nomograms were developed based on the competing model to describe the individual probability of colon cancer-specific death (CCSD) and non-CCSD. The subpopulation treatment-effect pattern plot (STEPP) was used to estimate the treatment-effect heterogeneity.

RESULTS

In the high-risk stage II subgroup, compared to the non-recipients, the hazard ratios (HR) of overall mortality for recipients were 0.83 (P = 0.001). The subdistribution hazard ratio (SHR) of CCSD for receipts was 1.22 (P = 0.021). The SHR of non-CCSD was 0.63 (P < 0.001). In the stage III subgroup, compared to non-recipients, the HR of the overall mortality for the recipients was 0.62 (P < 0.001). The SHR of CCSD was 0.77 (P < 0.001). The SHR of non-CCSD was 0.58 (P < 0.001). The chemotherapy efficacy differed significantly by risk score of non-CCSD (non-CCSD-RS) (P < 0.001). Recipients with high non-CCSD-RS had a rate of CCSD comparative to that of non-recipients (SHR 0.90, P = 0.150) in the stage III subgroup.

CONCLUSIONS

A survival analysis based on the overall mortality did not correctly interpret the effect of chemotherapy. Adjuvant chemotherapy did not provide an additional benefit to patients with high-risk stage II or patients with stage III at high risk of non-cancer death.

Tolerability, Safety, and Outcomes of Neoadjuvant Chemoradiotherapy With Capecitabine for Patients Aged ≥ 70 Years With Locally Advanced Rectal Cancer

INTRODUCTION

In studies of colorectal cancer, the elderly have been frequently underrepresented because comorbid conditions and functional status often lead to study exclusion. For elderly patients with an indication for neoadjuvant chemoradiotherapy (nCRT), physicians usually decide using clinical factors whether nCRT should be offered. The aim of the present retrospective study was to assess the tolerability of nCRT with capecitabine and the surgical outcomes in patients aged ≥ 70 years with locally advanced rectal cancer.

PATIENTS AND METHODS

Data from 1372 rectal cancer patients diagnosed from 2002 to 2012 at 4 Dutch hospitals were used. Patients aged ≥ 70 years were included if they had received nCRT, and their data were analyzed for treatment deviations, postoperative complications, mortality, disease-free survival (DFS), and overall survival (OS). The data were stratified into 3 age groups (ie, 70-74, 75-79, and ≥ 80 years).

RESULTS

We identified 447 patients aged ≥ 70 years. Of these patients, 42 had received nCRT, and 37 (88%) had completed nCRT. Radiation dermatitis, fatigue, and diarrhea were reported in 62%, 57%, and 43% of the 42 patients, respectively. Of the 42 patients, 40 (95%) underwent surgery, 1 patient refused resection, and 1 patient died during nCRT of severe mucositis due to dihydropyrimidine dehydrogenase deficiency. The postoperative complication rate was 30%, and the 30-day mortality rate was 0%. A pathologic complete response was found in 7.5%. The 2- and 5-year DFS and OS rates were 58.5% and 40.7% and 81.0% and 58.2%, respectively.

CONCLUSION

The results of the present multicenter study have shown that if selected on clinical factors, nCRT with capecitabine is safe and well tolerated in elderly patients. No negative effect on surgical outcome was measured, and the beneficial effect (pathologic complete response, DFS, and OS) seemed comparable to that for younger age groups. We believe that elderly patients should not be excluded from nCRT on the basis of age only.

Prognostic factors and hazard ratios in colorectal cancer patients over 80 years of age: a retrospective, 20-year, single institution review

Background

An aging population and a high incidence of colorectal cancer (CRC) in patients over the age of 80 make it important to understand survival times, hazard ratios and prognostic factors in this group. A better understanding of these factors will help clinicians determine appropriate therapeutic strategies for such patients, including when more aggressive treatment strategies may be preferred to palliative treatment.

Methods

A retrospective analysis of 619 CRC patients of ≥80 years of age from 1991-2010 at Baylor Scott & White Hospital in Temple, Texas. Twelve variables were analyzed through statistical analysis as potential prognostic factors for survival. Univariate and multivariate Cox proportional hazard models were used to determine hazard ratios. The elderly population was further stratified by age subgroup (80-84, 85-89, ≥90).

Results

Median survival time was 53.6, 30.0, and 11.3 months for age groups of 80-84, 85-89, and ≥90, respectively. Median survival time for stage 0/I, II, III, and IV patients was 72.4, 53.5, 28.0, and 5.9 months, respectively. Patients not receiving surgery had significantly higher mortality (hazard ratio 2.605; 95% CI, 1.826-3.694). For stage III CRC patients, those not receiving chemotherapy had significantly higher mortality (hazard ratio 1.808; 95% CI, 1.018-1.827).

Conclusions

Our study provides evidence to support the benefits of surgery and chemotherapy (for stage III) patients over 80, potentially contributing to improved clinical decisions in treating elderly CRC patients. Such patients are sometimes undertreated due to their underrepresentation in clinical trials. Additional prospective studies with a higher proportion of patients over 80 are needed.

Overall survival in elderly patients with colorectal cancer: A population-based study in the Caribbean

BACKGROUND

Population-based Cancer registries (PBCR) play an important role in cancer surveillance and research. The aim of this study was to examine overall survival in elderly patients with colorectal cancer (CRC) by analysing data from the Martinique PBCR between 1993 and 2012.

METHODS

The log-rank test was used to assess the statistical differences of the survival curves by each categorical variable: age at diagnosis, sex, histology, zone of residence, subsite, stage at diagnosis, and chemotherapy. A multivariable Cox model was performed to identify independent prognostic factors for overall survival in elderly patients with colorectal cancer.

