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Table 1.  

Treatment Available Data Conclusion
Surgery Older patients are less likely to be
offered curative surgeries.
Risk of perioperative mortality is
dependent on surgical expertise
and patient selection.22,24
Laparoscopic approaches may
offer a less-invasive treatment
with fewer adverse events.26
Consideration of the biologic
rather than the chronologic age
is warranted when considering
curative surgery for older
patients with colon cancer.
Chemotherapy with single-agent
5-fluorouracil (5-FU)
Older patients with early-stage
colon cancer are less likely to
receive adjuvant chemotherapy
despite sufficient long-term
survival benefit.28 Adjuvant
single-agent 5-FU has been
shown to improve clinical
outcomes of older adults with
colon cancer, despite increase
in hematologic adverse events
compared with younger patients.28–33

Stage II: Lack of benefit from
adjuvant 5-FU among patients
older than 70 years in the
QUASAR study.38
Older patients with a good
performance status and adequate
life expectancy can benefit from
adjuvant therapy with single-
agent 5-FU. The benefit for older
patients with stage II disease may
be more limited.
Chemotherapy with 5-FU +
Subgroup analyses and large
retrospective studies show limited
benefit for the addition of
oxaliplatin to adjuvant 5-FU for
older patients with early-stage
colon cancer.39–41
The addition of oxaliplatin to
adjuvant 5-FU is likely to increase
toxicity among older patients.
The clinical benefit of this
approach remains controversial.
Long-term surveillance Meta-analyses of randomized
clinical trials showed improved
survival for patients undergoing
intensive surveillance after
curative treatment for early-
stage colon cancer.45–48 Older
patients are less-often offered
the recommended monitoring
schedule after treatment
Fit older patients with adequate
life expectancy should undergo
the recommended surveillance
schedule after curative treatment
of early-stage colon cancer.

Treatment of Early-Stage Colon Cancer Among Older Patients: Summary of Available Data

Table 2.  

  • Age alone should not be a contraindication for curative surgery for early-stage colon cancer. Careful preoperative patient assessment and planning will result in optimal clinical outcomes.
  • Relative benefit from adjuvant treatment is similar across age groups; however, absolute benefit of chemotherapy may be smaller because of competing causes of death.
  • Older adults derive a relative benefit from 5-fluorouracil-based adjuvant therapy similar to younger patients, with only a slight increase in toxicity, mainly in hematologic toxicities.
  • The benefit of oxaliplatin-based therapy in adults older than 70 years is questionable and should be considered on an individual basis.

Take Home Messages Regarding Management of Older Patients With Early-Stage Colon Cancer

Table 3.  

  • Age alone should not be a contraindication for surgical resection of solitary liver metastasis from colon cancer, yet the risk of perioperative morbidity is higher among older patients.
  • The use of an OPTIMOX-1 or -2 strategy (combination chemotherapy alternating with 5-fluorouracil monotherapy treatment or chemotherapy-free intervals, respectively) is a preferred treatment strategy among older patients.
  • Older adults, compared with younger adults, derive a similar relative benefit from the approved agents for treatment of metastatic colon cancer, with potentially increased rates of adverse events.

Take Home Messages Regarding Management of Older Patients With Metastatic Colon Cancer

Table 4.  

Setting Treatment Available Data Conclusion
Solitary metastasis Surgery Retrospective analyses showed
increased rates of postoperative
morbidity and mortality among
older patients undergoing
hepatic resection. Increased risk
was seen among patients with
> 3 liver lesions, extrahepatic
disease, comorbidities, and lack of
postoperative chemotherapy.52,53
Surgical resection of
liver metastasis can be
considered a therapeutic
option for fit older
patients with limited
Systemic metastatic
Concurrent vs.
sequential therapy
Large randomized clinical
trials failed to report a survival
advantage from the use of
combination chemotherapy
compared with single-agent
treatment.54–56 Intermittent use of
combination therapy (OPTIMOX
strategy) has been shown to
be favorable among older
Careful assessment of
the risk/benefit ratio
for using combination
chemotherapy in the
treatment of older patients
with mCRC. OPTIMOX-1
or -2 may be a reasonable
strategy among older
chemotherapy (5-FU)
Retrospective analysis
demonstrates similar benefit in
terms of OS, RR, and PFS among
older patients with metastatic
disease treated with single-agent
5-FU to that seen among younger
patients.36 The use of capecitabine
is associated with increased toxicity
when used in frail older patients.59
Single-agent 5-FU can
improve clinical outcomes
of older patients with
The addition of oxaliplatin
or irinotecan to 5-FU for the
treatment of older patients
with mCRC results in increased
frequency of adverse events.60,63
Most reports show clinical
improvement, similar to that seen
in younger patients, with the use
of combination chemotherapy in
the metastatic setting.59,61,62,64
Fit older patients with
metastatic colon cancer
can be considered for combination
chemotherapy. Close
monitoring is required
because of increased risk
for adverse events.
Bevacizumab (anti-VEGF
Improved PFS and OS among older
patients with mCRC treated with
bevacizumab. Increased incidence
of arterial thrombolic events
among older patients, mainly in
those older than 75 years.68,70–72,75
Bevacizumab should be
offered to appropriate
older patients with
mCRC with combination
chemotherapy or single-
agent 5-FU. Cardiac
evaluation of patients
at high risk may be
panitumumab (anti-
EGFR antibody)
Subgroup analyses from large
randomized clinical trials fail to
show a benefit to the addition
of these agents to combination
chemotherapy among older
patients.76 The limited data
available report good tolerance
of these agents among older
Limited data are available
regarding the efficacy of
anti-EGFR antibody for
older patients with mCRC.

