Capecitabine as first-line treatment for patients older than 70 years with metastatic colorectal cancer: an oncopaz cooperative group study

Capecitabine in the management of colorectal cancer

5-Fluorouracil has been a mainstay in the treatment of colorectal cancer for nearly five decades; however, the use of oral formulations of the medication has been gaining increasing traction since capecitabine was approved for use in adjuvant settings by the US Food and Drug Administration in 2005. The use of capecitabine has since spread to a number of off-label indications, including the treatment of advanced or metastatic colorectal cancer and the neoadjuvant treatment of rectal cancer. In light of increasing utilization, it is critical that clinicians have a firm understanding of the literature supporting capecitabine across various settings as well as the attributes of the drug, such as its dosing recommendations, side-effect profile, and use in the elderly. The purpose of this review is to synthesize the literature in a fashion that can be used to help guide decisions. In a setting of increasing focus on cost, the pharmacoeconomic literature is also briefly reviewed.

FOLFOX4 in the treatment of metastatic colorectal cancer in elderly patients: a prospective study

Elderly patients constitute a subpopulation with special characteristics that differ from those of the general population and have been under-represented in clinical trials. We, prospectively, analyzed the toxicity and efficacy of the original FOLFOX4-regimen in the treatment of elderly patients affected by metastatic (m) colorectal cancer (CRC). Thirty-six consecutive patients aged 67-82 years (median age 72 years), 22 males and 14 females, with mCRC and measurable disease, were enrolled in the study. The primary site of metastases was the liver (36.1% of patients). The median ECOG Performance Status (PS) was 1. The main hematological and extra-hematological (grade 3 or 4) toxicities were neutropenia (38.9%) and neurological (13.9%), respectively. A total of 36 patients, aged 67-82 years were included. Twenty-two and 14 patients were male and female, respectively. The median age was 72 years (range 67-82). The primary site of metastases was the liver (36.1% of patients). The median ECOG Performance Status (PS) was 1. The overall response rate (ORR) was 44.4% and similar to original study. Median progression-free survival (PFS) was 7.5 months and median overall survival (OS) was 16 months. The main hematological and extra-hematological (grade 3 or 4) toxicities were neutropenia (38.9%) and neurological (13.9%), respectively. Tolerability, however, was manageable and no toxic death occurred. FOLFOX4-regimen maintains its efficacy, and safety ratio in elderly patients with mCRC and good performance status. It would be considered the treatment of choice in the treatment of this particular setting of patients.

Metastatic colorectal cancer in the elderly: An overview of the systemic treatment modalities (Review)

Colorectal cancer (CRC) is one of the most frequently occurring types of cancer. Worldwide, more than 800,000 new cases of CRC are diagnosed each year. The median ages at CRC diagnosis and death are 71 and 75 years, respectively. The majority ot patients (50-60%) with colorectal cancer are diagnosed at stage IV disease. Patients aged 65 or older are characterized by a higher incidence of significant co-morbidities, decreased regenerative capacity of bone marrow and worse general performance. Anti-neoplastic therapies used for the treatment of colorectal cancer include irinotecan, oxaliplatin, 5-fluorouracil, leucovorin, capecitabine and monoclonal antibodies. Analysis of the efficacy of the presented chemotherapeutic and chemoimmunotherapeutic regimens in the treatment of metastatic CRC in patients older than 65 and 70 years compared to 'younger' patients, generally demonstrated comparable efficacy, time to disease progression and overall survival. Age criterion should not be considered when assessing the eligibility of patients with metastatic CRC for treatment of the above-mentioned chemotherapeutic and chemoimmunotherapeutic regimens. Treatment should be individualized based on the potential risks and benefits anticipated for each patient.

Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer

BACKGROUND

The efficacy and safety of capecitabine and bevacizumab in elderly patients with metastatic colorectal cancer (mCRC) considered unsuitable for receiving first-line chemotherapy with an irinotecan or oxaliplatin-based combination were assessed in a phase II, open, multicentre, uncontrolled study.

