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

Adjuvant chemotherapy in patients with colorectal cancer. Is there a role in the older adult?

As global life expectancy has increased in most countries, there is a rising percentage of patients over 65 years old being diagnosed with colorectal cancer. Despite an increase in the incidence and prevalence of colorectal cancer in older adults, this cohort receives adjuvant therapy at a decreased rate due to anticipated intolerance. The presumed limitations seem to be based on chronologic age, competing life limiting diagnoses, and the paucity of data studying this population in major clinical trials. This review explores the data regarding disparities in the treatment of older patients with colorectal cancer, safety and efficacy of adjuvant therapy, and newer tools to make decisions based on the biologic age, rather than chronologic age, of the patient.

Effect of adjuvant chemotherapy on survival benefit in stage III colon cancer patients stratified by age: a Japanese real-world cohort study

Background

Adjuvant chemotherapy is relatively underused in older patients with colon cancer in Japan, and its age-specific effects on clinical outcomes remain unclear. This study aimed to assess the effect of adjuvant chemotherapy on survival benefit in stage III colon cancer patients stratified by age in a Japanese real-world setting.

Methods

In this multi-center retrospective cohort study, we analyzed patient-level information through a record linkage of population-based cancer registry data and administrative claims data. The study population comprised patients aged ≥18 years who received a pathological diagnosis of stage III colon cancer and underwent curative resection between 2010 and 2014 at 36 cancer care hospitals in Osaka Prefecture, Japan. Patients were divided into two groups based on age at diagnosis (< 75 and ≥ 75 years). The effect of adjuvant chemotherapy was analyzed using Cox proportional hazards regression models for all-cause mortality with inverse probability weighting of propensity scores. Adjusted hazard ratios were estimated for both age groups.

Results

A total of 783 patients were analyzed; 476 (60.8%) were aged < 75 years and 307 (39.2%) were aged ≥75 years. The proportion of older patients who received adjuvant chemotherapy (36.8%) was substantially lower than that of younger patients (73.3%). In addition, the effect of adjuvant chemotherapy was different between the age groups: the adjusted hazard ratio was 0.56 (95% confidence interval: 0.33–0.94, P = 0.027) in younger patients and 1.07 (0.66–1.74, P = 0.78) in older patients.

Conclusions

The clinical effectiveness of adjuvant chemotherapy in older patients with stage III colon cancer appears limited under current utilization practices.

Adjuvant chemotherapy for locally advanced rectal cancer in elderly patients after neoadjuvant chemoradiotherapy and surgery: Toxicity and survival outcomes

The treatment strategy for elderly patients with locally advanced rectal cancer (LARC) remains controversial. The aim of this study was to identify the significance of adjuvant chemotherapy (AC) for elderly patients with LARC after neoadjuvant chemoradiotherapy (nCRT) and surgical resection. Between February 2002 and December 2012, a total of 43 patients aged ≥70 years with LARC following nCRT and surgery were retrospectively reviewed. The median follow-up time was 51 months (range 15-161 months). All patients completed the programmed chemoradiotherapy, of which 20 patients (46.5%) received 5-fluorouracil-based AC, and other 23 patients (53.5%) received no adjuvant chemotherapy. The 5-year overall survival and disease-free survival rates for AC group and non-adjuvant chemotherapy (NAC) group were 74.7% vs 63.4% (P = .562) and 73.4% vs 66.3% (P = .445), respectively. More patients in AC group suffered from severe leucopenia than that in NAC group (60% vs 17.4%, P = .004). For elderly patients with LARC following nCRT and surgery, AC may not benefit for survival, but increase treatment related leucopenia.

Predicting Chemotherapy Toxicity and Death in Older Adults with Colon Cancer: Results of MOST Study

PURPOSE

Older patients with colon cancer (CC) are vulnerable to chemotherapy toxicity and death. Establishing simple scores specific for patients with CC to predict severe chemotoxicity or early death is needed to select the best treatment strategy.