RESULTS

Among 2230 patients included in the study, 60.8% were aged≥65years; mean age at diagnosis of these patients was 75.7±7.2years. For the period 2008-2012, 532 elderly patients were analysed; mean age of those receiving chemotherapy was 73.0±0.4 versus 77.9±0.4years for those not receiving chemotherapy (p<0.0001). Stage at diagnosis was evaluated in 87.8% (467/532) of patients; 63.0% (294/467) had stage III-IV and 49.3% of these patients (145/294) received chemotherapy. Chemotherapy was less frequently prescribed in patients aged 75-84 and ≥85 years as compared to those aged 65-74 years (41.1% and 15.0% versus 64.6% respectively; p<0.0001). Stage III-IV at diagnosis (HR=5.25; 3.70-7.45; p<0.0001), and not receiving chemotherapy (HR=3.05; 2.23-4.16; p<0.0001), were independent prognostic factors for overall survival.

CONCLUSION

Our study highlights the role of PBCR in evaluating cancer survival and patterns of care in elderly people of the French West- Indies. Chemotherapy was less frequently prescribed among the elderly.

[Geriatric assessment of patients with hematological neoplasms]

Hematological malignancies are typical diseases of the elderly. The aging of the population in the Western World results in a significant increase in the number of elderly patients with hematological malignant diseases. This has important consequences for medicine. One consequence of this development is that the need for tools for the evaluation of both functional and global status of the elderly increases. The use of these tools enables the hematologist to better stratify the patients, to individualize therapy better, to possibly modify therapy in order to improve implementation of supportive measures and interventions, to minimize toxicity and side effects and ultimately to tailor the treatment to the individual patient. Several tools are available for geriatric assessment (GA) and there is strong evidence that an effective GA can detect previously unknown problems. The targeted intervention improves the prognosis and compliance of therapy in elderly patients with hematological malignant diseases.

Glutathione maintenance mitigates age-related susceptibility to redox cycling agents

Isolated hepatocytes from young (4-6mo) and old (24-26mo) F344 rats were exposed to increasing concentrations of menadione, a vitamin K derivative and redox cycling agent, to determine whether the age-related decline in Nrf2-mediated detoxification defenses resulted in heightened susceptibility to xenobiotic insult. An LC50 for each age group was established, which showed that aging resulted in a nearly 2-fold increase in susceptibility to menadione (LC50 for young: 405μM; LC50 for old: 275μM). Examination of the known Nrf2-regulated pathways associated with menadione detoxification revealed, surprisingly, that NAD(P)H: quinone oxido-reductase 1 (NQO1) protein levels and activity were induced 9-fold and 4-fold with age, respectively (p=0.0019 and p=0.018; N=3), but glutathione peroxidase 4 (GPX4) declined by 70% (p=0.0043; N=3). These results indicate toxicity may stem from vulnerability to lipid peroxidation instead of inadequate reduction of menadione semi-quinone. Lipid peroxidation was 2-fold higher, and GSH declined by a 3-fold greater margin in old versus young rat cells given 300µM menadione (p<0.05 and p≤0.01 respectively; N=3). We therefore provided 400µMN-acetyl-cysteine (NAC) to hepatocytes from old rats before menadione exposure to alleviate limits in cysteine substrate availability for GSH synthesis during challenge. NAC pretreatment resulted in a >2-fold reduction in cell death, suggesting that the age-related increase in menadione susceptibility likely stems from attenuated GSH-dependent defenses. This data identifies cellular targets for intervention in order to limit age-related toxicological insults to menadione and potentially other redox cycling compounds.

Folfirinox in elderly patients with pancreatic or colorectal cancer-tolerance and efficacy

AIM

To study the tolerance and the efficiency of FOLFIRINOX in elderly patients diagnosed with colorectal or pancreatic cancer.

METHODS

This retrospective study included elderly patients aged over 70 years of age treated at Georges-Francois Leclerc Center by FOLFIRINOX for histological proved colorectal or pancreatic cancer between January 2009 and January 2015. Chemotheapy regimen consisted of oxaliplatin (85 mg/m² in over 120 min) followed by leucovorin (400 mg/m² in over 120 min), with the addition, after 30 min of irinotecan (180 mg/m² in over 90 min) then 5 fluorouracil (5FU) (400 mg/m² administred intravenous bolus), followed by 5FU (2400 mg/m² intraveinous infusion over 46 h) repeated every 2 wk. Geriatric parameters were recorded at the beginning. Toxicities were evaluated with the Common Terminology Criteria for Adverse Events 4.03. Tumor response was evaluated by CT scan. Treatment continued until disease progression, unacceptable toxicities or patient refusal.

RESULTS

Fifty-two patients aged from 70 to 87 years were treated by FOLFIRINOX, 34 had colorectal cancer and 18 had pancreatic cancer. Most of them were in good general condition, 82.7% had a 0-1 performance status and 61.5% had a Charlson Comorbidity Index < 10. The most frequent severe toxicities were neutropenia (17 patients, n = 32.7%) and diarrhea (35 patients n = 67.3%); 10 of the case of neutropenia and 5 of diarrhea registered a grade 4 toxicity. Thirty-nine patients (75%) initially received an adapted dose of chemotherapy. The dosage was adjusted for 26% of patients during the course of treatment. Tumor response evaluated by RECIST criteria showed a controlled disease for 25 patients (48.1%), a stable disease for 13 and a partial response for 12 patients. Time under treatment was higher for colorectal cancer with a median time of 2.44 mo (95%CI: 1.61-3.25). Overall survival was 43.88 mo for colorectal cancer and 12.51 mo for pancreatic cancer. In univariate or multivariate analysis, none of geriatric parameters were linked to overall survival. Only the type of tumor (pancreatic/colorectal) was linked in both analysis.

