Treatment of Elderly Patients with Colorectal Cancer

Adjuvant Chemotherapy in Elderly Colorectal Cancer Patients

The value of adjuvant chemotherapy in elderly patients has been the subject of many overviews, with opinions varying from “not effective”, since randomized trials have not been performed, to “as effective as in young individuals”, based upon many retrospective analyses of randomized trials that have included patients of all ages. In the absence of randomized trials performed specifically with elderly patients, retrospective analyses demonstrate that the influence on the time to tumour recurrence (TTR) may be the same as in young individuals, but that endpoints that include death for any reason, such as recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS), are poorer in the elderly. This is particularly true if oxaliplatin has been part of the treatment. The need for adjuvant chemotherapy after colorectal cancer surgery in elderly patients is basically the same as that in younger patients. The reduction in recurrence risks may be similar, provided the chosen treatment is tolerated but survival gains are less. Adding oxaliplatin to a fluoropyrimidine is probably not beneficial in individuals above a biological age of approximately 70 years. If an oxaliplatin combination is administered to elderly patients, three months of therapy is in all probability the most realistic goal.

Immune senescence and immune activation in elderly colorectal cancer patients

In our previous study, we found that low thymic output and short telomere length were associated with a higher risk of tumor in elderly cancer patients. Here, we aimed to examine in depth the impact of immunological and biological senescence and immune activation on disease outcome in elderly patients with colorectal cancer (CRC).Peripheral blood samples from 81 CRC patients were studied for immune activation, immune senescence and recent thymic emigrant(RTE) CD4 and CD8 cells by flow cytometry. T-cell receptor rearrangement excision circle (TREC) levels and telomere lengths were measured by real-time PCR. Plasma levels of microbial translocation markers, LPS and sCD14, were quantified by ELISA. While TREC levels and telomere length were not prognostic of disease outcome, high percentages of immune senescent and immune activated CD8 cells were associated with a higher risk of a negative event (relapse, progression, or death) in all studied patients and disease relapse in I-III staged patients. Levels of sCD14 and LPS were higher in patients who will experience a negative event than in patients who will not. In conclusion, in elderly CRC patients higher immunological senescence and immune activation negatively impact the disease outcome; how these characteristics influence the antineoplastic treatments remains to be investigated.

Frailty is an independent risk factor for recurrence and mortality following curative resection of stage I-III colorectal cancer

AIM

With population aging, the number of frail patients with colorectal cancer has increased. The Clinical Frailty Scale (CFS) is a validated tool for assessing frailty, and higher scores indicate worse clinical outcomes following cardiovascular procedures. This retrospective study aimed to examine preoperative frailty in relation to recurrence and mortality following curative resection of colorectal cancer.

METHODS

We retrospectively analyzed data for 729 consecutive patients undergoing curative resection of stage I-stage III colon and rectal adenocarcinoma between January 2009 and December 2016. Frailty was assessed using the CFS: 1 (very fit) to 9 (terminally ill), and frailty was defined as CFS ≥ 4. Recurrence-free survival (RFS) and overall survival (OS) were compared between frail and nonfrail patients. Cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

CFS score was negatively correlated with the Barthel index of activities of daily living (Spearman's ρ = -0.83). Of the 729 patients, 253 (35%) were frail. In multivariable analyses adjusting for potential confounders including age and disease stage, frailty was independently associated with shorter RFS (multivariable HR: 1.70, 95% confidence interval: 1.25-2.31, P < .001) and OS (multivariable HR: 2.04, 95% confidence interval: 1.40-2.99, P < .001). There were no significant interactions of frailty with age and disease stage regarding RFS and OS (P interaction > .72).

CONCLUSION

Preoperative frailty was independently associated with shorter RFS and OS following resection of nonmetastatic colorectal cancer, regardless of age and disease stage. Further trials are needed to establish treatment strategies for frail patients with colorectal cancer.

Advanced Age Is a Risk Factor for Recurrence After Resection in Stage II Colorectal Cancer

BACKGROUND/AIM

The number of older patients with colorectal cancer (CRC) is increasing. Stage II CRC is a heterogeneous group of cancers with different prognoses. We aimed to examine older patients in relation to clinical outcome following curative resection in stage II CRC.

PATIENTS AND METHODS

We analyzed data for 329 consecutive patients with stage II CRC following curative resection. Recurrence-free survival (RFS) and overall survival (OS) were compared between older patients ≥75 years of age and those <75 years. Cox proportional hazards model was used to compute hazard ratios (HRs) controlling for potential confounders.