SUBJECTS, MATERIALS, AND METHODS

This prospective multicenter study included patients aged ≥70 years with CC receiving adjuvant or first-line metastatic chemotherapy. Frailty markers (nutrition, physical activity, energy, mobility, strength), comprehensive geriatric assessment (functional status, comorbidities, falls, nutrition, cognition, and depression), and usual laboratory parameters were collected. Logistic or Cox regression was used to examine at 500 days the association between frailty markers, comprehensive geriatric assessment, laboratory parameters, and grade 3-4 toxicity or death.

RESULTS

A total of 97 patients (median age, 79.0 years) received adjuvant (37.1%) or metastatic (62.9%) chemotherapy. During the first 500 days, grade 3-4 toxicity occurred in 49.5%, and 30% died. The predictive model for grade 3-4 toxicity combined (polychemotherapy × 3) + (hypoalbuminemia <32 g/L × 2) + (abnormal grip strength × 1.5) + C-reactive protein >11 mg/L + Eastern Cooperative Oncology Group performance status (ECOG-PS), cutoff score >3. The predictive model for death combined (metastasis × 5) + (age × 2) + alkaline phosphatase >100 IU/mL + sex (female) + abnormal grip strength + ECOG-PS, cutoff score >6. For chemotoxicity prediction, sensitivity was 81.6% and specificity 71.4%. For death prediction, sensitivity was 89.7% and specificity was 83.6%.

CONCLUSION

These simple and efficient "ColonPrediscores" will help to better identify older patients with CC with increased risk of chemotherapy-related toxicity and/or death.

IMPLICATIONS FOR PRACTICE

The two scores assessed in this study, called "ColonPrediscores", offer a major advantage in that they do not need a previous complete geriatric assessment, which makes them an easy-to-use tool in oncologic settings.

Adjuvant Therapy for High-Risk Stage II or III Colon Adenocarcinoma: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: To determine the optimal adjuvant chemotherapy regimen for patients with high-risk stage II or III colon adenocarcinoma, we conducted this propensity score-matched, nationwide, population-based cohort study to estimate the effects of adjuvant treatments in high-risk stage II or III colon adenocarcinoma. Patients and Methods: Using propensity score matching, we minimized the confounding effects of sex, age, pathologic stage, tumor location, total chemotherapy cycles, and Charlson comorbidity index scores on adjuvant treatment outcomes in patients with high-risk stage II or III resectable colon adenocarcinoma. We selected the patients from the Taiwan Cancer Registry database and divided them into four groups: Group 1, comprising patients who received surgery alone; group 2, comprising those who received adjuvant fluoropyrimidine alone; group 3, comprising those who received adjuvant oxaliplatin-fluoropyrimidine-leucovorin (FOLFOX); and group 4, comprising those who received adjuvant folinic acid-fluorouracil-irinotecan (FOLFIRI). Results: In both univariate and multivariate Cox regression analyses, the adjusted hazard ratios (aHRs, as well as the 95% confidence intervals (Cis)) for mortality observed for groups 1, 2, and 4 relative to group 3 were 1.55 (1.32 to 1.82), 1.22 (1.05 to 1.43), and 2.97 (2.43 to 3.63), respectively. After a stratified subgroup analysis for high-risk stage II colon adenocarcinoma, we noted that the aHR (95% CI) for mortality for group 2 relative to group 3 was 0.52 (0.30 to 0.89). Conclusions: Adjuvant fluoropyrimidine alone is the most optimal regimen for patients with high-risk stage II colon adenocarcinoma compared with the other adjuvant chemotherapy regimens. Adjuvant FOLFOX can serve as an optimal regimen for patients with pathologic stage III colon adenocarcinoma, regardless of age, sex, or tumor location.

Utilisation of Adjuvant Chemotherapy and 5-Year Survival Analysis of Prospectively Recorded Cohort Data for Older Adults Versus Younger Adults with Resected Primary Colon Cancer

PURPOSE

Colon cancer is predominantly a disease of older adults. Studies determining the influence of age on outcomes of colon cancer have conflicting results. We aim to determine the long-term outcomes and utilisation of adjuvant chemotherapy of older adults compared with younger adults who had had a resection of a primary colon cancer.

