A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients

Prognostic impact of micrometastases in colon cancer: interim results of a prospective multicenter trial

OBJECTIVE

The 25% rate of recurrence after complete resection of stage II colon cancer (CC) suggests the presence of occult nodal metastases not identified by hematoxylin and eosin staining (H&E). Interim data from our ongoing prospective multicenter trial of sentinel node (SN) biopsy indicate a 29.6% rate of micrometastases (MM) identified by immunohistochemical staining (IHC) of H&E-negative SNs in CC. We hypothesized that these MM have prognostic importance.

METHODS

Between March 2001 and August 2006, 152 patients with resectable colorectal cancer were enrolled in the trial. IHC and quantitative RT-PCR (qRT) assay were performed on H&E-negative SNs. Results were correlated with disease-free survival.

RESULTS

The sensitivity of lymphatic mapping was significantly better in CC (75%) than rectal cancer (36%), P<0.05. Of 92 node-negative CC patients 7 (8%) were upstaged to N1 and 18 (22%) had IHC MM. Four patients negative by H&E and IHC were positive by qRT. At a mean follow-up of 25 months, 15 patients had died from noncancer-related causes, 12 had developed recurrence, 5 had died of CC (2 with macrometastases, 3 with MM), and 7 were alive with disease. The 12 recurrences included 4 patients with SN macrometastases and 6 with SN MM (2 by IHC, 4 by qRT). One of the 2 SN-negative recurrences had other positive lymph nodes by H&E. All patients with CC recurrences had a positive SN by either H&E/IHC or qRT. No CC patient with a negative SN by H&E and qRT has recurred (P=0.002).

CONCLUSION

This is the first prospective evaluation of the prognostic impact of MM in colorectal cancer. These results indicate that the detection of MM may be clinically relevant in CC and may improve the selection of patients for adjuvant systemic chemotherapy. Patients with CC who are node negative by cumulative detection methods (H&E/IHC and qRT) are likely to be cured by surgery alone.

Management and survival of colorectal cancer in the elderly in population-based studies

Colorectal cancer is a major problem in elderly patients. Most data on the management and survival of colorectal cancer has been provided by specialised hospital units and as such cannot be used as reference because of unavoidable selection bias. Cancer registries recording data on treatment and survival at a population level represent the best valuable resource to assess the management of patients. However, there is a paucity of reports published in the literature due to the difficulty to routinely collect such data. Relative survival rates in the elderly were lower than in younger patients. However, the gap that has separated younger from elderly patients is closing. Stage at diagnosis remains the major determinant of prognosis. There is also large variation in survival within countries: survival rates being dramatically lower in Eastern European countries, compared to Western European countries. Comorbidity, which is particularly frequent in the elderly, increases the complexity of cancer management and affects survival. Substantial improvement in the care of colorectal cancer in the elderly has been achieved (increase in the proportion of patients resected for cure, decrease in operative mortality, improvement in stage at diagnosis). Surgery should not be restricted on the basis of age alone. Further improvements can be made, in particular with respect to adjuvant therapy.

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE

To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival.

SUMMARY BACKGROUND DATA

The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival.

METHODS

Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis.

RESULTS

We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001).

CONCLUSIONS

In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.

Changes in disease pattern and treatment outcome of colorectal cancer: a review of 5,474 cases in 20 years

BACKGROUND AND AIMS

Colorectal cancer (CRC) is the third most common cause of cancer-related death in Taiwan. During the past 20 years, several advances have improved the treatment outcome and quality of life of CRC patients. The purpose of this study was to identify the changes in the clinicopathological features and outcome of CRC over this period.

MATERIALS AND METHODS

Based on the computerized database of the Taipei Veterans General Hospital, between January 1981 and December 2000, 5,474 CRC patients were identified and divided into 2 groups based on the date of treatment (1981-1990 and 1991-2000). The clinicopathological features, outcome, and prognostic factors were analyzed and compared.

RESULTS/FINDINGS

The age at onset of cancer was 61 years in the 1980s group and 66 years in the 1990s group. The frequency of rectal tumors decreased from 50% in the 1980s group to 44% in the 1990s group. Tumor, nodes, metastasis (TNM) stage distribution, surgical mortality, and anastomosis leakage were similar in the two groups. However, the 5-year overall survival rate was better in the 1990s group (56%) than that in the 1980s group (50%, P = 0.001). For rectal cancer patients, the local recurrence rate was lower in the 1990s group (6%) than that in the 1980s group (10%, P < 0.01). In stage III CRC, the 5-year overall survival rate was significantly higher in the 1990s group (54%) than that in the 1980s group (48%, P = 0.011). TNM stage was the most important independent prognostic factor for overall and disease-free survivals, followed by differentiation grade, CEA level, and treatment period.

INTERPRETATION/CONCLUSION

Advances in surgical technique and more standard use of chemotherapy have improved CRC outcome.

Place of multidisciplinary consulting meetings and clinical trials in the management of colorectal cancer in France in 2000

AIM

The 1998 consensus conference dealing with colon cancer, and the 2003 Cancer Plan underlined the need for multidisciplinary meetings and for including patients in therapeutic trials. The aim of this study, which pooled data from the French Cancer Registries operating within the Francim network, was to report on diagnostic and therapeutic practices in the general French population before implementation of the Cancer Plan.

METHODS

The study population was composed of 2935 patients with colorectal cancer diagnosed in 2000 in twelve French administrative districts accounting for 15% of the geographical area of France. Data were collected using a standardized procedure. Three categories of place of diagnosis were defined: public university hospitals, public non-university hospitals, and private clinics.

RESULTS

Overall, multidisciplinary meeting was conducted for 32.2% of patients with colorectal cancer. This proportion varied from 6.4% to 76.9%, depending on the geographical area (P<0.001). The place of diagnosis affected this practice: 52% in public university hospitals, 31% in public non-university hospitals and 29% in private clinics (P<0.001). In multivariate analysis, age (OR(>75 years): 0.71, P<0.001), site (OR(rectum): 1.80, P<0.001) and health care facilities (OR(public non-university vs public university): 0.36, P<0.001, OR(private vs public university): 0.40, P<0.001) affected the use of multidisciplinary meeting. Overall, 4.3% of patients were included in a therapeutic trial. This concerned 6.2% of patients aged under 75 and 1.0% of those aged over 75 (P<0.001). The proportion of inclusions, taking into account the trials proposed in 2000 and 2001, varied from 0.7% to 16.4% according to geographical area (P<0.001). This proportion was 10.3% if there had been multidisciplinary meeting and 5.1% if not (P<0.001). Neither cancer site, gender, nor healthcare facility responsible for diagnosis influenced trial inclusion.

