Saturday, September 23, 2023
| 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 + oxaliplatin |
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 completion.49 |
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
|
Take Home Messages Regarding Management of Older Patients With Early-Stage Colon Cancer
|
Take Home Messages Regarding Management of Older Patients With Metastatic Colon Cancer
| 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 comorbidities. |
| Systemic metastatic disease |
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 patients.57,58 |
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 patients. |
| Single-agent 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 mCRC. |
|
| Combination chemotherapy |
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 antibody) |
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 warranted. |
|
| Cetuximab/ 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 patients.77–79 |
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
|
Take Home Messages Regarding the Use of Targeted Therapy in the Management of Older Patients With Metastatic Colon Cancer
As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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:
As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and JNCCN - The Journal of the National Comprehensive Cancer Network. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00
AMA PRA Category 1 Credit(s)™
. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Medscape, LLC staff have disclosed that they have no relevant financial relationships.
For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability
and acceptance of continuing education credit for this activity, please consult your professional licensing board.
This activity is designed to be completed within the time designated on the title page; physicians should claim only those
credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the
activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.
Follow these steps to earn CME/CE credit*:
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it.
Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print
out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.
*The credit that you receive is based on your user profile.
CME Released: 2/6/2012
Valid for credit through: 2/6/2013, 11:59 PM EST
processing....
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.