METHODS

Treatment consisted of capecitabine 1250 mg m(-2) (or 950 mg m(-2) for patients with a creatinine clearance of 30-50 ml min(-1)) twice daily on days 1-14 and bevacizumab (7.5 mg kg(-1)) on day 1 every 3 weeks.

RESULTS

A total of 59 patients aged >or=70 years with mCRC were enrolled. In an intention-to-treat analysis, the overall response rate was 34%, with 71% of patients achieving disease control. Median progression-free survival and overall survival were 10.8 months and 18 months, respectively. In all, 32 patients (54%) had grade 3/4 adverse events (AEs), the most common being hand-foot syndrome (19%), diarrhoea (9%) and deep venous thrombosis (7%). Four patients died because of treatment-related AEs. A relationship was detected between creatinine clearance

CONCLUSION

Bevacizumab combined with capecitabine represents a valid therapeutic alternative in elderly patients considered to be unsuitable for receiving polychemotherapy.

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Key Words

• capecitabine
• bevacizumab
• colorectal neoplasms
• neoplasm metastasis
• aged

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MESH Headings

• Aged
• Aged, 80 and over
• Antibodies, Monoclonal/administration & dosage
• Antibodies, Monoclonal/adverse effects
• Antibodies, Monoclonal, Humanized
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Bevacizumab
• Capecitabine
• Colorectal Neoplasms/drug therapy
• Colorectal Neoplasms/mortality
• Deoxycytidine/administration & dosage
• Deoxycytidine/adverse effects
• Deoxycytidine/analogs & derivatives
• Disease-Free Survival
• Female
• Fluorouracil/administration & dosage
• Fluorouracil/adverse effects
• Fluorouracil/analogs & derivatives
• Humans
• Kaplan-Meier Estimate
• Male

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Grants Collapse

Affiliation(s)

J Feliu Medical Oncology Department, Hospital La Paz/Autónoma University School of Medicine. IdiPAZ. RETIC, P degrees de la Castellana, Madrid 261- 28046, Spain.
M J Safont
A Salud
F Losa
C García-Girón
C Bosch
P Escudero
R López
C Madroñal
M Bolaños
M Gil
A Llombart
J Castro-Carpeño
M González-Barón

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Feasibility and efficacy of capecitabine and FOLFIRI in patients aged 65 years and older with advanced colorectal cancer: a retrospective analysis

PURPOSE

A retrospective analysis was conducted to compare the tolerability and efficacy of single-agent capecitabine and 5-fluorouracil/leucovorin/irinotecan (FOLFIRI) in the first-line treatment of patients aged > or =65 years with metastatic colorectal cancer (mCRC).

METHODS

Consecutive patients with mCRC treated at the Military Medical Institute, Warsaw, between January 2003 and June 2008 were eligible. A total of 123 patients were identified (FOLFIRI, n = 67; capecitabine, n = 56).

RESULTS

The overall response rate with FOLFIRI was 28.1 versus 16.4% with capecitabine (P = 0.1398). Median time to disease progression with FOLFIRI was 8.8 versus 7.5 months with capecitabine (P = 0.20), and median overall survival was 19.0 versus 15.4 months (P = 0.93). In the FOLFIRI group, neutropenia and anaemia were significantly more frequent than in the capecitabine group. The main non-haematological toxicity was hand-foot syndrome found only in the capecitabine group.

CONCLUSION

Single-agent capecitabine and FOLFIRI are effective first-line regimens in patients aged > or =65 years with mCRC.

