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

Oxaliplatin- or irinotecan-based chemotherapy for metastatic colorectal cancer in the elderly

The tolerance and efficacy of oxaliplatin and irinotecan for metastatic colorectal cancer are unknown in elderly patients. Methods. All consecutive patients over 74 years treated with oxaliplatin or irinotecan for metastatic colorectal cancer were enrolled. The tumour response was assessed every 2–3 months and toxicity was collected at each cycle according to World Health Organisation criteria. A total of 66 patients were enrolled from 12 centres. The median age was 78 years (range, 75–88 years); 39 patients had no severe comorbidity according to the Charlson score. In total, 44 and 22 patients received oxaliplatin or irinotecan, respectively, in combination with 5-fluororuracil±folinic acid or raltitrexed in 64 patients. A total of 545 chemotherapy cycles were administered in first (41%), second (51%) or third line (8%). A dose reduction occurred in 190 cycles (35%). Complete response, partial response and stabilisation occurred in 1.5, 20 and 47% of patients, respectively. The median time to progression and overall survival were 6.8 and 11.2 months in first line and 6.3 and 11.6 months in second line, respectively. Grade 3 and 4 toxicity occurred in 42% of patients: neutropenia 17%, diarrhoea 15%, neuropathy 11%, nausea and vomiting 8% and thrombopenia 6%. There was no treatment-related death. In selected elderly patients, chemotherapy with oxaliplatin or irinotecan is feasible with manageable toxicity.

Colorectal cancer in the adjuvant setting: perspectives on treatment and the role of prognostic factors

In patients with stage III colorectal cancer (CRC) who have undergone potentially curative resection, adjuvant treatment with 6 months' of 5-fluorouracil (5-FU) plus folinic acid (FA) is generally accepted as standard treatment and leads to a 5% to 10% improvement in absolute survival when compared with a no-chemotherapy control. In stage II CRC, the benefit of adjuvant chemotherapy has yet to be established. In metastatic CRC, randomized trials of irinotecan have consistently demonstrated that use of the drug, either alone or in combination with 5-FU/FA, prolongs survival. To investigate whether this benefit can be extended to patients with earlier disease, a series of multicenter trials are randomizing stage III colon cancer patients to adjuvant 5-FU/FA regimens with or without the addition of irinotecan. The role of adjuvant irinotecan is also being assessed in stage II colon cancer and in patients with rectal tumors. The risk/benefit ratio of adjuvant therapy in both stage III and stage II disease would be decreased if patients at the highest risk of relapse could be identified. Data from retrospective analyses suggest that DNA indexes, angiogenesis and some genetic/biological markers (loss of heterozygosity at chromosome 18 and the presence of microsatellite instability) identify prognostic differences in colon cancer patients. Their value as a guide to the intensity of adjuvant therapy required should be tested by randomized trial, as should the use of markers such as thymidilate synthase overexpression as a means of tailoring drug choice to tumor characteristics.

Intensive care unit outcomes in elderly cancer patients

As the number of elderly patients receiving oncologic therapies increases, the need for better outcome predictors for the critically ill elderly with cancer increases. Physicians should not view age as an indicator of poor ICU outcome, as many elderly patients with cancer will derive the same benefit from intensive care as their younger counterparts. Such a gain can be accomplished without overuse of valuable resources. Similar prognostic factors that are applied to the younger cancer patients should also be applied to the elderly. These parameters, in addition to clinical judgment, can be helpful in deciding who will benefit from ICU care regardless of age. Oncologists and critical care physicians will need to collaborate and change the paradigm of ICU care for the elderly.

Chemotherapy options for the elderly patient with advanced non-small cell lung cancer

Combination chemotherapy has been shown to improve overall survival compared with best supportive care in patients with advanced non-small cell lung cancer (NSCLC). The survival advantage is modest and was initially demonstrated with cisplatin-containing regimens in a large meta-analysis of randomized trials reported in 1995. Newer chemotherapy combinations have been shown to be better tolerated than older cisplatin-based combinations, and some trials have also shown greater efficacy and survival benefits with these newer combinations. Combination chemotherapy is, therefore, the currently accepted standard of care for patients with good performance statuses aged less than 70 years with advanced NSCLC. However, there are limited data from clinical trials to support the use of combination chemotherapy in elderly patients over 70 years of age with advanced NSCLC. Subgroup analyses of large randomized phase III trials suggest that elderly patients with good performance statuses do as well as younger patients treated with combination chemotherapy. There are few randomized trials reported that evaluate chemotherapy in patients aged greater than 70 years only. Based on data from trials performed by an Italian group, single-agent vinorelbine has been shown to have significant activity in elderly patients with advanced NSCLC and to be well tolerated by those patients with Eastern Cooperative Oncology Group performance statuses of two or less, with associated improvements in measures of global health.