CONCLUSION

This population-based study underlines geographical variations in the management of colorectal cancer in France. In 2000, multidisciplinary meeting was conducted for an insufficient proportion of patients, and an insufficient number of patients were included in therapeutic trials. Repeating the same survey in 2005 will provide information on the effects of the Cancer Plan and the diffusion of these recommendations.

Survival rates for stage II colon cancer patients treated with or without chemotherapy in a population-based setting

BACKGROUND AND AIMS

There is considerable uncertainty as to whether adjuvant 5-fluorouracil-based chemotherapy provides survival benefit for colon cancer patients with stage II disease. Consequently, the current rates of chemotherapy use for this disease are low despite 5-year survival rates of only 70-80%. The aim of the present study is to compare the survival rate of stage II colon cancer patients treated by surgery alone with that of patients also treated by chemotherapy.

PATIENTS AND METHODS

A population-based observational study was conducted on the survival of stage II colon cancer patients (n = 812) diagnosed in Western Australia from 1993 to 2003. The study was restricted to patients aged < or =75 years, of whom 18% (n = 142) were treated with chemotherapy. Only 0.9% of patients older than 75 years received chemotherapy.

RESULTS

Patients who received chemotherapy were significantly younger (mean age 6 years) than those treated by surgery alone (65 years, P < 0.001), and their tumors were more often positive for vascular invasion (P = 0.007). Multivariate analysis that included all prognostic factors revealed adjuvant chemotherapy was associated with improved survival (HR = 0.62, 95% CI [0.39-0.98], P = 0.043), with women gaining more benefit (HR = 0.48, 95% CI [0.20-1.22], P = 0.09) than men (HR = 0.94, 95% CI [0.54-1.64], P = 0.8).

CONCLUSIONS

In view of the apparent survival benefit from chemotherapy for stage II colon cancer, the present study raises concerns about the current low rates of adjuvant treatment for this disease in the community, particularly for female patients.

Adjuvant therapies for colorectal cancer

The management of colon and rectal cancer has changed dramatically over the last 25 years. The use of adjuvant therapies has become standard practice in locally advanced (stage  III and selected stage II) colorectal cancer. Improved surgical techniques, chemotherapeutics and radiotherapy are resulting in higher cure rates and the development of agents targeting proliferative and angiogenic pathways offer further promise. Here we explore risk factors for local and distant recurrence after resection of colon and rectal cancer, and the role of adjuvant treatments. Discussion will focus on the evidence base for adjuvant therapies utilised in colorectal cancer, and the treatment of sub-groups such as the elderly and stage II disease. The role of adjuvant radiotherapy in rectal cancer in reduction of recurrence will be explored and the role and optimal methods for surveillance post-curative resection with or without adjuvant therapy will also be addressed.

The impact of chronic illnesses on the use and effectiveness of adjuvant chemotherapy for colon cancer

BACKGROUND

It is unclear how noncancer conditions affect the use or effectiveness of adjuvant therapy among older patients with colon cancer.

METHODS

The authors conducted a cohort study of older patients with stage III colon cancer who were diagnosed from 1993 to 1999 in the Surveillance, Epidemiology, and End Results-Medicare database. The correlations between receipt of adjuvant chemotherapy and heart failure, diabetes, and chronic obstructive pulmonary disease (COPD) were assessed. Multivariable regression analysis was used to assess the risk of death and hospitalization as a function of treatment and comorbidity status.

RESULTS

The study sample consisted of 5330 patients (median age, 76 years). The use of adjuvant therapy was related significantly to heart failure (36.2% vs 64.9% of patients with vs without heart failure, respectively; adjusted odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.40-0.60). More moderate correlations were observed for COPD (OR, 0.83; 95% CI, 0.70-0.99) and diabetes (OR, 0.81; 95% CI, 0.68-0.97). Among patients who had heart failure, the 5-year survival was significantly higher among those who received adjuvant chemotherapy (adjusted 5-year survival rate, 43%; 95% CI, 40-47%) than among those who did not receive adjuvant chemotherapy (30%; 95% CI, 27-34%). Among patients without heart failure, the 5-year survival estimates among treated and untreated patients were 54% (95% CI, 52-56%) and 41% (95% CI, 38-44%), respectively. The probability of all-cause, condition-specific, or toxicity-related hospitalization associated with adjuvant therapy was not altered by the presence of any of the 3 conditions.

CONCLUSIONS

Although chronic conditions appeared to be a strong barrier to the receipt of adjuvant chemotherapy, adjuvant therapy appeared to provide a significant survival benefit to patients who had colon cancer with the conditions studied.

Granulocyte colony-stimulating factors: finding the right indication

PURPOSE OF REVIEW

Neutropenic complications including febrile neutropenia represent major dose-limiting toxicities of cancer chemotherapy. Recommendations for the use of recombinant myeloid growth factors to reduce the risk of neutropenic complications and sustain dose intensity continue to evolve.

RECENT FINDINGS

Several randomized controlled trials and meta-analyses have confirmed that the myeloid growth factors reduce the risk of neutropenic complications and may facilitate delivered dose intensity in patients receiving cancer chemotherapy. Older age and certain comorbidities significantly increase the risk of febrile neutropenia and its consequences. Three new clinical practice guidelines for the use of the myeloid growth factors have been published by major professional oncology organizations including the American Society of Clinical Oncology, the European Organization for Research and Treatment of Cancer and the National Comprehensive Cancer Network. The recommendations and evidence basis for these guidelines are presented here. All three new or updated guidelines recommend prophylactic use of the myeloid growth factors in cancer patients receiving chemotherapy at 20% or greater risk of febrile neutropenia and in those with important variables that increase individual risk of neutropenic complications.