Chemotherapy for operable and advanced colorectal cancer

The majority of colorectal cancer patients receive chemotherapy either to palliate advanced unresectable disease or to reduce the risk of recurrence after radical surgery. Thanks to the improvements in systemic chemotherapy, in the last 20 years the median survival time for patients with unresectable metastatic disease has indeed progressively increased from less than 6 to almost 24 months and recurrences after radical surgery in patients with early-stage tumors have been halved. Although colorectal cancer incidence increase with aging, there is limited scientific evidence based on prospective clinical trials to guide the management of elderly colorectal cancer patients. In addition, aging is a continuum process making strict cut-off difficult to define and homogeneous subgroups hard to identify. There is significant heterogeneity also as regards comorbidities, overall physical ability, mental health and functional status. Specific guidelines for the medical treatment of elderly colorectal cancer patients are therefore difficult to draw. While fit patients are generally treated with adult protocols and frail individuals rarely receive chemotherapy, managing the intermediate vulnerable patients requires a careful balance between the biological and psycho-social costs of treatment, the aggressiveness of the tumor and its perception by the patient. In this review, the major achievements of chemotherapy in the treatment of colorectal cancer will be described and the available data addressing the extension of these chemotherapy programs to elderly patients will be discussed. Special emphasis will be given to the development of specific treatment strategies depending on the degree of disease aggressiveness. Empirical suggestions to adapt the chemotherapy programs developed for adult fit patients to subjects with various degrees of vulnerability and frailty will also be given along with practical indications for the use of specific chemotherapeutic agents in the presence of some common elderly-related comorbidities.

Chemotherapy options and outcomes in older adult patients with colorectal cancer

The majority of patients with colorectal cancer (CRC) are >/=65 years of age, yet older patients with CRC remain under-represented in clinical trials. Older adult patients may be more likely than younger patients to experience chemotherapy-related toxicities due to factors such as existing comorbidities, incompatibility of chemotherapy with other medications, and age-related reduction in the detoxification and elimination potential of the liver and kidneys. However, the older patient group are a heterogeneous population. The available data on treatment of older patients with CRC indicate that fit older adult patients have the potential to derive the same benefit as do younger patients. A comprehensive geriatric assessment can help to identify patients most likely to benefit from standard treatment. In this review, we will evaluate the chemotherapy regimens investigated in older adult patients with CRC, and how the safety profiles and efficacy of chemotherapy in the older adult compare with those observed in younger patients.

Chemotherapy for colorectal cancer in the elderly: Whom to treat and what to use

The median age at diagnosis of colorectal cancer is during the seventh decade, and the incidence of the disease increases continuously with age. However, as the age increases, the possibilities of receiving adequate cancer treatment diminish and the mortality rises. So, there is a huge need for defined treatment strategies in elderly patients with colorectal carcinoma. The geriatric population is a very heterogeneous group where patients with an excellent health status coexist with the patients with both co-morbidities and functional dependency. Therefore, it is necessary to personalize each treatment according to the degree of vulnerability of the elderly patients. It is essential to set up a multidimensional geriatric assessment in order to consider not only the stage of the disease, but also all the factors that may influence the survival and interfere with the treatment. The aim of this review is to discuss the potential benefits and issues of chemotherapy in the elderly patients affected with colorectal cancer.

Colorectal cancer treatment in elderly patients: an update on recent clinical studies

Colorectal cancer (CRC) is one of the most common cancers in the Western world, with > 500,000 new cases diagnosed each year. One of the strongest risk factors for colon cancer is age. Physicians and their older patients commonly face the dilemma of whether to give/receive systemic chemotherapy for CRC. Evidence supports similar survival benefits with adjuvant and palliative chemotherapy in elderly patients compared with younger age groups. Data on treatment- related side effects did not reveal a different toxicity profile for elderly patients. The safety and efficacy of systemic chemotherapy in fit older patients were proven, and this group of patients could be enrolled in clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and might not benefit from chemotherapy. 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. There is a paucity of reports published in the literature because of the difficulty in routinely collecting such data. We report an overview of recent studies (clinical trials, pooled analysis, and population studies) to provide more information and to identify new and better treatment options.