Irinotecan plus leucovorin-modulated 5-fluorouracil I.V. bolus every other week may be a suitable therapeutic option also for elderly patients with metastatic colorectal carcinoma

The aim of this study was to assess the safety and efficacy of biweekly irinotecan plus leucovorin-modulated 5-fluorouracil i.v. bolus in metastatic colorectal carcinoma according to the age of patients. For this purpose, we have analysed 108 patients randomly allocated to receive irinotecan 200 mg m(-2) i.v. (1-h infusion) on day 1, and L-leucovorin 250 mg m(-2) i.v. (1-h infusion) plus 5-fluorouracil 850 mg m(-2) i.v. bolus on day 2 every 2 weeks (IRIFAFU) in our previous SICOG 9801 trial. According to age, patients were retrospectively divided into three groups: younger (</=54 years, n=37), middle-aged (55-69 years, n=64), and elderly (>/=70 years, n=17). Apart from gender, pretreatment characteristics were well balanced across the three groups. WHO grade >/=3 neutropenia and diarrhoea affected on the whole 46 and 16 patients, respectively, without any significant difference according to age-grouping. Patients aged </=54 years stayed on therapy for a longer time (median 24 vs 14-15 weeks), and received more cycles (median 9 vs 7), than the older ones. Only one patient in the young group withdrew consent to therapy as opposed to four patients each in the aged and elderly one. Response rate was 38% for younger patients, 34% for aged, and 35% for the elderly ones. Median time to progression was 7.4, 8.0, and 5.3 months, and median survival time was 13.4, 15.3, and 13.9 months, respectively. We conclude that IRIFAFU given every other week may represent a suitable therapeutic option also for elderly patients with metastatic colorectal carcinoma.

Colorectal cancer in the elderly: is palliative chemotherapy of value?

Colorectal cancer is a disease of the elderly, with 70% of patients being aged 65 years or older. In Western countries, the total number of elderly patients with this disease is expected to further increase in the future. Since the incidence of adverse physical or socioeconomic conditions in the elderly is higher than in younger patients, a thorough assessment of the patient's suitability for therapy should be performed before a decision is made. Using a Comprehensive Geriatric Assessment (CGA) to subdivide the population of elderly cancer patients into three groups can help to guide treatment decisions. Both in the adjuvant and in the palliative setting, there are sufficient data supporting the use of fluorouracil-based chemotherapy in fit elderly patients who can tolerate cytotoxic treatment. Systemic chemotherapy has been shown to effectively reduce mortality in the adjuvant situation and to be of clinical benefit for patients with metastatic disease in terms of longer survival, control of symptoms and quality of life. In recent years, new substances such as oxaliplatin or irinotecan have shown significant activity in the treatment of patients with metastatic colorectal cancer. However, information on how to guide the use of these new drugs in elderly patients is still lacking. Limited data from clinical trials indicate treatment efficacy in selected elderly patients comparable to that observed in younger patients, with overall manageable toxicity. Clearly, further clinical trials in elderly patients with colorectal cancer are necessary as well as the incorporation of aspects of geriatric medicine into the teaching programme of medical oncologists.

Prognostic significance of microsatellite instability and Ki-ras mutation type in stage II colorectal cancer

OBJECTIVES

The survival of stage II colorectal cancer (CRC) patients is approximately 70% at 5 years. Identification of the patient subgroup at high risk for tumour recurrence and death would allow more informed use of chemotherapy for this stage of disease. Several clinical and pathological factors have been reported to associate with worse survival. In the present study we investigated the prognostic significance of two major genetic alterations in CRC: microsatellite instability (MSI+) and the type of Ki-RAS mutation.

METHODS

PCR-based molecular techniques were used to screen for MSI+ and Ki-RAS mutation in 396 stage II CRC patients with an average follow-up time of 75 months. Clinicopathological information was obtained by retrospective review of pathology reports.