CONCLUSION

For people over 70 years old, FOLFIRINOX regimen seems to induce manageable toxicities but similar, even higher, median survival rates compared to younger people.

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes

BACKGROUND

Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system.

METHODS

Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery).

RESULTS

Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001).

CONCLUSIONS

The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

Bevacizumab plus chemotherapy in elderly patients with previously untreated metastatic colorectal cancer: single center experience

Background

Metastatic colorectal cancer (mCRC) is mainly a disease of elderly, however, geriatric population is underrepresented in clinical trials. Patient registries represent a tool to assess and follow treatment outcomes in this patient population. The aim of the study was with the help of the patients’ register to determine the safety and efficacy of bevacizumab plus chemotherapy in elderly patients who had previously untreated metastatic colorectal cancer.

Patients and methods

The registry of patients with mCRC was designed to prospectively evaluate the safety and efficacy of bevacizumab-containing chemotherapy as well as selection of patients in routine clinical practice. Patient baseline clinical characteristics, pre-specified bevacizumab-related adverse events, and efficacy data were collected, evaluated and compared according to the age categories.

Results

Between January 2008 and December 2010, 210 patients with mCRC (median age 63, male 61.4%) started bevacizumab-containing therapy in the 1^st line setting. Majority of the 210 patients received irinotecan-based chemotherapy (68%) as 1^st line treatment and 105 patients (50%) received bevacizumab maintenance therapy. Elderly (≥ 70 years) patients presented 22.9% of all patients and they had worse performance status (PS 1/2, 62.4%) than patients in < 70 years group (PS 1/2, 35.8%). Difference in disease control rate was mainly due to inability to assess response in elderly group (64.6% in elderly and 77.8% in < 70 years group, p = 0.066). The median progression free survival was 10.2 (95% CI, 6.7–16.2) and 11.3 (95% CI, 10.2–12.6) months in elderly and < 70 years group, respectively (p = 0.58). The median overall survival was 18.5 (95% CI, 12.4–28.9) and 27.4 (95% CI, 22.7–31.9) months for elderly and < 70 years group, respectively (p = 0.03). Three-year survival rate was 26% and 37.6% in elderly vs. < 70 years group (p = 0.03). Overall rates of bevacizumab-related adverse events were similar in both groups: proteinuria 21/22 %, hypertension 25/19 %, haemorrhage 2/4 % and thromboembolic events 10/6 %, for elderly and < 70 years group, respectively.

Conclusions

In routine clinical practice, the combination of bevacizumab and chemotherapy is effective and well-tolerated regimen in elderly patients with metastatic colorectal cancer.

Coenzyme complex decreased cardiotoxicity when combined with chemotherapy in treating elderly patients with gastrointestinal cancer

OBJECTIVE

To investigate the effect of coenzyme complex on decreasing cardiotoxicity in elderly patients with gastrointestinal cancer who were treated by chemotherapy.

METHODS

From September 2011 to February 2015, we recruited 54 elderly (with more than 70 years of age) patients with gastrointestinal cancer, with advanced disease. Then treated with chemotherapy combined with or without coenzyme complex. After two cycles of treatment, the effect of coenzyme complex on decreasing cardiotoxicity were evaluated.

RESULTS

Chemotherapy was combined with coenzyme complex in 32 patients (22man, 10 woman; median age: 74 years, range: 70-87 years) without coenzyme complex in 22 patients (15man, 7 woman; median age: 73 years, range: 70-80 years) with gastrointestinal cancer. Cardiac event was significantly lower in patients treated with chemotherapy combined with coenzyme complex (p<0.01).

CONCLUSIONS

Coenzyme Complex decreased cardiotoxicity when combined with chemotherapy in treating elderly patients with gastrointestinal cancer.

KDR Mutation as a Novel Predictive Biomarker of Exceptional Response to Regorafenib in Metastatic Colorectal Cancer

This is the case of an 84-year-old woman diagnosed with Stage IVb colon adenocarcinoma (CRC) metastatic to the liver, retroperitoneum, anastomotic site, and distal rectal sigmoid colon. She experienced intolerable side effects to systemic chemotherapy with 5-fluorouracil and bevacizumab, as well as disease progression. Next generation sequencing of her tumor was ordered, and further discussion of her malignancy's genomic information took place at a multidisciplinary molecular tumor board. The patient had mutations in KRAS (Kirsten rat sarcoma viral oncogene homolog) which made her ineligible for epidermal growth factor receptor (EGFR) inhibitors; however, a KDR p.R961W c.2881C>T mutation was noted as a variant of unknown significance (VUS). KDR (kinase insert domain receptor) is the human gene encoding for vascular endothelial growth factor receptor 2 (VEGFR-2). She was then considered a suitable candidate for regorafenib, which she could only tolerate at a low dose of 40 mg daily, with the intent of prolonging her survival and to optimize her quality of life. We report her excellent tolerance and exceptional response to low dose regorafenib, including symptomatic, tumor marker, and sustained partial metabolic radiological improvement. In the largest Phase III trial of regorafenib in CRC, only five patients (1%) of 760 experienced a partial response (versus one patient, 0.4%, receiving placebo). KDR R961W mutation has been described but no functional data has been reported. This mutation occurs in the tyrosine kinase domain of the VEGFR-2. Regorafenib targets VEGFR-2 (KDR). Hereby we hypothesize KDR mutation as a novel predictive biomarker to exceptional response to regorafenib in metastatic colorectal cancer. To our knowledge, this is the first reported case of the potential correlation between KDR mutation and regorafenib use for the successful management of a patient with advanced CRC, leading to what is considered an exceptional response. Further studies based on this preliminary data are warranted.