Colon cancer in older adults

Colorectal cancer (CRC) is a common malignancy in the elderly. Randomized trials have demonstrated that adjuvant and palliative chemotherapy for CRC improves survival and quality of life. Unfortunately, there is a lack of evidence-based data about elderly patients to guide decisions regarding therapy. Clinical trials have generally excluded the vulnerable elderly population commonly seen in practice and included the robust elderly, who seem to benefit from chemotherapy as much as younger patients. The existing literature consists of pooled datasets from large studies and a few small dedicated trials on chemotherapy and its toxicity in elderly patients with CRC. We present illustrative data in this article and summarize our recommendations for managing the disease in elderly patients in a variety of clinical circumstances.

Review article: benefits and risks of chemotherapy in elderly patients with metastatic colorectal cancer

BACKGROUND

Although metastatic colorectal cancer (mCRC) is largely a disease of older individuals, our understanding of disease processes and their optimal treatment has been gained through trials with populations largely confined to younger individuals.

AIM

To identify through a review issues specific to geriatric patients with mCRC (physiological changes associated with aging, burden of coexisting illnesses, altered drug pharmacokinetics and functional impairment) and assess challenges to elderly patients posed by malignancy and exposure to cytotoxic medication.

METHODS

Our literature search for indexed articles published between 2000 and May 2008 employed terms including irinotecan, oxaliplatin, elderly, mCRC, targeted agents and biologicals.

RESULTS

Underrepresentation of older patients in clinical trials makes it difficult to extrapolate findings to older age groups. However, some trials have demonstrated that elderly patients can achieve survival benefits and toxicity comparable to younger patients, although dosage modifications may be required.

CONCLUSIONS

Currently, benefits with pharmacological therapy are suggested but not proven in the elderly population. Although concurrent illnesses and disabilities can complicate treatment decision making, chronological age alone should not disqualify these patients with mCRC from receiving optimal treatment similar to that offered to their younger cohorts.

A phase II study of first-line biweekly capecitabine and bevacizumab in elderly patients with metastatic colorectal cancer

PURPOSE

This phase II study was conducted to determine the efficacy and safety of capecitabine and bevacizumab in untreated elderly metastatic colorectal cancer patients.

METHODS

Patients received 1500 mg/m(2)/dose of capecitabine twice daily x 7 days and bevacizumab at 5mg/kg on day 1, in 2 week-cycles.

RESULTS

The study was closed early, due to poor accrual, after a total of 16 patients enrolled. Four patients had an objective response and 11 patients had stable disease. The median time to progression and overall survival were 9.5 and 21.2 months, respectively. The most common grade >or= 3 toxicities included diarrhea (13%) and hand and foot syndrome (25%). Three patients had an arterial thrombotic event and one patient developed a bowel perforation.

CONCLUSIONS

In this underpowered phase II study in elderly patients with metastatic colorectal cancer, capecitabine plus bevacizumab was associated with considerable clinical activity but at an increased risk of hand and foot syndrome and arterial thrombotic events.

Anticancer drug therapy in the older cancer patient: pharmacology and polypharmacy