RESULTS

In the multivariable analyses, patients ≥75 years were independently associated with shorter RFS (multivariable HR=2.56, 95% confidence interval (CI)=1.55-4.31, p<0.001) and OS (multivariable HR=4.36, 95%CI=2.08-9.97, p<0.001) in stage II CRC.

CONCLUSION

Older patients were independently associated with shorter RFS and OS following curative resection in stage II CRC.

TAB3 upregulates PIM1 expression by directly activating the TAK1-STAT3 complex to promote colorectal cancer growth

Transforming growth factor-β-activated kinase 1 (TAK1)-binding protein 3 (TAB3) and the proviral integration site for Moloney murine leukaemia virus 1 (PIM1) are implicated in cancer development. In this study, we investigated the relationship between TAB3 and PIM1 in colorectal cancer (CRC) and determined the potential role and molecular mechanism of TAB3 in PIM1-mediated CRC growth. We found that TAB3 and PIM1 expression levels were positively correlated in CRC tissues. The knockdown of TAB3 significantly decreased PIM1 expression and inhibited CRC proliferation in vitro and in vivo. The upregulation of PIM1 rescued the decreased cell proliferation induced by TAB3 knockdown, whereas PIM1 knockdown decreased TAB3-enhanced CRC proliferation. Additionally, TAB3 regulates PIM1 expression through the STAT3 signalling pathway and confirmed a positive correlation between TAB3 and phosphorylated-STAT3 expression in CRC tissues. Patients with high expression of TAB3 and phosphorylated-STAT3 had the worst prognosis. Mechanistically, TAB3 regulates PIM1 expression by promoting STAT3 phosphorylation and activation through the formation of the TAB3-TAK1-STAT3 complex. Overall, a novel CRC regulatory circuit involving the TAB3-TAK1-STAT3 complex and PIM1 was identified, the dysfunction of which may contribute to CRC tumorigenesis.

The C-reactive protein to albumin ratio predicts postoperative complications in oldest-old patients with colorectal cancer

PURPOSE

The C-reactive protein to albumin ratio (CAR) is a simple and useful score for predicting the outcomes of patients with various cancers. The aim of this study was to evaluate the CAR and short-term outcomes in oldest-old patients with colorectal cancer.

METHODS

A total of 126 patients aged 85 years and older with colorectal cancer who underwent resection for primary colon cancer from April 2015 to December 2018 were included. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.19 on receiver operating characteristic curve analysis. Clinical characteristics and inflammation-based scores were compared between patients with a high CAR (CAR ≥ 0.19, n = 44) and a low CAR (CAR < 0.19, n = 82).

RESULTS

A high preoperative CAR level (≥ 0.19) was significantly associated with stoma construction (p = 0.004), blood loss (p = 0.003), postoperative complications (p = 0.016), and systemic inflammation marker levels, including a low neutrophil to lymphocyte ratio (p = 0.006), a low platelet to lymphocyte ratio (p = 0.005), a low prognostic nutritional index (p < 0.001), and a high modified Glasgow prognostic score (p < 0.001). On univariate and multivariate analyses, only the CAR was an independent predictor of postoperative complications (HR 2.864, p = 0.029).

CONCLUSIONS

A high CAR was significantly associated with postoperative complications for oldest-old patients with colorectal cancer.

Treatment response in elderly patients with advanced colorectal cancer at King Abdulaziz Medical City, Princess Norah Oncology Center, Jeddah

INTRODUCTION

Colorectal carcinoma is the most evident carcinoma in the elderly. Despite its high incidence and mortality rate, there is insufficient research about the best treatment options for colorectal carcinoma.

OBJECTIVE

This study was designed to assess the best treatment modality for colorectal carcinoma in elderly Saudi patients.

METHODS

We conducted a retrospective analysis of medical records at the Princess Norah Oncology Center (PNOC), King Abdulaziz Medical City, Jeddah, Saudi Arabia. We included patients treated at PNOC between 2010 and 2015. Only patients aged above 70 years with advanced colon were included in the study.

RESULTS

The cohort included 57 patients with an average age of 76.51 with 27 alive patients and 30 dead patients. Nonmucinous adenocarcinoma had significant higher mortality (n = 20). Most patients received surgical treatment which was associated with less risk for mortality; however, it was nonsignificant. Surgery was followed by first-line treatment which had a mortality rate of 50%. The least treatment associated with mortality was local liver treatment (n = 0). Survival analysis found that only treatment with significant higher survival was shift to next line of treatment (at least once) [HR = 0.06, 95% CI (0.00, 0.79), P value = 0.03]. Other treatments were not associated with significant mortality reduction. First-line treatment was associated with higher mortality risk; nevertheless, it was nonsignificant.