RESULTS

Prominent vascular invasion was identified in 19% of cases and was found to be an independent prognostic factor for poor outcome (relative risk = 2.08, 95% confidence interval: 1.22-3.57, p = 0.008). The MSI+ phenotype was found in 23% of proximal tumours and Ki-RAS mutations in 38% of the overall series. Neither MSI+ nor the type of Ki-RAS mutation showed prognostic significance in this cohort of stage II CRC.

CONCLUSIONS

MSI+ and Ki-RAS mutation type are not useful markers for the identification of high-risk stage II CRC patients. Further prospective and/or cohort studies are required to determine whether these molecular changes have predictive value for survival benefit from 5-fluorouracil-based adjuvant chemotherapy.

New developments in therapy for colorectal cancer

Colorectal cancer remains a significant cause of cancer death, and its treatment is the subject of active, ongoing investigation within all treatment modalities, including surgery, chemotherapy, and radiotherapy. In this review we discuss selected interesting and important research findings since the year 2000 and comment on their potential impact on the adjuvant and advanced disease management of patients with colon and rectal cancer.

Metastatic colorectal cancer: systemic treatment in the new millennium

BACKGROUND

Colorectal cancer (CRC) is common in North America. Metastatic disease is present at diagnosis in 30% of the patients, and approximately half of early-stage patients will eventually present with metastatic disease. Until recently, few chemotherapy options were available to treat metastatic CRC.

METHODS

The authors review the results of recent clinical trials and the design of ongoing trials in the management of patients with metastatic colorectal cancer.

RESULTS

Fluorouracil (5-FU) with leucovorin (LV) modulation has a marginal but positive effect on survival in those patients. The recent incorporation of irinotecan (CPT-11) and oxaliplatin for the management of advanced CRC has generated further improvement in survival. The development of oral fluoropyrimidines, mimicking continuous infusion 5-FU, is convenient. In randomized trials, capecitabine was equally effective to bolus 5-FU and LV in the management of metastatic CRC.

CONCLUSIONS

Recently completed or ongoing clinical trials to study novel targeting agents have initiated a new era of drug development. Anti-angiogenesis drugs, tyrosine kinase inhibitors, and epidermal growth factor blockers are among this new generation of agents with encouraging preliminary data. Randomized trials will determine the impact of these newer agents on survival and quality of life of patients with metastatic CRC.

Pharmacology of antineoplastic agents in older cancer patients

Persons over the age of 65 years are the fastest growing segment of the United States population. In the next 30 years it will comprise over 20% of the population. Fifty percent of all cancers occur in this age group and therefore there will be an expected rise in the total cancer burden. Data is becoming available which will better guide the use of chemotherapy in the older patient population. Studies will be presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those which have entered practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in choosing chemotherapy include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes which occur in older patients. Interpatient variability and age related changes in drug metabolism are discussed. Careful attention to the physiologic changes with age, and dose adjustments necessary for end organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy.

Enrollment of older patients in cancer treatment trials in Canada: why is age a barrier?

PURPOSE

To evaluate the enrollment of older patients (>/= 65 years) in Canadian cancer treatment trials and compare accrual of older patients in Canada and the United States.

PATIENTS AND METHODS

A retrospective analysis of the number of older patients enrolled in National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) treatment trials between 1993 and 1996 was performed. These rates were compared with the corresponding rates in the general population of patients who were >/= 65 years old and had cancer, obtained from Statistics Canada, and those published by the Southwest Oncology Group (SWOG) in the United States.

RESULTS

Between 1993 and 1996, 4,174 patients were enrolled onto 69 NCIC CTG trials of 16 tumor types. Older patients accounted for 22% of trial enrollees, compared with 58% of the Canadian population with cancer. This discrepancy existed in all cancer types except for multiple myeloma. The percentages of older patients enrolled were also analyzed by study type: 15% in adjuvant trials, 25% in metastatic trials, 29% in investigational new drug trials, 24% in phase I trials, and 21% in supportive care trials. The overall proportion of older patients enrolled onto Canadian trials (22%) was slightly lower than that in SWOG trials (25%).

CONCLUSION

Age remains a barrier for accrual onto cancer treatment trials, even when reimbursement is not an issue. Strategies to overcome this barrier, including the implementation of trials specifically tailored to patients aged >/= 65 years, are prudent in light of our aging population.