OPINION STATEMENT

Older patients currently are the largest group of oncology patients and their numbers will continue to expand. There has been minimal participation of older patients in clinical trials. This has resulted in a lack of data to make high-level evidence-based decisions with regard to chemotherapy. There has now been a number of clinical trials which have given information with regard to age-related changes and the spectrum of toxicity that occurs with older patients. There is also an expanding literature on organ dysfunction. The overall data seem to indicate that there are a very few age-related changes in the pharmacokinetics of chemotherapy. The small changes that are present have not been clinically significant. It seems that the pattern of toxicity is more reflective of patient selection (functional status, performance status), comorbidity, and drug scheduling. The large number of drugs with significant renal excretion requires careful evaluation of renal function. Future clinical trial design needs to be adapted to older patients. Therefore, drugs, which will be primarily used by older patients, should be studied in older patients. These studies should involve pharmacokinetics, and oral therapies should include measurements of compliance. Phase II trials of new agents should consider prospectively dividing groups of patients by age (i.e., <75 years vs. >or=75 years). Phase I trials should consider accruing older patients. The studies can be performed in the older group by using progressive degrees of functional impairment and increasing comorbidity as a surrogate for dose limiting toxicity. Functional independence as a clinical benefit of cancer treatment in older individuals should be considered as an endpoint. Overall survival may not be an appropriate endpoint in clinical trials in the oldest group. Clinical trials should consider studying long-term functional and medical consequences of cancer treatment in long-term older cancer survivors. Journal editors should encourage the inclusion of age-related analyses in the reporting of clinical trials to provide meaningful information for clinicians caring for older patients. Ideally, the clinical trial design should prospectively incorporate age analysis to maximize clinical benefit of data generated. A careful assessment of medication used in older patients needs to be part of routine evaluation to minimize the adverse effects of polypharmacy.

Capecitabine in the treatment of advanced gastric cancer

Although the role of systemic chemotherapy has been established for the treatment of advanced gastric cancer, the prognosis of these patients remains poor, with a median overall survival of less than 1 year. Based on the results of several randomized Phase III trials, 5-fluorouracil continuous infusion plus cisplatin, with or without epirubicin, has become the global reference regimen for this patient population. However, treatment with fluorouracil infusion requires either frequent hospitalizations or the use of a central venous access device, harboring potential complications. Capecitabine, a tumor-activating oral prodrug of fluorouracil, may be more advantageous in terms of patient convenience, safety and efficacy. Two recent randomized Phase III trials have shown that capecitabine could replace infusional fluorouracil in cisplatin-based regimens. Furthermore, Phase II trials have shown that many other capecitabine-based doublet or triplet chemotherapy regimens incorporating newer cytotoxic agents are active and well tolerated. Many promising biological agents are now being tested in Phase III trials, incorporating capecitabine combinations as control arms, in patients with advanced gastric cancer.

Continuous oral capecitabine at fixed dose in patients older than 75 years with metastatic colorectal and gastric cancer: a study of the Multidisciplinary Oncology Group on Gastrointestinal Tumors

The aim of this study was to investigate the safety profile of continuous oral capecitabine at fixed dose in patients older than 75 years, having metastatic colorectal and gastric cancer. Capecitabine was administered at a fixed dose of 2000 mg daily without interruptions. Thirty-four patients were considered evaluable for toxicity and efficacy. The median age was 81 years (range 76-85). The median duration of treatment was 113 days (range 24-238 days). No grade 4 toxicity was observed. One patient had grade 3 nausea and vomiting, and one had grade 3 diarrhea. Partial responses were observed in six patients with colorectal cancer, and in one patient with gastric cancer. This study suggests that continuous oral capecitabine at a fixed daily dose of 2000 mg is well tolerated, and that it allows for the simplification and ease of dosing in elderly patients with metastatic colorectal and gastric cancer.

Phase II study of uracil-tegafur with leucovorin in elderly (> or = 75 years old) patients with colorectal cancer: ECOG 1299

PURPOSE

To evaluate the tolerability and effectiveness of uracil-tegafur (UFT) with leucovorin (LV) in the treatment of elderly patients with advanced colorectal cancer.

PATIENTS AND METHODS

Patients > or = 75 years of age with previously untreated colorectal cancer were eligible for this phase II, single-arm, open-label, multicenter cooperative group clinical trial. UFT 100 mg/m2 plus LV 30 mg orally every 8 hours for 28 days every 35 days was administered until progression.