Reasons for Underuse of Adjuvant Chemotherapy in Elderly Patients With Stage III Colon Cancer

BACKGROUND

Undertreatment has been frequently reported in the elderly cancer patient population. For this reason, we aimed to characterize adjuvant chemotherapy (AC) use among elderly patients (EPs) with stage III colon cancer (CC) and to identify potential reasons for undertreatment.

PATIENTS AND METHODS

Patients diagnosed with stage III CC between 2008 and 2010 were included in this review. Multivariate Cox regression models were constructed to evaluate the associations between AC and cancer-specific, disease-free, and overall survival and to determine whether these were modified by age.

RESULTS

We identified 810 patients: 423 (52%) men, 423 (52%) young patients (YPs), and 603 (74%) received AC. Compared with YPs, EPs were less likely to receive AC (57% vs. 91%; P < .01), particularly 5-fluorouracil and oxaliplatin (FOLFOX) (32% vs. 74%, P < .01). Frequent reasons for nontreatment included age, comorbidities, and perceived minimal benefit from AC. When AC was given, EPs had similar rates of treatment discontinuations (34% vs. 26%; P > .05) and dose reductions (63% vs. 61%; P > .05) as YPs. Reasons for treatment interruptions included side effects, progressive disease, and patient choice. Receipt of either FOLFOX or capecitabine was correlated with improved cancer-specific survival, disease-free survival, and overall survival compared with surgery alone; this effect was not modified by age.

CONCLUSION

Elderly patients with stage III CC frequently received either no AC or capecitabine monotherapy because of advanced age and comorbidities. The effect of AC on survival was similar across age groups, with comparable side effects and rates of treatment modifications. AC should not be withheld because of advanced age alone.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND

Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients.

MATERIALS AND METHODS

A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed.

RESULTS

Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization.

CONCLUSION

Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Efficacy and safety of laparoscopic surgery in elderly patients with colorectal cancer

Colorectal cancer (CRC) is predominantly a disease of the elderly. Elderly patients may also exhibit poorer outcomes due to the increased burden of comorbidities, functional dependency and limited life expectancy. The aim of this study was to evaluate the outcome of laparoscopic surgery in elderly patients with CRC. A total of 148 patients who underwent laparoscopic surgery at our institution between January, 2000 and December, 2011 were enrolled. We compared the differences between elderly patients (aged >75 years, n=48) and non-elderly patients (aged <75 years, n=100) and evaluated the demographics and disease-related operative and prognostic data. Postoperative complications occurred in 24 (16.2%) of the 148 patients. The American Society of Anesthesiologists score and comorbidity were found to be significantly correlated with complications and the multivariate analysis demonstrated that pulmonary disease, but not age, was an independent factor affecting postoperative complications (odds ratio = 3.21, 95% confidence interval: 1.02-10.14, P=0.0470). Patients with pulmonary comorbidities also exhibited similar rates of postoperative complications compared with 259 matched patients who underwent open surgery during same period (41.2 vs. 46.7%, respectively; P=0.7547). In conclusion, chronological age alone should not be considered a contraindication for laparoscopic surgery for CRC in elderly patients. In addition, selection criteria for laparoscopic CRC surgery in elderly as well as non-elderly patients should include pulmonary comorbidities.

CSBF/C10orf99, a novel potential cytokine, inhibits colon cancer cell growth through inducing G1 arrest

Cytokines are soluble proteins that exert their functions by binding specific receptors. Many cytokines play essential roles in carcinogenesis and have been developed for the treatment of cancer. In this study, we identified a novel potential cytokine using immunogenomics designated colon-derived SUSD2 binding factor (CSBF), also known as chromosome 10 open reading frame 99 (C10orf99). CSBF/C10orf99 is a classical secreted protein with predicted molecular mass of 6.5 kDa, and a functional ligand of Sushi Domain Containing 2 (SUSD2). CSBF/C10orf99 has the highest expression level in colon tissue. Both CSBF/C10orf99 and SUSD2 are down-regulated in colon cancer tissues and cell lines with different regulation mechanisms. CSBF/C10orf99 interacts with SUSD2 to inhibit colon cancer cell growth and induce G1 cell cycle arrest by down-regulating cyclin D and cyclin-dependent kinase 6 (CDK6). CSBF/C10orf99 displays a bell-shaped activity curve with the optimal effect at ~10 ng/ml. Its growth inhibitory effects can be blocked by sSUSD2-Fc soluble protein. Our results suggest that CSBF/C10orf99 is a novel potential cytokine with tumor suppressor functions.

Bevacizumab in first-line treatment of elderly patients with metastatic colorectal cancer: German community-based observational cohort study results

BACKGROUND

To evaluate the efficacy of first-line bevacizumab-based chemotherapy for untreated metastatic colorectal cancer (mCRC) based on age.

METHODS

Eligibility criteria focused on M1 disease without prior palliative chemotherapy. Choice of chemotherapy regimen was at the physician's discretion. Predefined efficacy endpoints were response rate, progression-free and overall survival (PFS, OS). Patients were analysed by age (<70 vs. ≥70 years, <75 vs. ≥75 years).

RESULTS

Of 1777 patients, 27% and 12% were ≥70 and ≥75 years, respectively. PFS was shorter in elderly patients (<70 vs. ≥70 years: 10.5 vs. 9.5 months, p = 0.074; <75 vs. ≥75 years: 10.5 vs. 8.9 months, p = 0.00019), as was OS (<70 vs. ≥70 years: 25.8 vs. 22.7 months, p < 0.0008; <75 vs. ≥75 years: 25.8 vs. 20.8 months; p < 0.0001). In the groups <70 and <75 years, PFS was longer in those receiving oxaliplatin-/irinotecan-containing regimens vs. those receiving 5-FU/capecitabine (<70 years: 10.6 vs. 9.0 months; p = 0.0065; <75 years: 10.6 vs. 9.2 months; p = 0.028); no difference in PFS was observed between oxaliplatin-/irinotecan-containing regimens vs. 5-FU/capecitabine regimens in both elderly age-group comparisons (≥70 years: 9.7 vs. 9.2 months; ≥75 years: 8.3 and 9.0 months).