CONCLUSION

Local radiotherapy and local liver ablation had the least mortality rate. However, in multivariate Cox regression analysis, we found that shift to next line of treatment was associated with the significant high survival rate.

Research Progress on Chemical Constituents and Anticancer Pharmacological Activities of Euphorbia lunulata Bunge

Euphorbia lunulata Bunge (ELB) is a traditional Chinese medicine possessing the functions of expectoration, cough relief, asthma relief, detoxification, and itching relief. Modern pharmacological studies have showed that ELB exhibits a variety of activities, such as antitumor, antibacterial, and antioxidant activities. In particular, the anticancer activities of ELB have attracted much attention. In this review, we summarize the recent research progress on the chemical constituents and anticancer activities of ELB by searching the PubMed, Web of Science, and China National Knowledge Infrastructure databases. The results show that more than 151 components have been identified from extracts of ELB, including 73 terpenoids, 28 flavonoids, 8 phenylpropanoids, 7 steroids, 19 phenols, and 5 alkaloids. ELB has been shown to exhibit significant inhibitory effects on lung, cervical, gastric, breast, and liver cancers, and its anticancer effects are mainly manifested in the 3 aspects, including cell cycle arrest, cell apoptosis, and inhibition of the migration of cancer cells.

When and how should surgery be performed in senior colorectal cancer patients?

Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.

Bee Collected Pollen and Bee Bread: Bioactive Constituents and Health Benefits

Bee products were historically used as a therapheutic approach and in food consumption, while more recent data include important details that could validate them as food supplements due to their bioproperties, which support their future use as medicines. In this review data, data collected from bee pollen (BP) and bee bread (BB) essays will be discussed and detailed for their nutritional and health protective properties as functional foods. Dietary antioxidants intake derived from BP and BB have been associated with the prevention and clinical treatment of multiple diseases. The beneficial effects of BP and BB on health result from the presence of multiple polyphenols which possess anti-inflammatory properties, phytosterols and fatty acids, which play anticancerogenic roles, as well as polysaccharides, which stimulate immunological activity. From the main bioactivity studies with BP and BB, in vitro studies and animal experiments, the stimulation of apoptosis and the inhibition of cell proliferation in multiple cell lines could be one of the major therapeutic adjuvant effects to be explored in reducing tumor growth. Tables summarizing the main data available in this field and information about other bio-effects of BP and BB, which support the conclusions, are provided. Additionally, a discussion about the research gaps will be presented to help further experiments that complete the tree main World Health Organization (WHO) Directives of Efficiency, Safety and Quality Control for these products.

Synthesis of Chalcone Derivatives: Inducing Apoptosis of HepG2 Cells via Regulating Reactive Oxygen Species and Mitochondrial Pathway

Chalcone derivatives, as a hot research field, exhibit a variety of physiological bioactivities and target multiple biological receptors. Based on the skeleton of (E)-1,3-diphenyl-2-propene-1-one, 14 chalcone derivatives were designed and synthesized, and evaluated as the antitumor candidates agents against four human cancer cell lines (A549, Hela, HepG2, and HL-60) as well as one normal cell line (WI-38). Among the title compounds, compound a14 showed better inhibitory activity against HepG2 cells (IC₅₀ = 38.33 µM) and had relatively weak cytotoxicity towards normal cells WI-38 (IC₅₀ = 121.29 µM). In this study, apoptosis, cycle arrest, assessment of reactive oxygen species (ROS) level, and measurement of mitochondrial membrane potential were adopted to explore the inhibitory mechanism of a14 towards HepG2. Compound a14 could effectively block the division of HepG2 cell lines in the G2/M phase and robustly induced generation of ROS, demonstrating that the generation of ROS induced by a14 was the main reason for resulting in the apoptosis of HepG2 cells. Moreover, the mitochondrial membrane potential (MMP) of HepG2 cells treated with a14 was significantly decreased, which was closely related to the enhanced ROS level. Furthermore, based on Western blot experiment, cell apoptosis induced by a14 also involved the expression of B-cell lymphoma-2 (Bcl-2) family and Caspase 3 protein. In summary, compound a14 could contribute to the apoptosis of HepG2 cells through regulating ROS-mitochondrial pathway, which provides valuable hints for the discovery of novel anti-tumor drug candidates.