RESULTS

Fifty-eight patients were enrolled between June 2000 and July 2001, and 55 were treated. The median age of treated patients was 81 years (range, 75 to 90 years), 26 patients were (47%) women, and 80% had good performance status (0 to 1). The observed overall response rate was 22% (95% CI, 11.8% to 35.0%). The estimated median overall survival time was 13.0 months (95% CI, 9.6 to 17.4 months), and median progression-free survival time was 4.6 months (95% CI, 2.6 to 6.7 months). Among the 56 treated patients (including one ineligible patient), 31 (55%) experienced grade 3 to 4 toxicities, most commonly diarrhea (25%) and GI toxicity (36%), with patients older than 85 years of age at highest risk.

CONCLUSION

The results of this trial support the efficacy of oral UFT/LV in elderly patients with colorectal cancer. The regimen is tolerated moderately well overall, particularly as compared with other fluoropyrimidine regimens, although there is increased GI toxicity in the most elderly. These results suggest that studies using newer oral fluoropyrimidine analogs should be investigated in this patient population.

Current treatment strategies in elderly patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common cancers in the Western world, with > 500,000 new cases diagnosed each year. One of the strongest risk factors for colon cancer is age. The incidence rates rise from 10 in 100,000 at age 40-45 years to 300 in 100,000 at age 75-80 years, with the median age at diagnosis of CRC being 71 years. With the general demographic shift toward an aging population, the number of people aged > 65 years is expected to increase. This article reviews the development of treatment for elderly patients with metastatic CRC, from single-agent fluoropyrimidines to combination therapies.

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.

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.

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.

Management of hand-foot syndrome induced by capecitabine

INTRODUCTION

Capecitabine (Xeloda) is a systemic prodrug of 5-fluorouracil (5-FU), which is administered in an oral formulation. Hand-foot syndrome (HFS) has proven to be a chronic dose-limiting toxicity of capecitabine, leading to significant morbidity in patients receiving this agent. The purpose of this review is to define the pathophysiology, risk factors, incidence and management of capecitabine-induced HFS.

METHODS

Literature for this review article was collected from the following databases: PubMed, CINAHL, and the proceedings of the American Society of Clinical Oncology (ASCO) confined to the years 1995-2006. The following key terms were used in the search: hand-foot syndrome, palmar-plantar erythrodysesthesia, capecitabine, Xeloda, colorectal cancer, and metastatic breast cancer.

RESULTS

HFS associated with capecitabine is a serious dose-limiting toxicity. Incidence of grade 3/4 toxicity is of extreme significance, and introduces the need for dose reductions and/or interruptions in capecitabine therapy. Drug-related therapies studied include topical emollients and creams, systemic and topical corticosteroids, nicotine patch, vitamin E, pyridoxine, and COX-2 inhibitors. However, due to the lack of randomized, controlled trials with these therapies, the current mainstay of treatment for the management of this toxicity is interruption of therapy and, if necessary, dose reduction.

CONCLUSION

Treatment interruption or dose reduction remain the only methods shown to effectively manage HFS, but supportive measures to reduce pain and discomfort and prevent secondary infection are very important. Many other prophylactic and treatment strategies have been investigated, with pyridoxine and COX-2 inhibitors being the most promising in case reports and retrospective studies; therefore, prospective, randomized, controlled trials are needed to prove their efficacy.

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.

Oral Anticancer Drugs in the Elderly

The increasing number of elderly people in the world population has led to a parallel increase in the number of older cancer patients, with over 45% of all cancers in Europe occurring in patients >70 years of age. The increasing tendency to use oral chemotherapy is thus of interest in the elderly, given that both elderly patients and their physicians prefer to use less complex and toxic regimens when such treatments have equivalent efficacy to more complex regimens. However, data from studies designed to evaluate these therapies in the elderly are currently limited. Factors that must be considered before prescribing oral agents to this subset of patients include age-related physiological changes affecting clinical pharmacology, adherence, the patient's capability to self-administer medications, and safety issues concerning the older patient and his or her caregivers. The idea that elderly patients may benefit from the introduction of oral chemotherapy is very fashionable, but to date there is no proof that this approach is as effective as intravenous therapy in this age group, particularly since randomised trials are lacking. This review discusses these issues and reviews current information about the use of specific oral chemotherapeutic drugs for major neoplastic diseases in the elderly.