Participation of patients 65 years of age or older in cancer clinical trials

PURPOSE

Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation.

PATIENTS AND METHODS

We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly.

RESULTS

Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage cancers than in trials for late-stage cancers (P <.001). Furthermore, protocol exclusion criteria on the basis of organ-system abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol exclusions were relaxed, elderly participation in cancer trials would be 60%.

CONCLUSION

The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or requirements, this step may not be sufficient.

Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort

PURPOSE

Randomized trials have demonstrated that adjuvant chemotherapy improves survival for patients with stage III colon cancer and that chemotherapy combined with radiation therapy improves survival for patients with stage II or III rectal cancer. This population-based study was designed to assess use of these treatments in clinical practice.

PATIENTS AND METHODS

From the California Cancer Registry, we identified all patients diagnosed during 1996 to 1997 with stage III colon cancer (n = 1,422) and stage II or III rectal cancer (n = 534) in 22 northern California counties. To supplement registry data on adjuvant therapies and ascertain reasons they were not used, we surveyed physicians or reviewed office records for 1,449 patients (74%).

RESULTS

Chemotherapy rates varied widely by age from 88% (age < 55 years) to 11% (age >or= 85 years), and radiation therapy varied similarly. Adjusting for demographic, clinical, and hospital characteristics, chemotherapy was used less often among older and unmarried patients, and radiation therapy was used less often among older patients, black patients, and those initially treated in low-volume hospitals. Adjusted rates of chemotherapy varied significantly (P <.01) among individual hospitals: 79% and 51%, respectively, at one SD above and below average (67%). Physicians' reasons for not providing adjuvant therapy included patient refusal (30% for chemotherapy, 22% for radiation therapy), comorbid illness (22% and 14%, respectively), or lack of clinical indication (22% and 45%, respectively).

CONCLUSION

Use of adjuvant therapy for colorectal cancer varies substantially by age, race, marital status, hospital volume, and individual hospital, indicating opportunities to improve care. With enhanced data on adjuvant therapies, population-based registries could become a valuable resource for monitoring the quality of cancer care.

Adjuvant chemotherapy in colon cancer: what is the evidence?

Over the last 12 years, numerous randomized trials have addressed the role of adjuvant chemotherapy in resected colon cancer. Together, these studies give conclusive evidence of the benefit of adjuvant 5-fluorouracil combined with folinic acid in stage III (node positive) disease and this is now considered the standard of care. The chemotherapy appears to be equally effective whether it is given daily for 5 days per month or on a weekly schedule. The overall effect is a relative reduction in tumour -recurrence of 25% or an absolute improvement in survival of 10%. However, doubt remains as to the role of adjuvant chemotherapy in stage II colon cancer. To date, most of the randomized trials have demonstrated a relative reduction in tumour recurrence but have not shown any significant impact on survival. It seems likely that this inability to demonstrate a survival benefit from adjuvant chemotherapy in stage II disease relates to the fact that the trials have been underpowered to do so. Nevertheless, the absolute survival advantage is only about 2% and clinicians need to weigh this against the costs and toxicities of the treatment when managing these patients.

First-line chemotherapy with fluorouracil and folinic acid for advanced colorectal cancer in elderly patients: a phase II study

BACKGROUND

Colorectal cancer is one of the most common cancers in the elderly. Information on tolerability and efficacy of 5-Fluorouracil-based chemotherapy in such patients is limited. Primary aim of the study was to describe tolerability and activity of chemotherapy with the "de Gramont" schedule (FU bolus [400 mg/m ] + FU continuous infusion [600 mg/m ] + folinic acid [100 mg/m ] on days 1 and 2, every 2 weeks), in patients with advanced colorectal cancer aged 70 or older.

PATIENTS AND METHODS

Patients aged 70 or more, with stage IV colorectal cancer, ECOG performance status not worse than 2.

RESULTS

Thirty-four patients were treated at two participating centers. Seven (20.6%, 95% exact CI = 8.7-37.9) had an objective response, complete in 3 and partial in 4 patients. Five cases of unacceptable toxicity were registered (2 cardiac, 1 each for liver, anemia and diarrhea). Fitting the statistical model to the observed data indicated that the treatment was sufficiently active and tolerated.