SUMMARY

Consistent clinical practice guidelines based on multiple randomized control trials and meta-analyses should further guide the appropriate and cost-effective use of these agents.

A practical approach to geriatric assessment in oncology

More than half of new cancers are diagnosed in elderly patients, but data from randomized clinical trials do not represent the elderly population. Comprehensive geriatric assessment (CGA) can contribute valuable information to oncologists for risk stratification of elderly cancer patients. Functional impairments, frailty markers, cognitive impairments, and physical disabilities increase the risk for adverse outcomes during cancer treatment. Evidence is accumulating that selected elderly cancer patients benefit from CGA and geriatric interventions. However, perceived barriers to CGA include time, familiarity, cost, and lack of a well-defined procedure to interpret and apply the information. We present a model for rapid selection of elderly who would benefit from CGA using screening tools such as the Vulnerable Elders-13 Survey. We also define important geriatric functional risk factors, including mobility limitation, frailty, and dementia, and demonstrate how brief screening tests can make use of data realistically available to clinical oncologists to determine a stage of aging. Summary tables and a decision tree demonstrate how these data can be compiled to determine the risk for toxicities and to anticipate ancillary support needs.

Multidisciplinary approach to the geriatric oncology patient

Given the dramatic demographic shift observed in developed countries, the medical community, especially oncologists, geriatricians, and primary care providers, are confronted with the expanding challenge of the management of elderly people with cancer. Ageing is associated with the accumulation of multiple and various medical and social problems. With a prevalence comparable to that of other chronic conditions in this age group, such as diabetes or dementia, cancer holds a prominent place among diseases of the elderly. The care of elderly cancer patients is fundamentally interdisciplinary. Communication and collaboration between geriatricians/primary care providers and oncologists represent key features of effective care in geriatric oncology. The combination of the disease-oriented approach of oncologists and the patient-oriented approach of geriatricians is the most powerful way to better serve this specific population. The medical approach of elderly cancer patients should ideally be under the lead of geriatricians or primary care providers sensitive to geriatric issues. Oncologists should manage the biologic consequences of the interplay between cancer and ageing. Close collaboration between clinicians will help promote active dedicated clinical research and the development of guidelines on the management of elderly people with cancer.

Managing older patients with colorectal cancer

Colorectal cancer (CRC) is predominantly a disease of older persons, and our population is aging. Physicians and their older patients commonly face the dilemma of whether or not to give/receive systemic chemotherapy for CRC. Evidence supports the safety and efficacy of systemic chemotherapy in fit older patients motivated enough to enroll onto clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and may not benefit from chemotherapy. However, the majority of patients are neither fit nor frail, and current evidence is insufficient to either quantify or qualify the benefit of chemotherapy for this intermediate group of patients. Thus, treatment decisions must be individualized based on each older person's physical state (eg, their function and degree of comorbidity) and values. Despite a growing body of data, a great deal of work is still needed to establish optimal strategies to care for patients diagnosed with cancer later in life.

International Society of Geriatric Oncology Chemotherapy Taskforce: evaluation of chemotherapy in older patients--an analysis of the medical literature

The elderly comprise the majority of patients with cancer and are the recipients of the greatest amount of chemotherapy. Unfortunately, there is a lack of data to make evidence-based decisions with regard to chemotherapy. This is due to the minimal participation of older patients in clinical trials and that trials have not systematically evaluated chemotherapy. This article reviews the available information with regard to chemotherapy and aging provided by a task force of the International Society of Geriatric Oncology (SIOG). Due to the lack of prospective data, the conclusions and recommendations made are a consensus of the participants. Extrapolation of data from younger to older patients is necessary, particularly to those patients older than 80 years, for which data is almost entirely lacking. The classes of drugs reviewed include alkylators, antimetabolites, anthracyclines, taxanes, camptothecins, and epipodophyllotoxins. Clinical trials need to incorporate an analysis of chemotherapy in terms of the pharmacokinetic and pharmacodynamic effects of aging. In addition, data already accumulated need to be reanalyzed by age to aid in the management of the older cancer patient.

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

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

Adjuvant Therapy in the Elderly: Making the Right Decision

Adjuvant chemotherapy has led to improvements in relapse-free and overall survival in patients with breast, colon, and non–small-cell lung cancer, yet many older patients are not offered these potentially life-saving treatments. Moreover, older patients have been either excluded or under-represented in most adjuvant trials, limiting the generalizability of these treatments to older populations. Limited data in elders suggest that older patients derive significant benefits from adjuvant therapies provided they have life expectancies exceeding 5 years. Making treatment decisions in elders is challenging. Many have major comorbidities that may substantially limit life expectancy and minimize or negate the benefits of adjuvant chemotherapy. In this review, we discuss the potential benefits of adjuvant treatment in older patients with solid tumors with a focus on general principles involved in the selection of adjuvant therapy for patients with breast, colon, and non–small-cell lung cancer. In addition, we discuss the role of comorbidity and how it factors in treatment decisions. Finally, we discuss future research directions and funding for elders with cancer.

The role of the surgeon in whether patients with lymph node-positive colon cancer see a medical oncologist

BACKGROUND

Chemotherapy improves survival for patients with stage III colon cancer, but some older patients with lymph node-positive colon cancer do not see a medical oncologist and, thus, do not receive adjuvant chemotherapy.

METHODS

To evaluate the role of the surgeon in determining referrals to medical oncology among patients with stage III colon cancer, the authors conducted a retrospective cohort study of 6158 patients aged >or=66 years who were diagnosed with stage III colon cancer from 1992 through 1999 by using the Surveillance, Epidemiology, and End Results-Medicare linked database. Multilevel analysis was used to simultaneously model variations in patients' seeing a medical oncologist at the patient and surgeon levels.

RESULTS

Twenty-one percent of the total variance in seeing a medical oncologist was attributable to the surgeon after adjusting for available patient, tumor, and surgeon characteristics. The individual surgeon characteristics that significantly predicted whether the patient saw a medical oncologist were year since graduation (<or=10 years vs >20 years; hazard ratio [HR], 1.60; 95% confidence interval [95% CI], 1.19-2.16), practicing in a teaching hospital (yes vs. no: HR; 1.30; 95% CI, 1.07-1.58), and volume of patients with colon cancer (<30 patients vs >or=121 patients; HR, 0.66; 95% CI, 0.46-0.94). Surgeon sex, race, board certification, and type of practice were not independent predictors of medical oncology referral.