Anal carcinoma of the elderly treated with radiotherapy alone or with concomitant radio-chemotherapy

PURPOSE

To analyse the results achieved with radio-chemotherapy (RTCT) or radiotherapy alone (RT) in elderly patients (pts) affected with squamous cell anal cancer.

METHODS AND MATERIALS

From 1990 to 2002, 62 pts aged > or =70 years were treated with RT (14) or RTCT (48). There were 9 stage I, 29 stage II, 11 stage IIIa and 13 stage IIIb. MMC+5FU was given concomitantly with RT in an early period, later replaced by Cddp+5FU. In the RTCT group, 36Gy were delivered to pelvic+inguinal lymph nodes, with a tumor boost (18Gy).

RESULTS

Stage II fared significantly better than stage III in terms of locoregional control (LRC) but not overall survival (OS). Pts treated with RTCT had improved LRC, but not OS. LRC was 81% at 3 and 5 years for the RTCT group; the RT group had a LRC of 61% at 3 years. There were more locoregional relapses in the MMC group (29%) versus the Cddp group (19%) and in pts treated with a split (32%) versus no split (19%). No G3 acute toxicity was observed in the RT group; in the RTCT group 15 pts (31%) developed a G3+ acute toxicity. G3+ late damage occurred in 2 pts in the RT only group and in 3 pts in the RTCT group.

CONCLUSIONS

Elderly people considered fit for RTCT should undergo the same schedules used for younger people. MMC or Cddp+5FU are feasible in the elderly, even without a planned split.

Stereotactic body radiation therapy for extracranial oligometastases: does the sword have a double edge?

Understanding the acute and chronic toxicities of stereotactic body radiation therapy (SBRT) for extracranial oligometastases might reveal treatment parameters that can be modulated to enhance the therapeutic ratio. Therefore, we searched PubMed from 1995 to 2005 for reports on stereotactic body radiation therapy, with emphasis on treatment of metastatic lesions of the lung and/or liver. Reports of SBRT for primary tumors of these sites were included to increase the number of evaluable patients. The reports were categorized by organ system and evaluated based on number of patients, number of lesions treated, dose fractionation scheme, and local control. A total of 15 lung studies (including 683 patients) and 7 liver studies (including 156 patients) were identified. Overall grade 3 to 5 toxicity was seen in up to 15% of patients in the lung SBRT studies and up to 18% of patients in the liver SBRT studies. Only 3 deaths were reported after SBRT of the liver and 2 after SBRT of the lung for treatment related mortality rates of 2% and 0.3%, respectively. No definitive relationship was found between radiation dose and toxicity. Conversely, radiation treatment volume may be associated with the infrequent toxicities that occur. The literature supports SBRT as a safe and effective treatment for oligometastases of the liver and lung. Further studies are needed to define the optimal dose and fractionation schedule.

Chemotherapy for elderly patients with advanced colorectal carcinoma

There is an increasing need to redefine treatment strategies in elderly patients with advanced colorectal carcinoma since they constitute more than 50% of newly diagnosed patients. Taking into account that the vast majority of clinical trials in advanced colorectal carcinoma include patients up to 75 years old, it seems reasonable to consider those patients over 75 years as elderly. In general, 20% of patients have favorable factors (fewer than four liver nodules less than 5 cm in size) and are suitable for local treatments (surgery or local-ablative therapies). Additionally, 40% of patients have poor performance status or are severely disabled owing to geriatric syndromes and/or comorbid diseases (advanced stage) that preclude any treatment strategies. The remainder of patients (fit elderly patients not suitable for radical treatments) constitute the focus of this review.