CONCLUSIONS

The de Gramont scheme is active and tolerated in elderly patients with advanced colorectal cancer.

Can older cancer patients tolerate chemotherapy? A prospective pilot study

BACKGROUND

To the authors' knowledge, few data currently are available regarding the tolerance to chemotherapy in older cancer patients. This prospective pilot study evaluated the changes in functional, mental, nutritional, and comorbid status, as well as the quality of life (QOL), in geriatric oncology patients receiving chemotherapy.

METHODS

Sixty patients age > or = 70 years who were undergoing cancer chemotherapy were recruited in a university-based comprehensive cancer center. Changes in physical function were measured by the Eastern Cooperative Oncology Group performance status (ECOG PS) and Instrumental Activities of Daily Living (IADLs), mental health changes were measured by the Mini-Mental State Examination and the Geriatric Depression Scale (GDS), comorbidity was measured by Charlson's index and the Cumulative Illness Rating Scale-Geriatric, nutrition was measured by the Mini-Nutritional Assessment, and QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G). Changes were assessed at baseline and at the end of treatment (EOT). Grade 4 hematologic and Grade 3-4 nonhematologic toxicities were recorded.

RESULTS

Thirty-seven patients (63%) completed both assessments. Older cancer patients demonstrated a significant decline in measurements of physical function after receiving chemotherapy, as indicated by changes in scores on the IADL (P = 0.04) and on the physical (P = 0.01) and functional (P = 0.03) subscales of the FACT-G. They also displayed worse scores on the GDS administered postchemotherapy (P < 0.01). Patients who experienced severe chemotoxicity had more significant declines in ECOG PS (P = 0.03), IADL (P = 0.03), and GDS (P = 0.04), and more gain in the social well-being subscale (P = 0.02) of the FACT-G, than those who did not experience severe chemotoxicity. However, changes in most scores were small in magnitude clinically. No significant change was found between baseline and EOT in nutrition, comorbidity, and other aspects of the FACT-G.

CONCLUSIONS

Older cancer patients undergoing chemotherapy may experience toxicity but generally can tolerate it with limited impact on independence, comorbidity, and QOL levels. It is important to recognize and monitor these changes during geriatric oncology treatment.

Safety and efficacy of outpatient treatment with CPT-11 plus bolus folinic acid/5-fluorouracil as first-line chemotherapy for metastatic colorectal cancer

The combination of irinotecan (CPT-11), bolus 5-fluorouracil (5-FU) and folinic acid (FA) (Saltz regimen) has recently been questioned as first-line chemotherapy for metastatic colorectal cancer after high early death rates due to gastrointestinal and thromboembolic events were reported in two US trials. Therefore, we carefully evaluated the safety and efficacy of this regimen, with high value placed on the management of delayed diarrhea. Forty-six patients with metastatic colorectal cancer received this first-line treatment in nine German outpatient clinics. Dose reductions were mandatory from the first cycle in case of toxicity grade >2. Chemotherapy was administered only to diarrhea-free patients. During a total of 175 cycles administered treatments were delayed for 1 week in 11.6% and given at a reduced dose in 14.5%. All and 40 patients were evaluable for toxicity and response, respectively. Grade 3/4 toxicities included diarrhea (n=10), leukopenia (n=9), neutropenia (n=3) and anemia (n=4). One non-fatal pulmonary embolism occurred. Four complete responses (CR) and 10 partial responses were seen, for an overall response rate of 35%. In addition, 16 patients (40%) had stable disease. Resectability of liver metastases was achieved in three patients, including one pathologically confirmed CR. Median progression-free and overall survival were 5 and 13 months, respectively. We conclude that outpatient treatment with the Saltz regimen was well tolerated. Severe gastrointestinal toxicity and thromboembolic events were rarely observed and never fatal. As down-staging was possible, combinations of CPT-11 and FA/5-FU should be further investigated in neoadjuvant protocols.