CONCLUSION

First-line bevacizumab-based chemotherapies were effective in German mCRC patients ≥75 years of age, but PFS and OS were significantly shorter in this age group vs. younger patients.

An update on the management of metastatic colorectal cancer in the elderly

SUMMARY 

The availability of new chemotherapeutic and targeted agents has changed the life expectancy of patients with metastatic colorectal cancer thanks to the possibility of sequentially administering fluoropyrimidines combined with irinotecan and oxaliplatin plus monoclonal antibodies. This approach is seldom feasible in the elderly, especially because of the poor tolerability of some agents. Frail patients should only receive palliative treatment. Oppositely, fit elderly patients can be treated with more aggressive therapies, similarly to the younger ones. What is not sufficiently known is how to manage the elderly categorized as intermediate. In the coming years, it appears necessary how to accurately differentiate the elderly through a comprehensive geriatric assessment performed with validated scales and uniformed criteria simpler than those currently available.

A positive family history of cancer or lifestyle factors may not explain the high incidence of early-onset colorectal cancer in India

SUMMARY 

Aim: Colorectal cancer (CRC) patients from developing countries such as India exhibit distinct clinico-pathological characteristics including an early age of onset and predominant tumor localization in the rectum. However, the reason(s) for increased occurrence among the young is not clear. Materials & methods: In the current study, we performed a comparative analysis of several epidemiological features in early and late-onset CRC patients from India including association with familial syndromes, diet and lifestyle habits. Results: Surprisingly, there was no significant association of any epidemiological variable with early-onset CRC. Conclusion: Perhaps low penetrance syndromes and/or other genetic causes may be responsible for an early age of onset among Indian CRC patients.

Targeted therapy in older patients with solid tumors

The introduction of targeted therapy has ushered in the era of personalized medicine in cancer therapy. The increased understanding of tumor heterogeneity has led to the determination of specific targets that can be exploited in treatment. This review highlights approved drugs in different therapeutic classes, including tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, drugs targeted to the human epidermal growth factor receptor 2, BRAF-mutation targeted drugs, anti-epidermal growth factor receptor inhibitors, and anti-vascular endothelial growth factor therapy. There have not been elderly patient-specific trials of these therapies. Most of the data are extrapolated from larger trials in which older patients generally were a fraction of the participants. Therapeutic recommendations are made on the basis of this analysis with the recognition that the older clinical trial participants may not be representative of patients seen in daily practice. Patient selection and geriatric evaluation are critical for appropriate drug selection, dosing, and monitoring. With care, these therapies are a major step forward in the safe and effective treatment of older patients with cancer.

Age-specific cancer incidence rates increase through the oldest age groups

BACKGROUND

In the United States, from 2005 to 2009, nearly 8% of all cancers diagnosed and 15% of cancer deaths occurred in individuals aged 85 years and older (85+ age group). With the aging of the U.S. population, an analysis of incidence of cancer in the elderly population may provide information for clinical care and resource allocation.

MATERIALS AND METHODS

Previously reported data were retrieved from the Surveillance Epidemiology and End Results (SEER) 18 Registry for years 2000 to 2010 and Central Brain Tumor Registry of the United States (CBTRUS) for years 2004 to 2008. Cancers included invasive cases only, except for nonmalignant meningiomas, and rates were per 100,000.

RESULTS

The age-specific cancer incidence rate (IR) increases with age until a decrease in the 85+ age group. IR for all cancers combined for this age group was 2,317 per 100,000. Statistically, males had significantly higher IR compared with females (3,194 versus 1,911 [P≤0.0001]). Blacks had an IR similar to whites (2,255 versus 2,340 [P=0.12]). Despite a drop in the overall IR in this oldest age group, IR for certain cancers continued to increase. Among these cancers, gastrointestinal cancers like colorectal, pancreatic and stomach had the highest incidence and mortality rates.

CONCLUSIONS

This study contributes to measuring cancer burden in the oldest old population. In certain cancers, including meningiomas, the IR continues to rise with advancing age. Management of cancer in elderly is challenging and screening persons in the 85+ age group for frailty very thoroughly may help guide decisions of palliative versus aggressive therapies.

Pathological stage significantly predicts survival in colorectal cancer patients: a study from two tertiary care centers in India

SUMMARY

Aims: An increase in incidence of early-onset colorectal cancer (EOCRC) in developing countries, including India, is reported recently; however, systematic analyses of clinico-pathological features and disease prognosis has seldom been undertaken. Materials & methods: We studied clinical data pertaining to 1259 colorectal adenocarcinoma patients from two tertiary cancer centers in south India. Results: Approximately 45% of patients were aged below 50 years and poor grade and late-stage tumors were significantly associated with early disease onset. Although tumor grade and stage significantly influenced disease-free survival independently, significant association between survival and age of onset or tumor location was not detected unlike previous observations. Conclusion: Given the sizeable proportion of EOCRC, implementation of the revised Bethesda guidelines may not be tenable in India. More importantly, the previous observation of EOCRC being significantly associated with poor survival could, in part, be due to a higher proportion of advanced-stage tumors.