CONCLUSIONS

Surgeons accounted for approximately 20% of the variation in patients seeing a medical oncologist. Interventions at the level of the surgeon may be appropriate to improve the care of patients with colon cancer.

Chemotherapy in the elderly

People over the age of 65 years constitute the fastest-growing segment of the US population. Within the next 30 years, this group will comprise over 20% of the total population. Importantly, 50% of all cancers and 70% of cancer mortality occur in this age group. Choosing the correct chemotherapy regimen and dose for the older patient can be extremely difficult due to physiological changes that occur with aging, as well as other comorbidities associated with this age group. Treatment decisions need to be based on a patient’s individual performance, functional status, life expectancy, and their wishes and opinions. Although there are no accepted algorithms to guide management decisions in elderly cancer patients, data are becoming available that will help guide the use of chemotherapy in the older patient population.

Preoperative radiotherapy in elderly patients with rectal cancer

PURPOSE

We performed a retrospective analysis in order to evaluate the compliance with preoperative radiotherapy in patients aged>or=70 with locally advanced resectable rectal cancer, and to evaluate the influence of comorbidities on treatment tolerance and oncological results.

METHODS

From March 1984 to December 2000, 95 patients with T3-T4 N0 M0 rectal cancer received a preoperative radiotherapy in 2 radiotherapy departments. Nineteen patients received concomitant chemotherapy.

RESULTS

All patients completed the radiation schedule. Six patients suffered grade 3 acute WHO toxicity. Surgical resection was performed in 87 patients. There were 3 post-operative deaths. Analysis of peri-operative complications showed thromboembolism (4.9%), ileus (9.8%) and diarrhoea (6.1%). After a median follow-up of 29 months, the 3- and 5-year overall survival rates were 65% and 49% respectively. In univariate analysis, a tumour located in the mid part of the rectum, a radiation dose less than 40 Gy, the absence of chemotherapy were significantly associated with a poor prognosis. There was a trend to a better survival for patients with a Charlson score of 0 (P=0.0584). In multivariate analysis, only initial WHO performance status was significant.

CONCLUSIONS

Compliance with preoperative radiotherapy is good in elderly patients. Toxicity rates are similar to those described in randomised trials in which only younger patients were included. Initial WHO performance status<or=1 is significantly associated with better survival.

International Society of Geriatric Oncology (SIOG) recommendations for the adjustment of dosing in elderly cancer patients with renal insufficiency

A SIOG taskforce was formed to discuss best clinical practice for elderly cancer patients with renal insufficiency. This manuscript outlines recommended dosing adjustments for cancer drugs in this population according to renal function. Dosing adjustments have been made for drugs in current use which have recommendations in renal insufficiency and the elderly, focusing on drugs which are renally eliminated or are known to be nephrotoxic. Recommendations are based on pharmacokinetic and/or pharmacodynamic data where available. The taskforce recommend that before initiating therapy, some form of geriatric assessment should be conducted that includes evaluation of comorbidities and polypharmacy, hydration status and renal function (using available formulae). Within each drug class, it is sensible to use agents which are less likely to be influenced by renal clearance. Pharmacokinetic and pharmacodynamic data of anticancer agents in the elderly are needed in order to maximise efficacy whilst avoiding unacceptable toxicity.

Adjuvant chemotherapy in elderly patients (>or=75 yr) completely resected for colon cancer stage III compared to younger patients: toxicity and prognosis

PURPOSE

To compare benefits and risks to adjuvant chemotherapy following complete resection of node-positive colon cancer stage III for patients aged >or=75 yr and younger.

METHOD

A retrospective study compared recurrence-free and overall survival, toxicity, and dose intensity of adjuvant bolus 5-FU according to the Mayo regimen chemotherapy in consecutive patients aged 19-74 (n=203) and >or=75 yr (n=24).

RESULTS

The estimated 5-yr proportional survival rates were 0.65 for patients age less than 75 yr compared to 0.65 (p=0.96) for elderly. The frequencies of anemia (0%), thrombocytopenia (0%), leukopenia (4%), infection (8%), vomiting (0%), mucositis (17%), diarrhea (13%) CTC grade 3 or 4 toxicity in elderly patients were not significantly different from that in younger patients (p > 0.05). Significantly more elderly (8%) had a decline in performance status to grade 3 or 4, as compared to younger patients (4%) (p=0.002). 5-FU dose reduction was necessary for significantly more elderly (51%) as compared to younger patients (28%) (p=0.02), and fewer elderly (54%) completed the scheduled six treatment courses as compared to younger patients (82%) (p=0.05).

CONCLUSIONS

Adjuvant 5-FU chemotherapy should be considered for elderly patients aged >or=75 yr in good performance at high risk of recurrence of colon carcinoma after resection.

Colorectal cancer

Cancers of the colon and rectum will affect 1 in 17 North Americans during their lifetime. The progress witnessed in the treatment of these cancers in recent years has been remarkable. Improvements have been realized in surgical technique, radiation therapy, and systemic therapies, particularly with the addition of oxaliplatin and irinotecan to the previously limited armamentarium of fluorouracil alone. Targeted therapies directed at the vascular endothelial growth factor pathway and the epidermal growth factor pathway are now key players in the treatment of colorectal cancer. With current-day therapies, more than 75% of patients with localized disease are recurrence free at 3 years, and up to 50% of patients with advanced unresectable disease are alive at 2 years. This review focuses on the evidence supporting the current role of chemotherapy and radiation therapy in the adjuvant management of colorectal cancers and the strategy of combining chemotherapy and biological therapy in the treatment of metastatic disease.