Treatment of Metastatic Colorectal Cancer Among Older Patients: Summary of Available Data

Table 5.  

  • Older patients derive similar clinical benefit from the use of bevacizumab in the metastatic setting as younger patients, with higher rate of toxicities, mainly arterial thromboembolic events.
  • Data regarding the use of anti–epidermal growth factor receptor therapy among older patients are limited; retrospective analyses show an acceptable toxicity profile.

Take Home Messages Regarding the Use of Targeted Therapy in the Management of Older Patients With Metastatic Colon Cancer


Challenges in the Management of Older Patients With Colon Cancer

  • Authors: Efrat Dotan, MD; Ilene Browner, MD; Arti Hurria, MD; Crystal Denlinger, MD
  • CME Released: 2/6/2012
  • Valid for credit through: 2/6/2013, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This activity is intended for primary care physicians, oncologists, surgeons, and other physicians who care for patients with colon cancer.

The goal of this activity is to evaluate the efficacy and safety of colon cancer treatment among older adults.

Upon completion of this activity, participants will be able to:

  1. Analyze colon cancer outcomes among older adults
  2. Evaluate the use of adjuvant 5-fluorouracil among older adults with colon cancer
  3. Assess other chemotherapy agents for the treatment of colon cancer among older adults
  4. Analyze surveillance for colon cancer recurrence among older adults


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  • Efrat Dotan, MD

    Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania


    Disclosure: Efrat Dotan, MD, has disclosed no relevant financial relationships.

  • Ilene Browner, MD

    The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland


    Disclosure: Ilene Browner, MD, has disclosed no relevant financial relationships.

  • Arti Hurria, MD

    Department of Medical Oncology, Cancer and Aging Research Program, City of Hope Comprehensive Cancer Center, Duarte, California


    Disclosure: Arti Hurria, MD, has disclosed the following relevant financial relationships: Participated in research for: GlaxoSmithKline; Celgene Corporation; Abraxis Oncology
    Participated on the advisory board for: GTX

  • Crystal Denlinger, MD

    Fox Chase Cancer Center, Philadelphia, Pennsylvania


    Disclosure: Crystal Denlinger, MD, has disclosed no relevant financial relationships.


  • Kerrin M. Green, MA

    Assistant Managing Editor, Journal of the National Comprehensive Cancer Network


    Disclosure: Kerrin M. Green, MA, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

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  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Challenges in the Management of Older Patients With Colon Cancer

Authors: Efrat Dotan, MD; Ilene Browner, MD; Arti Hurria, MD; Crystal Denlinger, MDFaculty and Disclosures

CME Released: 2/6/2012

Valid for credit through: 2/6/2013, 11:59 PM EST


Abstract and Introduction


Most patients with colon cancer are older than 65 years. Their treatment poses multiple challenges, because they may have age-related comorbidities, polypharmacy, and physical or physiologic changes associated with older age. These challenges include limited data on the ability to predict tolerance to anticancer therapy and the appropriate use of treatment modalities in the setting of comorbidity and concurrent frailty. The low number of older patients enrolled in large clinical trials results in a paucity of evidence to guide oncologists in the appropriate management of this population. In early-stage disease, clinical dilemmas arise regarding the ability of older patients to undergo successful curative surgical procedures and the risk/benefit ratio of adjuvant chemotherapy. The management of metastatic disease raises questions regarding the clinical benefit of various anticancer therapies and the role of combination therapy with possible increased toxicity in the noncurative setting. Overall, the available evidence shows that fit older patients are able to tolerate treatment and derive similar clinical benefits to younger patients. Limited data are available to guide treatment for less-fit, more-vulnerable older patients. This lack of data leads to variations in treatment patterns in older adults, making them less likely to receive standard therapies. This review provides an overview of the available data regarding the management of older adults with colon cancer i n the adjuvant and metastatic settings. (JNCCN 2012;10:213–225)


The field of geriatric oncology is rapidly growing as the average age of the U.S. population steadily rises and the number of older patients diagnosed with cancer continues to increase. Estimates show that 20% of the U.S. population will be older than 65 years by 2030 and that 70% of cancers will occur in this population.[1,2] Cancer is the leading cause of death among older men and women aged 60 to 79 years.[3] Colon cancer, in particular, is commonly seen in older patients, with a median age at diagnosis of 71 years and 40% of cases diagnosed in patients older than 75 years.[4] The probability of developing colon cancer is 1 in 22 for men and 1 in 24 for women older than 70 years, compared with 1 in 67 for men and 1 in 94 for women aged 60 to 69 years.[3] Thus, oncologists should anticipate treating increasing numbers of older patients with colon cancer in the future.

Despite this large and growing patient population, older patients have traditionally been underrepresented in prospective randomized clinical trials, possibly because of eligibility criteria that specify performance status and comorbidity requirements. Hutchins et al.[5] compared the proportion of patients older than 65 years with each type of cancer enrolled in SWOG trials versus the proportion of older patients in the general U.S. population with the same disease. Only 40% of patients with colon cancer enrolled in clinical trials were older than 65 years, whereas more than 70% of patients with colon cancer in the general U.S. population surpassed this age limit. More recently, similar results were shown in evaluations of enrollment of older oncology patients in NCI-sponsored phase II and III studies and in FDA cancer drug registration studies.[6–8] These low rates make it difficult to practice evidence-based medicine while treating geriatric patients with cancer.