A postauthorization survey to document the therapeutic management of oxaliplatin as a first-line chemotherapy regimen in South Africa in patients with metastatic colorectal cancer

Oxaliplatin is a standard first-line treatment for metastatic colorectal cancer. The objectives were to document the therapeutic management of oxaliplatin in South Africa, determine the incidence and severity of sensory neuropathy, and record the 2-year survival rate. Meccelox was a prospective, noncontrolled, open label, multicentre, observational survey of adult patients with stage IV metastatic colorectal cancer treated with oxaliplatin-based chemotherapeutic regimens. The study was conducted from August 2007 to November 2011 in 29 sites in South Africa by 66 participating treating physicians. Among the 195 enrolled patients, 61% were treated with FOLFOX regimen (5-fluorouracil/folinic acid plus oxaliplatin) for an average of 12 cycles and 32% patients were treated with XELOX (capecitabine plus oxaliplatin) for an average of 6–8 cycles, with the main reason for discontinuation being completion of the preplanned prescribed regimen. In Meccelox survey, 80% of patients were treated with intent of palliation. Overall 64% of patients reported symptoms of sensory neuropathy. The 2-year survival rate was 30%. Conclusions. Patients received a specified preplanned number of chemotherapy cycles rather than being treated until disease progression or toxicity. Both the incidence of neuropathy and the 2-year survival rate were less than previous reports.

Colorectal cancer treatment and follow-up in the elderly: an inexplicably different approach

The incidence of colorectal cancer increases as age progresses. At present, elderly patients have received substandard cancer treatment not supported by "evidence." Geriatric assessment should be performed preoperatively and selected elderly patients must be offered standard surgical treatment receiving the same complementary therapies as a younger patient. It should be stressed that elderly patients should not be deprived of their decision-making role. In our experience, more than 43% of patients with colorectal cancer are ≥70 years of age, and we believe that they should receive the same type of follow-up. This would allow for the detection and removal of polyps, treatment of malignant tumors, and psychological support similarly to younger patients. Significantly, in our experience, the incidence of reoperation for neoplastic disease is similar in the two patient populations.

Assessment of solid cancer treatment feasibility in older patients: a prospective cohort study

PURPOSE

To assess solid cancer treatment feasibility in older patients.

METHODS

Between 2007 and 2010, 385 consecutive elderly patients (mean age: 78.9 ± 5.4 years; 47.8% males) with solid malignancies referred to two geriatric oncology clinics were included prospectively. We recorded feasibility of first-line chemotherapy (planned number of cycles in patients without metastases and three to six cycles depending on tumor site in patients with metastases), surgery (patient alive 30 days after successfully performed planned surgical procedure), radiotherapy (planned dose delivered), and hormonal therapy (planned drug dose given), and we recorded overall 1-year survival.

RESULTS

Main tumor sites were colorectal (28.6%), breast (23.1%), and prostate (10.9%), and 47% of patients had metastases. Planned cancer treatment was feasible in 65.7% of patients with metastases; this proportion was 59.0% for chemotherapy, 82.6% for surgery, 100% for radiotherapy, and 85.2% for hormonal therapy. In the group without metastases, feasibility proportions were 86.8% overall, 72.4% for chemotherapy, 95.7% for surgery, 96.4% for radiotherapy, and 97.9% for hormonal therapy. Factors independently associated with chemotherapy feasibility were good functional status defined as Eastern Cooperative Oncology Group performance status <2 (p < .0001) or activities of daily living >5 (p = .01), normal mobility defined as no difficulty walking (p = .01) or no fall risk (p = .007), and higher creatinine clearance (p = .04).

CONCLUSION

Feasibility rates were considerably lower for chemotherapy than for surgery, radiotherapy, and hormonal therapy. Therefore, utilization of limited geriatric oncology resources may be optimized by preferential referral of elderly cancer patients initially considered for chemotherapy to geriatric oncology clinics.

Systemic treatment of gastrointestinal cancer in elderly patients

PURPOSE

Gastrointestinal cancer (GI) incidence increases with each decade of life and is the leading cause of death in patients aged >70 years. Nevertheless, elderly patients are often excluded or underrepresented in clinical trials. We performed a review of current recommendations in the management of GI elderly cancer patients.

METHODS

A comprehensive literature review was performed analyzing data about several meta-analysis and studies regarding chemotherapeutic regimens in elderly patients with colorectal and gastroesophageal cancers.

RESULTS

Most of the studies demonstrated that the elderly experience the same advantages and toxicities from chemotherapy as younger individuals despite the fact that the data reviewed in this article provide evidence that elderly with GI cancers are underrepresented in clinical trials and few trials are conducted addressing the different risks and aims in older population. Each individual should be assessed for an appropriate regimen of treatment in the adjuvant or metastatic gastrointestinal cancer setting, and the decision of how to treat elderly must incorporate goals and preferences of the patient after a careful discussion of risks and benefits.

CONCLUSION

Chronological age alone is not a sufficient factor to withhold curative/palliative treatment from an elderly GI cancer patient, and cofactors regarding their functional, social, and mental status have to be considered. For this purpose, several tools exist that may be utilized, such as geriatric assessment scores, comorbidity indices, frailty indices, scores for predicting toxicity from chemotherapy, and prognostic indices for survival.

Analysis of docetaxel therapy in elderly (≥70 years) castration resistant prostate cancer patients enrolled in the Netherlands Prostate Study

BACKGROUND

Prostate cancer truly is an age-associated disease. Due to the increased life expectancy and more sensitive diagnostic techniques in the Western world, prostate cancer is diagnosed more frequently and with rapidly increasing incidence and prevalence rates. However, age above 65 or 70 years has been an exclusion criterion in clinical trials for decades and the knowledge about chemotherapy tolerance in elderly is limited.

METHODS

We performed a retrospective analysis of data acquired from the recently published Netherlands Prostate Study (NePro) to evaluate the influence of advanced age on docetaxel therapy in elderly men (>70 years) with castration resistant prostate cancer (CRPC) and bone metastases. Statistical analyses were performed stratified for age into four categories: <70 (n=315), 70-74 (n=150), 75-79 (n=85), and ≥80 years old (n=18).