Pharmacotherapeutic considerations for elderly patients with colorectal cancer

Introduction: Oncology care in the elderly presents a dilemma. The majority of cancer cases are diagnosed in the elderly yet they are underrepresented in clinical trials. In addition to limited evidence-based medicine, the elderly is a heterogeneous population filled with pharmacotherapeutic challenges and barriers. Elderly metastatic colorectal cancer (mCRC) treatment decisions encompass these challenges.Areas covered: Treatment based solely on chronological age is an unacceptable practice. Physiologic factors such as function, cognition, comorbidities, polypharmacy, among others must be considered. Oncology guidelines emphasize using a geriatric assessment (GA) as opposed to traditional oncology performance status measures to best identify risks. Our review shines light on these issues as they pertain to elderly unresectable metastatic colorectal cancer (mCRC).Expert opinion: The practical use of GA tools in oncology remain to be determined. Current barriers are the lack of a consistent tool to unify decision-making, provider education, and evidence-based use/outcomes in specific cancers. mCRC antineoplastic data surrounding GAs are scarce, and current mCRC national treatment algorithms are not stratified to encompass GA-driven therapy. Therefore, providers lack clear guidance or practicality of use. We hope mCRC trial designs will abandon age cutoffs and instead place more focus on GAs for inclusion and outcomes.

The Long Noncoding RNA, LINC01555, Promotes Invasion and Metastasis of Colorectal Cancer by Activating the Neuropeptide, Neuromedin U

Background

This study aimed to investigate the role of the long noncoding RNA (lncRNA), LINC01555, on the migration and invasion of colorectal cancer (CRC) cells, its expression in CRC tissue, and its interaction with the neuropeptide, neuromedin U (NmU).

Material/Methods

LINC01555 expression in SW620 and HCT116 CRC cells, and NCM460 normal colorectal cells, and 48 resection specimens containing CRC and adjacent normal tissue, was detected by quantitative real-time polymerase chain reaction (qRT-PCR). Cox regression analysis was used to assess the relationship between LINC01555 expression and patient survival. The effects of LINC01555 expression on CRC cell proliferation, migration, and invasion were assessed using the cell counting kit-8 (CCK-8) assay, the colony formation assay, and the transwell assay. Functional studies determined the interaction between LINC01555 and NmU in the development of CRC.

Results

The Cancer Genome Atlas (TCGA) dataset showed that LINC01555 was highly expressed in CRC tissue when compared with adjacent normal colorectal tissue. LINC01555 expression was positively correlated with tumor stage, but negatively correlated with disease-free survival (DFS) and overall survival (OS) and was an independent risk factor for CRC. The receiver operating characteristic (ROC) curve analysis showed the diagnostic specificity of LINC01555 in CRC. Knockdown of LINC01555 inhibited cell proliferation, migration, and invasion of CRC cells. Functional studies showed that knockdown of NmU reduced cell migration and invasion of CRC cells that overexpressed LINC01555.

Conclusions

Increased expression of LINC01555 was found in CRC tissues and promoted the invasion of CRC cells by upregulating the expression of NmU.

Anti-Cancer and Protective Effects of Royal Jelly for Therapy-Induced Toxicities in Malignancies

Royal jelly (RJ) is a glandular secretion produced by worker honeybees and is a special food for the queen honeybee. It results in a significant prolongation of the lifespan of the queen honeybee compared with the worker honeybees through anti-inflammatory, anti-oxidant and anti-microbial activities. Consequently, RJ is used as cosmetic and dietary supplement throughout the world. In addition, in vitro studies and animal experiments have demonstrated that RJ inhibits cell proliferation and stimulates apoptosis in various types of malignant cells and affects the production of various chemokines, anti-oxidants and growth factors and the expression of cancer-related molecules in patients with malignancies, especially in patients treated with anti-cancer agents. Therefore, RJ is thought to exert anti-cancer effects on tumor growth and exhibit protective functions against drug-induced toxicities. RJ has also been demonstrated to be useful for suppression of adverse events, the maintenance of the quality of life during treatment and the improvement of prognosis in animal models and patients with malignancies. To understand the mechanisms of the beneficial effects of RJ, knowledge of the changes induced at the molecular level by RJ with respect to cell survival, inflammation, oxidative stress and other cancer-related factors is essential. In addition, the effects of combination therapies of RJ and other anti-cancer agents or natural compounds are important to determine the future direction of RJ-based treatment strategies. Therefore, in this review, we have covered the following five issues: (1) the anti-cancer effects of RJ and its main component, 10-hydroxy-2-decenoic acid; (2) the protective effects of RJ against anti-cancer agent-induced toxicities; (3) the molecular mechanisms of such beneficial effects of RJ; (4) the safety and toxicity of RJ; and (5) the future directions of RJ-based treatment strategies, with a discussion on the limitations of the study of the biological activities of RJ.