METHODS

Consecutive patients who had resection of a primary colon cancer between January 1, 2000 and December 31, 2010 were identified from a prospective database and stratified into three age groups: ≤ 69 years, 70 to 79 years, and ≥ 80 years. Age-related differences in patients, cancer, and treatment characteristics were determined by chi-square tests. Five-year overall survival and cancer-specific survival were determined by Kaplan-Meier method and by multivariable Cox regression analysis to adjust for potential confounding factors.

RESULTS

Of 1135 included patients, 469 (41%) patients were aged ≤ 69 years, 382 (34%) were 70-79 years, and 284 (25%) were ≥ 80 years. Increasing age group predicted more comorbidity (p < 0.001), cardiac comorbidity (p < 0.001), right-sided cancers (p < 0.001), and less adjuvant chemotherapy (stage III only; p < 0.001). Increasing age group was associated with worse overall survival by stage (p < 0.001) but not cancer-specific survival by stage (p = 0.83). Adjuvant chemotherapy in patients with stage III colon cancer independently predicted improved overall survival (p < 0.001) and cancer-specific survival (p = 0.01).

CONCLUSIONS

Compared with younger adults, older adults with colon cancer had worse survival outcomes and received less adjuvant chemotherapy.

Making sense of adjuvant chemotherapy in colorectal cancer

Surgical resection is the only curative treatment for locoregional colon cancer. The goal of adjuvant chemotherapy is to eradicate micro-metastatic disease and improve survival. This has been most clearly demonstrated in stage III (node-positive) disease, whereas benefit of adjuvant chemotherapy in stage II disease remains controversial. In stage III colon cancer, 6 months of adjuvant chemotherapy with oxaliplatin-based chemotherapy have been accepted as the standard for the last 15 years. The recent IDEA collaboration has challenged this in 2018; while overall was a negative non-inferiority study, pre-planned subset analyses do support that for patients with low-risk stage III disease, 3 months of XELOX (capecitabine and oxaliplatin combination) is non-inferior to 6 months. In stage II colon cancer, where the potential benefit of adjuvant chemotherapy is small, the emergence of biomarkers has helped in decision-making. Tumors with deficient mismatch repair protein (dMMR) do not benefit from 5-fluorouracil-based chemotherapy. For patients with high clinicopathological risk stage II disease with proficient mismatch repair proteins and good performance status, six months of adjuvant chemotherapy is still recommended. In the management of rectal cancers, where the risk of local recurrence is higher, chemoradiation (CRT) is often included as neoadjuvant or adjuvant therapy in the management of stage II and III rectal cancer. The benefit of adjuvant chemotherapy in rectal cancer has been extrapolated from adjuvant colon cancer studies with updated results from adjuvant rectal cancer studies demonstrating similar benefits. This review summarizes the current landscape of adjuvant therapy for patients with resected stage II and III colorectal cancer.

Adjuvant therapy for stages II and III colon cancer: risk stratification, treatment duration, and future directions

Background

To date, the role of adjuvant systemic therapy in stages ii and iii colon cancer remains a topic of interest and debate. The objective of the present review was to assess the most recent data, specifically addressing methods of risk stratification, duration of therapy, and future directions.

Methods

PubMed and medline were searched for literature pertinent to adjuvant chemotherapy in either stage ii or stage iii colorectal cancer.

Summary

Locoregional disease, histopathology, age, laterality, and a number of other biologic and molecular markers appear to have a role in disease risk stratification. The duration of adjuvant therapy for stage iii disease can vary based on risk factors, but use of adjuvant therapy and duration of therapy in stage ii disease remain controversial. Future directions should include genomic assays and improved study design to provide concrete evidence about the duration of adjuvant folfox or capox and about other types of chemotherapy and immunotherapy.

Chemotherapy Toxicity in Elderly Population ≥65 Years: A Tertiary Care Hospital Experience from India