Opportunities for near-infrared thermal ablation of colorectal metastases by guanylyl cyclase C-targeted gold nanoshells

Colorectal cancer is the third most common malignancy and the second most common cause of cancer-related mortality worldwide. While surgery remains the mainstay of therapy, approximately 50% of patients who undergo resection develop parenchymal metastatic disease. Unfortunately, current therapeutic regimens offer little improvement to the survival of patients with parenchymal metastases in the liver and lung. In that context, there is a significant unrealized opportunity at the intersection of engineering and biology for the development of novel targeted therapeutic approaches to colorectal cancer metastases. This opportunity exploits the discovery that an intestinal receptor, guanylyl cyclase C, which mediates diarrhea induced by bacterial heat-stable enterotoxins (STs), is over-expressed by metastatic colorectal tumors only. Moreover, it leverages recent advances in the fabrication of metal nanoshells with defined thicknesses absorb near-infrared (NIR) light, resulting in resonance and transfer of thermal energies of more than 40 degrees C. Thus, the conjugation of ST to gold nanoshells, which can undergo resonance excitation by NIR light and emit heat, represents a previously unrecognized approach for the targeted therapy of parenchymal colorectal cancer metastases, specifically to the liver and lung. This article discusses the potential of ST-targeted nanoshells for NIR thermal ablation of metastatic colorectal tumors and highlights the significant challenges and solutions linked to the translation of this emerging technology to patient care.

Treatment of 5-fluorouracil refractory metastatic colorectal cancer: an Australian population-based analysis

Randomised trials have established the importance of oxaliplatin (O) and irinotecan (I) in advanced colorectal cancer (CRC). However, patients enrolled in clinical studies represent a restricted population and little is known about the use of O and I in the general population and the subsequent outcomes outside clinical studies. We used the Australian Health Insurance Commission (HIC) database to describe prescribing patterns of O and I and their impact on survival in all patients with 5-fluorouracil (5-FU) refractory CRC in Australia in 2002 and 2003. In 2999 patients, there was a marked increase in initial treatment with O rather than I; 48% of patients received O first in 2002 vs 66% in 2003 (P<0.001). Overall 40–45% of patients received both O and I; however, younger patients were more likely to receive both drugs (P<0.001). After 5-FU failure and treatment with O or I, the proportion of patients surviving 6 or 12 months was estimated to be 0.67 (95% CI, 0.66–0.69) and 0.42 (95% CI, 0.40–0.44), respectively. Survival was superior for patients who received both O and I; however, the sequence of agents had no impact. Older patients (⩾70 years) had inferior survival no matter which drug was used as initial treatment. Analysis of the Australian HIC database provides a valuable means of assessing patterns of use and outcomes of new therapies.

The impact of age in the outcome of patients with advanced or recurrent cervical cancer after platinum-based chemotherapy

OBJECTIVES

Cervical cancer is a disease of middle-aged and elderly but still there are young women diagnosed with advanced disease that is incurable with local treatment and is treated with platinum-based combination chemotherapy. It is unknown whether these young patients have a poorer outcome compared to older patients or whether elderly patients have inferior outcome than younger patients when treated with combination chemotherapy.

METHODS

We compared the outcome between young (<35), elderly (>70) and middle-aged (35-70) women who were treated with platinum-based combination chemotherapy for advanced, recurrent or persistent disease.

RESULTS

Two hundred and eighteen patients were included in our database. The baseline clinical and disease characteristics were not different between age groups but anemia and thrombocytosis were more frequent in younger patients. Median survival for all patients was 13.4 (95%CI 11-15.8) months while survival of patients<35 years of age was 9 months (95% CI 5.8-12), of patients older than 70 was 10 months (95% CI 6.9-13) of patients 35 to 70 years of age was 14.5 months (95% CI 11-18) (p=0.004). Multiple factors were significant for survival in univariate analysis but only weight loss, pain score and relapse inside an irradiated filed were significant predictors of outcome in multivariate analysis.

CONCLUSIONS

Very young (<35) and elderly (>70) patients have a worse prognosis after treatment with combination chemotherapy for advanced or recurrent cervical cancer. Nevertheless, this difference is not significant when adjusted for other prognostic factors.

Guanylyl cyclase C: a molecular marker for staging and postoperative surveillance of patients with colorectal cancer

Staging patients with colorectal cancer defines their prognosis and therapeutic management. Unfortunately, histopathology, the current standard for staging, is relatively insensitive for detecting occult micrometastases and a significant fraction of patients are understaged and, consequently, undertreated. Similarly, current approaches to postoperative surveillance of patients with colorectal cancer detect disease recurrence at a point when interventions have little impact on survival. The detection of rare cells in tissue, for accurately staging patients, and in blood, for detecting disease recurrence, could be facilitated by employing sensitive and specific markers of disease. Guanylyl cyclase C (GCC), the receptor for the diarrheagenic bacterial heat-stable enterotoxin, is expressed selectively by cells derived from intestinal mucosa, including normal intestinal cells and colorectal tumor cells, but not by extragastrointestinal tissues and tumors. The nearly uniform expression of relatively high levels by metastatic colorectal tumors suggests that GCC may be a sensitive and specific molecular marker for metastatic colorectal cancer cells. Employing GCC reverse transcriptase PCR, occult colorectal cancer micrometastases were detected in lymph nodes that escaped detection by histopathology. Moreover, marker expression correlated with the risk of disease recurrence. Similarly, GCC reverse transcriptase PCR revealed the presence of tumor cells in blood of all patients examined with metastatic colorectal cancer and, in some studies, was associated with an increased risk of disease recurrence and mortality. These observations suggest that GCC reverse transcriptase PCR is a sensitive and specific technique for identifying tumor cells in extraintestinal sites and may be useful for staging and postoperative surveillance of patients with colorectal cancer.

Expanded Treatment Options in the Adjuvant Therapy of Colon Cancer: Implications for Oncology Nurses

PURPOSE/OBJECTIVES

To review the role of adjuvant therapy in the treatment of patients with colon cancer.

DATA SOURCES

Published articles, Internet sources, and books.

DATA SYNTHESIS

Colon cancer is a very common cancer in men and women. Chemotherapy, consisting primarily of 5-fluorouracil, has been used to treat colon cancer since the 1950s, but additional effective agents against metastatic disease now are available. The options for adjuvant chemotherapy have increased dramatically. Ongoing studies are evaluating the role of biologics in adjuvant therapy of colon cancer.

CONCLUSIONS

Use of oxaliplatin in the adjuvant setting has further defined exciting new therapy options for patients with colon cancer.