RESULTS

We analysed 568 patients (median age 68.1 years, range 46-89 years, 44.5% aged ≥70 years). There was no relation between dosage and age (p=0.60). We found no significant differences between the number of dose reductions, time to progression (TTP), overall survival, chemotherapy tolerance and toxicity up to the age of 80 years. However, when compared to younger men, men aged 80 years or above more frequently experienced grade 3/4 toxicity and were five times less likely to complete the first three treatment cycles at the intended dose (Odds ratio (OR) 5.34, p=0.0052) and showed decreased overall survival (15.3 months versus 24.5 months in <80 years group, p=0.020).

CONCLUSION

In CRPC patients up to the age of 80 years, docetaxel chemotherapy is well tolerated, with toxicity levels and TTP comparable to those of younger patients. For chemotherapeutic treatment of patients above the age of 80 years an individual assessment should be made.

Angiogenic inhibitors for older patients with advanced colorectal cancer: Does the age hold the stage?

Although major progress has been achieved in the treatment of advanced colorectal cancer (CRC) with the employment of antiangiogenic agents, several questions remain on the use of these drugs in older patients. Since cardiovascular, renal and other comorbidities are common in the elderly, an accurate assessment of the patients’ conditions should be performed before a treatment decision is made. Since most CRC patients enrolled in clinical trials testing antiangiogenic drugs were aged < 65 years, the efficacy and tolerability of these agents in elderly patients has not been adequately explored. Data suggest that patients with advanced CRC derive similar benefit from bevacizumab treatment regardless of age, but the advantage of other antiangiogenic drugs in the same class of patients appears more blurred. Literature data suggest that specific antiangiogenic-related toxicities such as hypertension or arterial thromboembolic events may be higher in the elderly than in the younger patients. In addition, it should be emphasized that the patients included in the clinical studies discussed herein were selected and therefore may not be representative of the usual elderly population. Advanced age alone should not discourage the use of bevacizumab. However, a careful patients’ selection and watchful monitoring of toxicities are required to optimize the use of antiangiogenics in this population.

Relative effectiveness and safety of chemotherapy in elderly and nonelderly patients with stage III colon cancer: a systematic review

BACKGROUND

Chemotherapy effectiveness in clinical practice may differ from the efficacy demonstrated in clinical trials, particularly among populations underrepresented in clinical trials, such as elderly patients with cancer. This review aims to examine the relative effectiveness of chemotherapy for stage III colon cancer in elderly versus nonelderly patients.

METHODS

A systematic literature review was conducted using the Agency for Healthcare Research and Quality approach. Literature searches were performed in Medline and Evidence-Based Medicine Reviews databases. Chemotherapy regimens approved for stage III colon cancer were reviewed. Four effectiveness and 15 safety outcomes were extracted.

RESULTS

From 708 identified articles, 25 articles provided data on the relative effectiveness and safety of chemotherapy among elderly versus nonelderly patients. Four of 14 studies showed lower overall survival treatment effects, whereas one of five and one of four studies indicated more favorable treatment effects for time to progression and overall response rate. Grade 3 or 4 adverse events were higher among elderly patients for cardiac disorder (2/5 studies), leukopenia (1/5), neutropenia (4/16), thrombocytopenia (2/13), febrile neutropenia (1/4), infection (2/10), dehydration (2/6), diarrhea (6/20), and fatigue (6/13). Grade 3 or 4 adverse events were lower for neutropenia (2/16 studies), nausea/vomiting (1/16), and neuropathy (1/9).

CONCLUSION

The majority of the evidence suggests that chemotherapy has similar relative effectiveness and safety for patients >65 years of age versus younger patients with stage III colon cancer. When differences are reported, treatment effects are more often worse among the elderly. This review suggests that without other reasons for withholding treatment, elderly patients should receive chemotherapy as often as nonelderly patients.

Bevacizumab in older patients with advanced colorectal or breast cancer

The incidence of colorectal and breast cancer is growing among the 550 million living people aged 65 or older. Bevacizumab was the first anti-angiogenic agent approved for the treatment of the advanced phase of these cancers. Although older chronological age still hampers the use of modern treatments, there is a widespread awareness that chronological and physiological (i.e. functional) ages may largely differ, and that seniority itself should not be a stringent limit for the introduction of anti-angiogenics. However, the use of bevacizumab in the general older population is questionable. There is limited evidence of a favorable risk-to-benefit ratio, with efficacy data deriving from clinical trials that selected only elderly patients in rather good health. While summarizing the recent advances, this review highlights specific clinical features characterizing those older patients who may benefit the most from receiving bevacizumab.

High and low dose folinic acid, 5-fluorouracil bolus and continuous infusion for poor-prognosis patients with advanced colorectal carcinoma

OBJECTIVE

Evaluation and assessment of response rate, duration and toxicity in patients subjected to 5-FU based chemotherapy.

BACKGROUND

The therapeutic ratio shifts with different 5FU/LV regimens and none yet serve as the internationally accepted Gold Standard. A bimonthly regimen of high dose leucovorin is reported to be less toxic and more effective than monthly low dose regimens. We here compare therapeutic responses and survival benefit of the two regimens in poor prognosis patients with advanced colorectal carcinoma.