Context: Trials in the elderly have established that older individuals may benefit from chemotherapy to the same extent as younger individuals. Although the elderly patient is a prototype for cancer, very few clinical trials focus on the therapeutic decisions most directly facing older adults. Aims: This study was undertaken to study the chemotherapy-induced severe toxicity among elderly. Settings and Design: This study was a prospective, observational cohort study. The study commenced in October 2014 after obtaining clearance from the hospital ethics and protocol committee. Subjects and Methods: A total of 100 patients were included in the study. All patients were of age ≥65 years, had malignancy, and were planned to start with chemotherapy. Development of Grade 3/4/5 nonhematologic (NH) or Grade 4/5 hematologic (H) toxicities was taken as the development of severe toxicity. Statistical Analysis Used: The quantitative variables were expressed as a mean ± standard deviation and compared using unpaired t-test. P < 0.05 was considered statistically significant. Results: Overall, 64 (64%) patients were able to complete their prescribed treatment. Forty-four patients (44%) of our study cohort experienced Grade 4 H or Grade 3/4 NH toxicity. The most common H Grade 4 toxicities were neutropenia (6%) and thrombocytopenia (5%). The most common NH toxicities were fatigue (18%), infection (10%), and cardiac abnormalities (4%). Conclusions: Less than 50% of elderly patients experience severe chemotherapy-related toxicity. First 30 days are most important for toxicity assessment as 45% of patients experienced toxicity in this time frame.

Treatment selection bias for chemotherapy persists in colorectal cancer patient cohort studies even in comprehensive propensity score analyses

Introduction

Propensity score methods are increasingly used to address confounding related to treatment selection in observational studies. Studies estimating the effect of chemotherapy in colon cancer (CC) patients, however, often lacked information on pertinent comorbidities and functional status (FS). We assessed to what extent comorbidities and FS impact treatment decisions in colorectal cancer patients and explain the benefit of chemotherapy in stage III CC patients.

Methods

Stage II-III colorectal cancer patients diagnosed in 2003-2014 and recruited into a population-based study were included (N=1102). Associations of comorbidity and FS with treatment patterns were examined with multivariable logistic regression. The contribution of lower comorbidity and higher FS to the benefit of chemotherapy was estimated with propensity score weighted Cox models in 430 stage III CC patients who were followed over a median time of 4.7 years.

Results

In stage II (high-risk) and III CC patients, Charlson comorbidity scores 1, 2 and 3+ were associated with 57%, 66% and 70% lower odds of chemotherapy use, respectively. In combination with older age and poor FS, comorbidity was associated with 97% and 83% decreased odds of adjuvant chemotherapy use in CC and rectal cancer patients, respectively. In stage III CC patients, lower comorbidity and higher FS explained 38% and 24% of the overall and disease-specific survival benefits of chemotherapy, respectively. Selection bias was observed even in the comprehensive models, as chemotherapy was still associated with substantially higher non-disease-specific survival (hazard ratio (HR): 0.66; 95% confidence interval (CI): 0.46-0.92), especially in patients <75 years (HR: 0.33; 95% CI: 0.17-0.63).

Conclusion

Lower comorbidity and higher FS of recipients of chemotherapy explain approximately 40% of the benefits of chemotherapy in stage III CC patients. Regardless of how comprehensive propensity score analyses might be in observational studies, treatment selection bias might persist and affect estimates of treatment effects.

Efficacy and tolerability of adjuvant therapy in ≥70-year-old patients with T3N0M0 colorectal cancer: An observational study

BACKGROUND

This study aimed to retrospectively investigate the efficacy and tolerability of adjuvant chemotherapy in ≥70-year-old patients with stage IIA (T3N0M0) colorectal cancer.

METHODS

Lymphovascular invasion, perineural invasion, margin positivity, dissected lymph node count of <12, and presence of perforation/obstruction were accepted as risk factors. Those patients with at least one risk factor were regarded as having high risk.

RESULTS

The study included 168 patients, among which 95 (56.5%) were male and 73 (43.5%) were female. The median age of patients was 73 years (range: 70-94). One hundred one (60.1%) patients were identified to have high risk. Eighty-one (87%) patients received 5-flourouracil+leucovorin and 12 (13%) patients received capecitabine regimens as adjuvant chemotherapy. The patients receiving capecitabine regimen had significantly higher rates of dose reduction at initiation and during the treatment. Among low-risk group, there was no statistically significant difference between patients with and without adjuvant chemotherapy in terms of disease-free survival or overall survival (p = 0.528 and p = 0.217, respectively). In high-risk group, patients receiving adjuvant chemotherapy significantly differed from those not receiving adjuvant chemotherapy in terms of median disease-free survival and overall survival (p = 0.009 and p < 0.001, respectively). While the grade, lymph node status, and adjuvant chemotherapy were identified as the most significant independent factors for disease-free survival, the most significant factors for overall survival were the age, Eastern Cooperative Oncology Group performance status, adjuvant chemotherapy, and recurrence.