IMPLICATIONS FOR NURSING

Oncology nurses caring for patients with colon cancer should be aware of new changes in therapy options. Although the addition of new therapies increases the tools in the drug arsenal for the common disease, management of toxicities of therapy is crucial as well. This article reviews changes in therapy options and toxicity management, including discussion of key issues for oncology nurses in the care of patients with colon cancer.

Colorectal cancer

Cancers of the colon and rectum will affect 1 in 17 North Americans during their lifetime. The progress witnessed in the treatment of these cancers in recent years has been remarkable. Improvements have been realized in surgical technique, radiation therapy, and systemic therapies, particularly with the addition of oxaliplatin and irinotecan to the previously limited armamentarium of fluorouracil alone. Targeted therapies directed at the vascular endothelial growth factor pathway and the epidermal growth factor pathway are now key players in the treatment of colorectal cancer. With current-day therapies, more than 75% of patients with localized disease are recurrence free at 3 years, and up to 50% of patients with advanced unresectable disease are alive at 2 years. This review focuses on the evidence supporting the current role of chemotherapy and radiation therapy in the adjuvant management of colorectal cancers and the strategy of combining chemotherapy and biological therapy in the treatment of metastatic disease.

Racial disparities and socioeconomic status in association with survival in a large population-based cohort of elderly patients with colon cancer

BACKGROUND

To the authors' knowledge, few studies have addressed racial disparities in the survival of patients with colon cancer by adequately incorporating treatment and socioeconomic factors in addition to patient and tumor characteristics.

METHODS

The authors studied a nationwide and population-based, retrospective cohort of 18,492 men and women who were diagnosed with stage II or III colon cancer at age >or=65 years between 1992 and 1999. This cohort was identified from the Surveillance, Epidemiology, and End Results (SEER) cancer registries-Medicare linked databases and included up to 11 years of follow-up.

RESULTS

A larger proportion (70%) of African-American patients with colon cancer fell into the poorest quartiles of socioeconomic status compared with Caucasians (21%). Patients who lived in communities with the lowest socioeconomic level had 19% higher all-cause mortality compared with patients who lived in communities with the highest socioeconomic status (hazards ratio [HR], 1.19; 95% confidence interval [95% CI], 1.13-1.26; P < .001 for trend). The risk of dying was reduced only slightly after controlling for race/ethnicity (HR, 1.17; 95% CI, 1.10-1.24). Compared with Caucasian patients with colon cancer, African-American patients were 21% more likely to die after controlling for age, sex, comorbidity scores, tumor stage, and grade (HR, 1.21; 95% CI, 1.12-1.30). After also adjusting for definitive therapy and socioeconomic status, the HR of mortality was only marginally significantly higher in African Americans compared with Caucasians for all-cause mortality (HR, 1.10; 95% CI, 1.02-1.19) and colon cancer-specific mortality (HR, 1.16; 95% CI, 1.01-1.33).

CONCLUSIONS

Lower socioeconomic status and lack of definitive treatment were associated strongly with decreased survival in both men and women with colon cancer. Racial disparities in survival were explained substantially by differences in socioeconomic status.

Toxicities and Survival Among Octogenarians and Nonagenarians with Colorectal Cancer Treated with Chemotherapy or Concurrent Chemoradiation Therapy

PURPOSE

Patients aged > or = 70 years with colon cancer benefit from chemotherapy, with no major added toxicities compared with a younger population. However, the safety and efficacy of chemotherapy or chemoradiation therapy in octogenarians and nonagenarians with colorectal cancer (CRC) has not been previously reported.

PATIENTS AND METHODS

We conducted a retrospective study of the safety and efficacy of chemotherapy or chemoradiation therapy in patients with CRC treated between January 2002 and June 2006 at Roswell Park Cancer Institute.

RESULTS

Thirty-three patients were identified, 24 of whom had colon cancer and 9 of whom had rectal cancer. Twenty-two patients with metastatic colon cancer and 8 patients with rectal cancer were evaluable for toxicity. All patients were started on an attenuated regimen of chemotherapy. A high rate of severe diarrhea (46%) and treatment-related hospitalizations (73%) were noted among patients with metastatic colon cancer. Toxicities were managed by treatment interruptions. The median overall survival among the metastatic colon cancer cohort was 20.6 months (95% confidence interval, 11.1-26.4 months). Among the patients with rectal cancer, 5 had locally advanced disease and were treated with chemoradiation therapy. Chemotherapy was interrupted in 3 of 5 patients because of toxicity. Radiation therapy was discontinued because of toxicity in 1 of 5 patients.

CONCLUSION

Our results suggest the susceptibility of patients with CRC aged > or = 80 years to chemotherapy toxicity. This age group should receive an attenuated dose of chemotherapy and be evaluated for dedicated clinical trials. Despite the high rate of treatment toxicity, selected octogenarians and nonagenarians with advanced CRC could benefit from chemotherapy, with overall survival neighboring that seen in younger populations.

ASCO 2006 Update of Recommendations for the Use of Tumor Markers in Gastrointestinal Cancer

Purpose

To update the recommendations for the use of tumor marker tests in the prevention, screening, treatment, and surveillance of gastrointestinal cancers.

Methods

For the 2006 update, an update committee composed of members from the full Panel was formed to complete the review and analysis of data published since 1999. Computerized literature searches of Medline and the Cochrane Collaboration Library were performed. The Update Committee's literature review focused attention on available systematic reviews and meta-analyses of published tumor marker studies.