UGT1A1*28 polymorphism as a determinant of irinotecan disposition and toxicity

The metabolism of irinotecan (CPT-11) involves sequential activation to SN-38 and detoxification to the pharmacologically inactive SN-38 glucuronide (SN-38G). We have previously demonstrated the role of UGT1A1 enzyme in the glucuronidation of SN-38 and a significant correlation between in vitro glucuronidation of SN-38 and UGT1A1 gene promoter polymorphism. This polymorphism (UGT1A1*28) is characterized by the presence of an additional TA repeat in the TATA sequence of the UGT1A1 promoter, ((TA)7TAA, instead of (TA)6TAA). Here we report the results from a prospective clinical pharmacogenetic study to determine the significance of UGT1A1*28 polymorphism on irinotecan disposition and toxicity in patients with cancer. Twenty patients with solid tumors were treated with a 90 min i.v. infusion of irinotecan (300 mg m(-2)) once every 3 weeks. The frequency of UGT1A1 genotypes was as follows: 6/6--45%, 6/7--35% and 7/7--20%, with allele frequencies of 0.375 and 0.625 for (TA)7TAA and (TA)6TAA, respectively. Patients with the (TA)7TAA polymorphism had significantly lower SN-38 glucuronidation rates than those with the normal allele (6/6>6/7>7/7, P = 0.001). More severe grades of diarrhea and neutropenia were observed only in patients heterozygous (grade 4 diarrhea, n = 1) or homozygous (grade 3 diarrhea/grade 4 neutropenia, n = 1 and grade 3 neutropenia, n = 1) for the (TA)7TAA sequence. The results suggest that screening for UGT1A1*28 polymorphism may identify patients with lower SN-38 glucuronidation rates and greater susceptibility to irinotecan induced gastrointestinal and bone marrow toxicity.

Adjuvant chemotherapy use for Medicare beneficiaries with stage II colon cancer

PURPOSE

Clinical trials have not demonstrated that adjuvant chemotherapy improves survival for patients with resected stage II colon cancer. Nevertheless, patients may receive this treatment despite its uncertain benefit. The objective of this study was to determine the extent to which adjuvant chemotherapy is used for patients with stage II colon cancer.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 3,151 patients aged 65 to 75 with resected stage II colon cancer and no adverse prognostic features. The primary outcome was chemotherapy use within 3 months of surgery ascertained from claims submitted to Medicare. Relationships between patient characteristics and adjuvant chemotherapy use were measured and their significance was assessed using multivariable logistic regression. Survival for treated and untreated patients was compared using a Cox model.

RESULTS

Twenty-seven percent of patients received chemotherapy during the 3 postoperative months. Younger age at diagnosis, white race, unfavorable tumor grade, and low comorbidity were each associated with a greater likelihood of receiving treatment. Sex, the number of examined lymph nodes in the tumor specimen, the urgency of the surgical admission, and median income was each unrelated to treatment. Five-year survival was 75% for untreated patients and 78% for treated patients. After adjusting for known between-group differences, the hazard ratio for survival associated with adjuvant treatment was 0.91 (95% confidence interval, 0.77 to 1.09).

CONCLUSION

A substantial percentage of Medicare beneficiaries with resected stage II colon cancer receive adjuvant chemotherapy despite its uncertain benefit.

Effectiveness of adjuvant fluorouracil in clinical practice: a population-based cohort study of elderly patients with stage III colon cancer

PURPOSE

Although randomized controlled trials (RCTs) consistently show that adjuvant fluorouracil (5-FU) extends the survival of patients with stage III colon cancer, it is not yet known whether this benefit exists in populations underrepresented on clinical trials, particularly the elderly with medical comorbidity treated in the community. In this study, we ask the following: (1) What is the hazard of death associated with adjuvant 5-FU in the general population of elderly stage III colon cancer patients? (2) Does the hazard vary with patient age?

PATIENTS AND METHODS

In this prospective, nonrandomized, population-based cohort study of 3,357 elderly Medicare beneficiaries who had undergone resection of stage III colon cancer according to the Surveillance, Epidemiology, and End-Results registries, we use propensity score matching to compare the all-cause mortality of patients who received 5-FU to matched untreated patients.

RESULTS

5-FU reduces the hazard of death by 27% (hazard ratio, 0.73; 95% confidence interval [CI], 0.65 to 0.82) across the 6 years of our data in a Cox model. At 5 years, 52.7% (95% CI, 49.6% to 55.6%) of the treated and 40.7% (95% CI, 38.1% to 43.4%) of the matched untreated are still alive. We find that these effects do not diminish with advancing patient age.