PATIENTS AND METHODS

A total of 35 patients with histologically confirmed colorectal carcinoma were subjected to de Gramont and Mayo Clinic regimen. Nineteen patients were treated with high dose folinic acid (200 mg/m2), glucose 5%, 5-FU (400 mg/m2) and 22 hr. CIV (600 mg/m2) for two consecutive days every two weeks. These patients had failed responses to previous chemotherapy and were above sixty years of age with poor general status. Sixteen patients (six below 60 years) with progressive disease were subjected to low dose folinic acid (20 mg/m2)for five days, 5FU(425 mg/m2) injection bolus for 5 days, every five weeks. An initial evaluation was made in sixty days and responders were reevaluated at sixty days interval or earlier in case of clinical impairment. Based on positive prognosis, the therapy was continued. Evaluation of treatment response was made on the basis of WHO criteria.

RESULTS

The response rate was 44% in thirty four evaluable patients, with 4 complete responses (11.8%) and 11 (32.4%) partial responses. The two schedules were well tolerated, whereas, mild toxicity without WHO Grade ≥ 2 events was assessed. The response duration was extended (12 months) in a few patients with age above sixty years treated by high dose bimonthly regimen of 5FU/LV.

CONCLUSION

The regimens are safe and effective in advanced colorectal carcinoma patients with poor general status.

XELOX and bevacizumab followed by single-agent bevacizumab as maintenance therapy as first-line treatment in elderly patients with advanced colorectal cancer: the boxe study

PURPOSE

The addition of bevacizumab to oxaliplatin-based chemotherapy significantly improved progression-free survival (PFS) in patients with metastatic colorectal cancer (CRC). An increased risk of arterial thromboembolic events has been observed in some trials in older patients, and the potential benefit of a maintenance therapy with bevacizumab alone has not been clearly demonstrated. This phase II study was designed to evaluate the efficacy and safety of XELOX (capecitabine plus oxaliplatin) plus bevacizumab followed by bevacizumab alone in elderly patients with advanced CRC.

METHODS

Treatment consisted of bevacizumab 7.5 mg/kg and oxaliplatin 130 mg/m(2) on day 1, plus capecitabine 1,000 mg/m(2) twice daily on days 1-14, every 3 weeks up to a maximum of 8 cycles. Patients then received maintenance therapy consisting of bevacizumab alone (7.5 mg/kg) once every 3 weeks up to disease progression. The primary study end-points were safety and response rate.

RESULTS

A total of 44 patients were recruited. In an intention-to-treat analysis, the overall response rate was 52% [95% confidence interval (CI) 37 to 68%], with 86% of patients achieving disease control. Median PFS and overall survival were 11.5 months (95% CI 10.0-12.9 months) and 19.3 months (95% CI 16.5-22.1 months), respectively. In all, 10 patients (23%) had grade 3/4 adverse events (AEs), the most common being diarrhea (9%), neutropenia (7%), peripheral neuropathy (7%), and stomatitis (7%). No patients died because of treatment-related AEs. The rate of bevacizumab-related AEs (hypertension, thromboembolic events, and gastrointestinal perforation) was consistent with that reported earlier in the general CRC population.

CONCLUSION

The combination of XELOX and bevacizumab is effective and has a manageable tolerability profile when administered to elderly patients with advanced CRC. Maintenance therapy with single-agent bevacizumab may be considered to extend PFS in this setting of patients.

Differences in the therapeutic approach to colorectal cancer in young and elderly patients

PURPOSE

To analyze differences in the therapeutic approach to and tumor-related mortality of young and elderly colorectal cancer (CRC) patients.

PATIENTS AND METHODS

This was a descriptive study of a retrospective cohort, based on administrative databases, of all patients with CRC diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, type of treatment received, survival time, and cause of death. We compared differences between a young group (YG) (age <75 years) and an older group (OG) (age ≥75 years) and assessed the variables associated with receiving different therapeutic options (multivariate analysis) and with survival time (Cox proportional hazards models).

RESULTS

The study included 503 patients (YG, 320; OG, 183), with mean ages of 63.1 years in the YG and 81.8 years in the OG. No differences were observed between the groups in degree of differentiation, extension, tumor stage, or comorbidity. After adjustment for gender, comorbidity, and tumor localization and extension, YG patients were more likely than OG patients to receive surgery, radiotherapy, and chemotherapy and less likely to receive palliative care. After a median follow-up of 36.5 months, YG patients had a longer tumor-specific survival time than OG patients (36.41 months vs 26.05 months). After further adjustment, the YG had a lower tumor-specific mortality risk (hazard ratio, 0.66) than the OG.

CONCLUSION

In comparison with younger patients, elderly CRC patients are undertreated, mainly because of their age and not because of their tumor type or comorbidity. Elderly patients have a significantly shorter tumor-specific survival time, partially because of this undertreatment.

Age and treatment choices in advanced colorectal cancer

SUMMARY Colorectal cancer is primarily a disease of the elderly. During the past 15 years, the median survival for metastatic colorectal cancer has increased significantly. Older patients are a heterogeneous population, and chronological age is not a reliable predictor of tolerance of treatment. There is now a significant body of evidence that demonstrates equal efficacy and tolerability of treatment between older and younger patients. Despite this, chemotherapy use declines with advancing age. Further research is needed to enable optimal management of this significant group of patients.

Management of cancer in the older adult

Cancer incidence and mortality rise exponentially in the elderly. With the aging of the population there is an urgent need to address this issue with evidence-based guidelines. Delayed diagnosis and incomplete workup and treatment are well documented in this population. Incorporation of a geriatric evaluation in oncology practice should be routinely implemented to prevent adverse outcomes. Treatment decisions in the elderly should not be based solely on survival gains but should also take quality of life into consideration. Cancer treatment is safe and effective in the elderly population. Social issues and other comorbidities should be addressed to improve compliance and outcome. Many unanswered questions regarding the optimal management of elderly cancer patients can be addressed only with the new clinical trials. Eliminating age bias among health care providers by providing education will help achieve optimal care for the elderly with cancer.