Recommendations and Conclusion

For colorectal cancer, it is recommended that carcinoembryonic antigen (CEA) be ordered preoperatively, if it would assist in staging and surgical planning. Postoperative CEA levels should be performed every 3 months for stage II and III disease for at least 3 years if the patient is a potential candidate for surgery or chemotherapy of metastatic disease. CEA is the marker of choice for monitoring the response of metastatic disease to systemic therapy. Data are insufficient to recommend the routine use of p53, ras, thymidine synthase, dihydropyrimidine dehydrogenase, thymidine phosphorylase, microsatellite instability, 18q loss of heterozygosity, or deleted in colon cancer (DCC) protein in the management of patients with colorectal cancer. For pancreatic cancer, CA 19-9 can be measured every 1 to 3 months for patients with locally advanced or metastatic disease receiving active therapy. Elevations in serial CA 19-9 determinations suggest progressive disease but confirmation with other studies should be sought. New markers and new evidence to support the use of the currently reviewed markers will be evaluated in future updates of these guidelines.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Xeloda® in Adjuvant Colon Cancer Therapy (X-ACT) Trial: Overview of Efficacy, Safety, and Cost-Effectiveness

The X-ACT (Xeloda in Adjuvant Colon Cancer Therapy) trial compared the efficacy and safety of the oral fluoropyrimidine capecitabine with bolus 5-fluorouracil (5-FU)/leucovorin (LV; Mayo Clinic regimen) as adjuvant therapy for stage III colon cancer. A total of 1987 patients were enrolled at 164 centers worldwide. Disease-free survival (primary study endpoint) in the capecitabine arm was at least equivalent to that in the 5-FU/LV arm; the upper limit of the hazard ratio was significantly (P < 0.001) below the predefined margins for noninferiority. Capecitabine was also associated with significantly fewer fluoropyrimidine-related grade 3/4 adverse events (AEs; P < 0.001) and fewer AE-related hospital admissions/days than 5-FU/LV. Pharmacoeconomic analyses performed in several countries show that the savings in direct costs (drug administration and AE-related costs) associated with capecitabine versus 5-FU/LV offset the acquisition costs of the drug. Furthermore, capecitabine reduces patient travel time and costs, making it a "dominant" strategy (ie, less costly and more effective) in the adjuvant setting. In conclusion, efficacy, safety, convenience, and cost findings from the X-ACT trial show that capecitabine offers at least equivalent clinical benefit compared with bolus 5-FU/LV and can replace intravenous 5-FU/LV in the adjuvant treatment of stage III colon cancer. The X-ACT trial has not only helped to better define the role of capecitabine but has also broadened the options available to patients with early-stage disease to include a uniquely effective oral outpatient treatment.

Metastatic colorectal cancer: Therapeutic options

For the past several decades, the therapy for metastatic colorectal cancer had modest benefits because of the limited therapeutic options. Bolus 5-fluorouracil (5FU) and leucovorin (LV) were the standard of care in the United States until 2002, with a response rate of 25% and a median survival of 10 to 12 months. However, with the advent of new agents, namely oxaliplatin and irinotecan, there has been a dramatic change in the way we treat metastatic colorectal cancer. Based on many well-conducted large randomized trials, we have evidence that combination chemotherapy incorporating oxaliplatin or irinotecan with infusional 5FU/LV is superior to 5FU/LV, with doubling of overall survival (OS) to approximately 20 months. There remains some uncertainty as to the best first-line regimen. This might be irrelevant because studies have shown that OS is dependent on exposure to all the active agents, regardless of the time period of exposure. Bevacizumab, which uses anti-angiogenic strategies, has improved disease-free survival (DFS) and OS when combined with standard chemotherapy and is a vital component of metastatic colorectal cancer therapy. However, there are no data supporting its use past progression. Cetuximab, an epithelial growth factor receptor inhibitor, is mainly used in irinotecan-refractory patients. In spite of all these advances, 5-year OS rates continue to be limited. Patients with curative resection of metastatic disease seem to have longer DFS and better 5-year OS rates. This should be a potential goal for responding patients with upfront unresectable, organ-limited disease.

Patterns of care for adjuvant therapy in a random population-based sample of patients diagnosed with colorectal cancer

OBJECTIVES

Over the past decade, clinical trials have proved the efficacy of treatments for colorectal cancer (CRC). This study tracks dissemination of these treatments for patients diagnosed with stage II and III disease and compares risk of death for those who received guideline therapy to those who did not.

METHODS

We conducted a stratified randomly sampled, population-based study of CRC treatment trends in the United States. Multivariate models were used to explore patient characteristics associated with receipt of treatments. We pooled data with a previous study-patients diagnosed in 1987-1991 and 1995. Cox proportional hazards models were used to assess observed cause-specific and all-cause mortality.

RESULTS

In 2000, guideline therapy receipt decreased among stage III rectal cancer patients, but increased for stage III colon and stage II rectal cancer patients. As age increased, likelihood of receiving guideline treatment decreased (p < 0.0001). Overall, race/ethnicity was significantly associated with guideline therapy (p = 0.04). Rectal patients were less likely to have received guideline treatment. Consistent with randomized clinical trial findings, all-cause mortality was lower in patients who received guideline therapy, regardless of Charlson comorbidity score.

CONCLUSIONS

Mortality was decreased in patients receiving guideline therapy. Although, rates of guideline-concordant therapy are low in community clinical practice, they are apparently increasing. Newer treatment (oxaliplatin, capecitabine) started to disseminate in 2000. Racial disparities, present in 1995, were not detected in 2000. Age disparities remain despite no evidence of greater chemotherapy-induced toxicity in the elderly. More equitable receipt of cancer treatment to all segments of the community will help to reduce mortality.

Pooled analysis of safety and efficacy of oxaliplatin plus fluorouracil/leucovorin administered bimonthly in elderly patients with colorectal cancer

PURPOSE

Oxaliplatin, fluorouracil, and leucovorin are commonly used to treat advanced and resected colorectal cancer. This analysis compares the safety and efficacy of oxaliplatin plus fluorouracil/leucovorin administered bimonthly (FOLFOX4) in patients age younger than and at least 70 years.

PATIENTS AND METHODS

This retrospective analysis included 3,742 colorectal cancer patients (614 age > or = 70) from four clinical trials testing FOLFOX4 in the adjuvant, first-, and second-line settings. End points included grade > or = 3 adverse events, response rate (in advanced disease), progression or relapse-free survival, dose-intensity, and overall survival in the studies with mature survival data.

RESULTS

Grade > or = 3 hematologic toxicity (neutropenia [43% v 49%; P = .04] and thrombocytopenia [2% v 5%; P = .04]) were significantly higher in older patients. Older age was not associated with increased rates of severe neurologic adverse events, diarrhea, nausea/vomiting, infection, overall incidence of grade > or = 3 toxicity (63% v 67%; P = .15), or 60-day mortality (1.1% v 2.3%; P = .20). The relative benefit of FOLFOX4 versus control did not differ by age for response rate, progression or recurrence free-survival (hazard ratio, 0.70 for FOLFOX4 v control for age < 70, 0.65 for age > or = 70; P = .42), or overall survival (hazard ratio, 0.77 age < 70, 0.82 age > or = 70; P = .79). Dose-intensity did not differ by age at cycles 1, 3, 6, or 12.