CONCLUSION

The survival benefit of adjuvant 5-FU that has been demonstrated in participants of RCTs is also evident in a population sample of elderly Medicare beneficiaries with stage III colon cancer treated in the community. Furthermore, this survival benefit does not appear to diminish with patient age. These findings support the continued use of adjuvant 5-FU in the general population of elderly patients with stage III colon cancer and suggest that oncologists in the community are practicing at a high level of effectiveness.

Adjuvant therapy in colon cancer: current status and future directions

The role of adjuvant chemotherapy in patients with stage III colon cancer is now well established and 5-FU/LV should be the reference regimen to which new drugs are tested against in the adjuvant setting. In stage II colon cancer, because the risk of recurrence is lower, any absolute benefit of chemotherapy is likely to be less than in stage III disease. The studies performed so far have been generally underpowered to detect what might be a clinically significant effect on survival. Molecular profiling of tumours may identify individuals more likely to benefit from adjuvant therapy and tailor individual treatment in the future. After potential curative treatment for localised colon cancer, about two out of five patients will experience disease recurrence, but the most effective strategies for follow-up remain to be established. New drugs such as irinotecan, oxaliplatin and oral fluoropyrimidines may offer improved efficacy or patients' convenience in the adjuvant setting and their impact on survival will be evaluated in the recently closed large randomised studies. This review summarises the current status of adjuvant therapy in colon cancer and describes the future directions for research.

Adjuvant chemotherapy for colorectal cancer

Colorectal cancer is the second leading cause of cancer death in Western countries. If surgery remains the only cure, recurrence rates for colon cancer range from 30% to 60% for stage III tumors. Adjuvant chemotherapy is the standard treatment for stage III colon tumors and consists of monthly administration of bolus 5-fluorouracil and leucovorin for 5 consecutive days a month over a 6-month period (Mayo regimen). Adjuvant chemotherapy for stage II colon cancer remains controversial, and its administration is not routinely recommended except in certain high-risk and selected patients. Immunotherapy, new drug-based therapies or combinations, and cyclooxygenase-2 inhibitors are being tested in the adjuvant setting. Total mesorectum excision is now the gold standard surgical technique for rectal cancer resection, and this procedure has dramatically decreased local recurrence. Nevertheless, adjuvant chemoradiotherapy is commonly indicated in the United States. In Europe, neoadjuvant radiotherapy is recommended for stage II and III resectable rectal cancers; the role of chemotherapy remains mostly investigational.

A 'modified de Gramont' regimen of fluorouracil, alone and with oxaliplatin, for advanced colorectal cancer

The standard de Gramont (dG) regimen of fortnightly leucovorin, bolus fluorouracil and 22-h infusion of fluorouracil, d1+2, and the same regimen plus oxaliplatin, are effective but also cumbersome. We therefore present simplified 'Modified de Gramont' (MdG) regimens. Forty-six advanced gastrointestinal cancer patients entered a dose-exploring study of MdG, including an expanded cohort of colorectal cancer patients at optimum dose. Treatment (fortnightly) comprised: 2-h i.v.i. leucovorin (350 mg d,l-LV or 175 mg l-LV, not adjusted for patient surface area); bolus fluorouracil (400 mg m(-2)), then ambulatory 46-h fluorouracil infusion (2000-3600 mg m(-2), cohort escalation). Subsequently, 62 colorectal patients (25 unpretreated; 37 fluorouracil-resistant) received MdG plus oxaliplatin (OxMdG) 85 mg m(-2). Fluorouracil pharmacokinetics during MdG were compared with dG. The optimum fluorouracil doses for MdG alone were determined as 400 mg m(-2) bolus + 2800 mg m(-2) 46-h infusion. A lower dose of 400 mg m(-2) bolus + 2400 mg m(-2) infusion which, like dG produces minimal toxicity, was chosen for the OxMdG combination. Fluorouracil exposure (AUC(0-48 h)) at this lower dose is equivalent to dG. With OxMdG, grade 3-4 toxicity was rare (neutropenia 2.8% cycles; vomiting or diarrhoea <1% cycles), but despite this there were two infection-associated deaths. Oxaliplatin was omitted for cumulative neurotoxicity in 17 out of 62 patients. Objective responses in colorectal cancer patients were: 1st-line MdG (22 assessable): PR=36%, NC=32%, PD=32%. 1st-line OxMdG (24 assessable): CR/PR=72%; NC=20%; PD=8%; 2nd line OxMdG (34 assessable): PR=12%; NC=38%; PD=50%. MdG and OxMdG are convenient and well-tolerated. OxMdG was particularly active as 1st-line treatment of advanced colorectal cancer. Both regimens are being further evaluated in the current UK MRC phase III trial.