XELOX (capecitabine plus oxaliplatin) as first-line treatment for elderly patients over 70 years of age with advanced colorectal cancer

The purpose of this phase II trial was to determine the efficacy and safety of the XELOX (capecitabine/oxaliplatin) regimen as first-line therapy in the elderly patients with metastatic colorectal cancer (MCRC). A total of 50 patients with MCRC aged > or = 70 years received oxaliplatin 130 mg m(-2) on day 1 followed by oral capecitabine 1000 mg m(-2) twice daily on days 1-14 every 3 weeks. Patients with creatinine clearance 30-50 ml min(-1) received a reduced dose of capecitabine (750 mg m(-2) twice daily). By intent-to-treat analysis, the overall response rate was 36% (95% CI, 28-49%), with three (6%) complete and 15 (30%) partial responses. In total, 18 patients (36%) had stable disease and 14 (28%) progressed. The median times to disease progression and overall survival were 5.8 months (95% CI, 3.9-7.8 months) and 13.2 months (95% CI, 7.6-16.9 months), respectively. Capecitabine was well tolerated: grade 3/4 adverse events were observed in 14 (28%) patients: 11 (22%) diarrhoea, eight (16%) asthenia, seven (14%) nausea/vomiting, three (6%) neutropenia, three (6%) thrombocytopenia, and two (4%) hand-foot syndrome. There was one treatment-related death from diarrhoea and sepsis. In conclusion, XELOX is well tolerated in elderly patients, with respectable efficacy and a meaningful clinical benefit response. Given its ease of administration compared with combinations of oxaliplatin with 5-FU/LV, it represents a good therapeutic option in the elderly.

A phase II study of fixed-dose capecitabine and assessment of predictors of toxicity in patients with advanced/metastatic colorectal cancer

The purpose of this study was to evaluate the safety and activity of fixed-dose capecitabine in patients with advanced colorectal cancer and to correlate pretreatment plasma concentrations of homocysteine and serum and red cell folate with toxicity. Patients received capecitabine 2000 mg (4 x 500 mg tablets) twice daily on days 1-14 every 3 weeks. They were reviewed weekly during the first cycle and then three weekly for safety assessment. Eligibility criteria were advanced/metastatic colorectal cancer, < or = 2 prior chemotherapy regimens, ECOG performance status 0-2 and life expectancy >12 weeks. A total of 60 patients were enrolled and 55 were evaluable for efficacy. The median age was 72 years and 63% of patients had a performance status of 1 or 2. Confirmed tumour responses were reported in 15 patients (28%; 95% confidence interval (CI), 15.7-40.3%). The median time to disease progression was 4.9 months and median overall survival was 11.2 months. The median ratio of fixed dose to body surface area (BSA)-calculated dose was 88% (range 65-108%). Significant myelosuppression was not observed. Grade 2/3 treatment-related adverse events were diarrhoea (34%), fatigue (27%), stomatitis (15%) and hand-foot syndrome (22%). Dose reduction due to adverse events was required in 16 patients (29%) and multiple reductions in five patients (9%). There was no grade 3/4 haematological toxicity, any grade 4 adverse events or treatment-related deaths. Patients with higher pretreatment levels of serum folate experienced significantly greater toxicity (P = 0.02, CI: 1.0-1.2) during cycle 1 and over the entire treatment period (P = 0.04, CI: 1.0-1.3). Pretreatment homocysteine concentrations did not predict for toxicity. In conclusion, fixed-dose capecitabine appears to have similar efficacy and safety compared to the currently recommended dose schedule based on body surface area and simplifies drug administration. A high pretreatment folate may be predictive of increased toxicity from capecitabine.

Radiation Modifiers: Treatment Overview and Future Investigations

Many radiosensitizers are in current clinical use. In addition, a myriad of potential new targeted therapies, which may also interact with radiation, are in clinical development. The clinical utility of new targeted therapies, in combination with existing radiation sensitizers (chemotherapies) requires further evaluation, as does the understanding of their acute and late radiation effects. Free radical scavengers appear to show promise as radioprotectors, but data for mucoprotection are less convincing.