CONCLUSION

FOLFOX4 maintains its efficacy and safety ratio in selected elderly patients with colorectal cancer. Its judicious use should be considered without regard to patient age, although scant data are available among patients older than 80 years.

Adjuvant chemotherapy in the elderly: whom to treat, what regimen?

As the elderly population continues to grow, adjuvant chemotherapy treatment in the elderly is becoming an increasingly important issue for the practicing oncologist. Decisions regarding adjuvant treatment involve a careful assessment of the risk for recurrent disease and side effects from treatment, balancing these risks against the beneficial effects of treatment. In this review, we discuss methods for assessing the elderly patient in terms of life expectancy, comorbid disease, and functional capacity. This assessment can then be used to help identify appropriate candidates for adjuvant chemotherapy. Tools for estimating the risk for relapse and mortality and the reduction in these risks with various forms of treatment are useful for clarifying treatment options. Elderly patients have been underrepresented in clinical trials, and patients are often given less intense and possibly inferior standard treatment as a function of age. Ongoing clinical trials targeting the elderly patient may help answer questions about the relative risks and benefits of adjuvant treatment in this age group. Recent data show that most fit elderly patients derive a benefit from standard adjuvant chemotherapy regimens that is equal to that of younger patients.

Are the recommendations of the French consensus conference on the management of colon cancer followed up?

The aim of this study was to determine how the guidelines published after this conference have spread. Pretherapeutic evaluation and treatment were assessed for all colon cancers diagnosed in a well-defined French population in 2000. Patients were classified either as managed according to the recommendations, or as undermanaged or overmanaged. Outside the emergency context, pretherapeutic work-up was classified as in conformity with the consensus in 48.0% of the cases, as undervalued in 21.9% and as overvalued in 30.1%. The resection rate at 90% was not far from the optimum. Pathological data allowed us to classify nearly all cases according to the tumour node metastasis classification; however, the number of examined nodes was below the recommendations in 30.8% of cases. Chemotherapy was performed according to the recommendations in 71.4% of cases, 23.1% were undertreated and 5.5% were overtreated. The multivariate analysis indicates that patients aged 75 years or more were less likely to receive chemotherapy than was recommended (P<0.001). This study suggested that the main reasons for not following guideline recommendations were inertia due to previous practices, difficulty to perform a recommended behaviour and lack of familiarity.

Management of advanced colorectal cancer: state of the art

Colorectal cancer (CRC) caused over 500 000 deaths worldwide in 2002. Recent advances in the treatment of advanced disease include the incorporation of two new cytotoxic agents, irinotecan and oxaliplatin, into first-line regimens. The concept of planned sequential therapy involving three active agents during the course of a patient's treatment is evolving. Coupled with the integrated use of targeted monoclonal antibodies, we can now expect overall survival rates for advanced disease to exceed 20 months. This review considers current treatments and suggests where future progress may occur.

Insight into the treatment of cancer in older patients: Developments in the last decade

In the last decades there has been an increased interest in the treatment of elderly cancer patients and a change in attitude of both clinicians and their patients has occurred. Drugs are now available that might be considered "elderly-friendly" and the enormous advances in surgical procedures and supportive treatments over the recent years have enabled adverse effects to be minimized. A Geriatric Assessment is increasingly used as a tool to define those patients who are more suitable for aggressive chemotherapy or, on the contrary, palliative treatment. For almost all cancers, older patients are better treated today than they were in the past, even though we are still far from optimal management. Despite the perceived barriers to including elderly patients in clinical trials, there are few data to support excluding them. We must not permit increased age in cancer patients to continue to be an important and independent risk factor for receiving inadequate care.

POSSUM predicts decreased overall survival in curative resection for colorectal cancer

PURPOSE

Poor condition at operation determined by the physiologic POSSUM score is related to postoperative mortality and morbidity of colorectal cancer surgery. This study was designed to analyze the relationship between condition of patients with colorectal cancer at operation and long-term overall survival.

METHODS

A total of 542 patients survived a radical resection for Stages I, II, or III colorectal cancer. Physiologic POSSUM score at surgery, exclusive of age, was calculated for all patients. Mean physiologic POSSUM score was used as cutoff point to determine low-risk and high-risk group patients. A Cox proportional hazard analysis was performed to study the effect of low-risk and high-risk group on overall survival and to identify independent risk factors.

RESULTS

Five-year overall survival was significantly higher in low-risk group patients than in high-risk group patients (low-risk group 66.6 percent vs. high-risk group 48.5 percent; P < 0.001). Differences in overall survival also were found when patients in Stages I, II, and III were analyzed separately. Risk factors for overall survival were advanced stage of disease, poor tumor differentiation, mucinous adenocarcinoma, older than age 70 years, and poor condition of the patient at time of operation.

CONCLUSIONS

Poor condition at operation, as determined by physiologic POSSUM score, is a risk indicator for long-term overall survival in colorectal cancer patients.

End Points for Adjuvant Therapy Trials: Has the Time Come to Accept Disease‐Free Survival as a Surrogate End Point for Overall Survival?

The intent of adjuvant therapy is to eradicate micro-metastatic residual disease following curative resection with the goal of preventing or delaying recurrence. The time-honored standard for demonstrating efficacy of new adjuvant therapies is an improvement in overall survival (OS). This typically requires phase III trials of large sample size with lengthy follow-up. With the intent of reducing the cost and time of completing such trials, there is considerable interest in developing alternative or surrogate end points. A surrogate end point may be employed as a substitute to directly assess the effects of an intervention on an already accepted clinical end point such as mortality. When used judiciously, surrogate end points can accelerate the evaluation of new therapies, resulting in the more timely dissemination of effective therapies to patients. The current review provides a perspective on the suitability and validity of disease-free survival (DFS) as an alternative end point for OS. Criteria for establishing surrogacy and the advantages and limitations associated with the use of DFS as a primary end point in adjuvant clinical trials and as the basis for approval of new adjuvant therapies are discussed.