Cost-effectiveness of chemotherapy for nonsmall-cell lung cancer

After decades of research into its prevention and treatment, lung cancer remains the leading cause of cancer death in North America and Europe. Approximately 75% of all new lung cancer diagnoses are of the nonsmall-cell subtype, and less than 25% of these patients are potentially operable upon first detection. First-generation cisplatin-based chemotherapy regimens for patients with metastatic disease achieved a median survival of 175 days, with 15 to 20% of patients alive at 1 year.In recent years, vinorelbine, gemcitabine, paclitaxel, and docetaxel have emerged as promising agents in the treatment of advanced nonsmall-cell lung cancer. Evidence from randomized trials demonstrates that when these agents are combined with cisplatin, the objective tumor response is 25 to 40%, with a median overall survival approaching 300 days. In addition, recent studies have shown that single-agent docetaxel improves survival and quality of life in patients with platinum-refractory nonsmall-cell lung cancer. Since these modest but important improvements in the management of nonsmall-cell lung cancer are achieved at a significant cost, cost has emerged as a major consideration in health policy decision-making. This article reviews the pharmacoeconomic literature to provide guidance on the cost-effective use of chemotherapy in the treatment of advanced nonsmall-cell lung cancer.

Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study

PURPOSE

Combined adjuvant fluorouracil (5-FU)-based chemotherapy with radiation is now the standard of care for locally advanced rectal cancer in the United States. We investigated the use of these treatments for stages II and III rectal cancer among the elderly and the effectiveness of these treatments on a population-based scale.

PATIENTS AND METHODS

The linked Surveillance, Epidemiology, and End-Results-Medicare database was used to identify 1,807 Medicare beneficiaries > or = 65 years of age with stage II or III rectal cancer who underwent surgical resection between 1992 and 1996. We excluded members of a health maintenance organization in the 12 months before or 4 months after their diagnosis and those who died within 4 months of diagnosis. We used multivariate analysis to identify factors associated with combined 5-FU and radiation therapy, and propensity score methodology to determine survival benefit for those treated.

RESULTS

We found that 37% of patients received both adjuvant 5-FU and radiation therapy, 11% 5-FU alone, and 14% radiation alone. Decreasing age, increasing lymph node positivity, comorbid conditions, and nonblack race were associated with increased probability of treatment with 5-FU and radiation. Combined chemotherapy/radiation therapy was associated with improved survival for stage III (relative risk, 0.71; 95% confidence interval, 0.56 to 0.90), but not for stage II rectal cancer (relative risk, 0.89; 95% confidence interval, 0.70 to 1.14).

CONCLUSION

The association of combined treatment with improved survival in node-positive disease was similar to that observed in other studies. In the absence of data from well-designed randomized controlled trials, our observational data support efforts on the part of clinicians to make appropriate referrals and provide combined treatment for elderly patients with stage III rectal cancer.

Adjuvant chemotherapy for colon cancer

Colorectal cancer is one of the most frequent cancers in the world, especially in occidental countries. The primary curative therapy is surgical resection of the tumour. Within the last 15 years, appropriately powered prospective randomized trials have demonstrated that adjuvant post-operative chemotherapy should be the standard treatment for stage III cancers (node-positive disease). 5-Fluorouracil(5FU)/levamisole was used in the early 1990s but has now been replaced by 5FU/leucovorin. The recommended duration of treatment is 6 months. Combining levamisole with 5FU/leucovorin does not improve efficacy. In patients with stage II colon cancer it is still unclear whether adjuvant chemotherapy is effective. In an attempt to define groups of stage II cases that may benefit from adjuvant chemotherapy, considerable efforts have been made to determine molecular genetic factors (tumour-ploidy and mutations or alterations in oncogenes and tumour-suppressor genes). Regional therapy (particularly portal vein infusion) is one of the other therapeutic strategies still considered to be investigational. Current clinical trials are evaluating the role of non-fluorinated pyrimidine agents in an adjuvant setting.