CONCLUSION

The findings of our study showed improved disease-free survival and overall survival in high-risk ≥70-year-old patients who received adjuvant chemotherapy due to T3N0M0 colorectal cancer. We believe that 5-flourouracil+leucovorin or capecitabine regimens should be recommended for these older high-risk patients who could receive adjuvant chemotherapy regardless of age.

Basket Trials for Intractable Cancer

Currently, genomic characterization has become standard of care for tumor types such as non-small cell lung cancer, breast cancer, melanoma, and colorectal cancer. A deep understanding of genomic alterations in different tumor types would help identify potentially actionable genomic changes which occur across a wide variety of tumor types. A basket trial is a new type of clinical trial for which eligibility is based on the presence of a specific genomic alteration, irrespective of histology. Basket trials are phase II screening trials for the off-label use of a targeted drug in patients with the same genomic alterations for which it was approved. Intractable cancer refers to a type or condition of cancer which is unresponsive or resistant to treatment; intractable cancers may be classified into five subtypes as follows: hard-to-treat condition of common advanced cancer after multiple-line therapy, rare cancer in which no standard of care has been recommended, advanced cancer in which standard of care does not work well, cancer accompanied with organ dysfunction, and cancers in older or younger cancer patients. Previous studies have demonstrated that in basket trials, genomic-guided therapy yields clinical benefits in intractable cancer, thereby providing novel insights into the optimal clinical management of such cancers. In this review, we describe a novel way to classify intractable cancer, and summarize the current knowledge on such cancers. We additionally provide information on the role of basket trials in intractable cancer.

Serum biomarkers for predicting overall survival and early mortality in older patients with metastatic solid tumors

OBJECTIVES

We aimed to explore serum biomarkers for predicting survival of older patients with metastatic solid tumors who received first line palliative chemotherapy.

MATERIALS AND METHODS

Serum samples were prospectively collected before first-line chemotherapy at 11 academic centers in Korea. All patients were participants in a prospective cohort study of older patients with metastatic solid tumors. Serum levels of C-reactive protein (CRP), CXCL10, SIRT1, VEGF-A, activin A, C-terminal telopeptide of type I collagen (CTx), total 25-hydroxyvitamin D were measured by ELISA and interleukin-6 (IL-6), myostatin, irisin, FGF-19, FGF-21, FGF-23 by Luminex multiplex assay. Overall survival (OS) was determined.

RESULTS

Serum samples from 138 patients (median age: 75 years, range: 70-92 years) were collected from February 2014 to December 2016. During a median follow up time of 13.8 months, 73 (52.9%) patients died. Among 13 serum markers, CRP (log-rank, P = 0.009), activin A (P = 0.007), and myostatin (P = 0.047) were significantly correlated with OS in univariate analyses. Activin A (hazard ratio [HR] 2.22, 95% confidence interval [CI] 1.32-3.72; P = 0.003) and myostatin (HR 3.02, 95% CI 1.39-6.57; P = 0.005) were significantly associated with OS after adjustment for other clinical factors. In predicting early (6-month) mortality, two inflammatory markers, IL-6 and CRP, were included in the decision-tree model.

CONCLUSION

In older patients with cancer, high serum concentrations of activin A and myostatin were predictive of poor OS. IL-6 and CRP might be useful to select older patients at risk of early mortality. These markers could be incorporated into predictive tools for clinical decision-making and warrant further investigation.

Therapeutic drug monitoring as a tool to optimize 5-FU-based chemotherapy in gastrointestinal cancer patients older than 75 years

AIMS

Most clinical trials exclude elderly people, leading to a limited understanding of the benefit-to-risk ratio in this population. Despite existing data regarding the oncological management of elderly receiving fluorouracil (5-FU)-based regimen, our objective was to investigate 5-FU exposure/toxicity relationship in patients ≥75 years and compare the effectiveness of 5-FU therapeutic drug monitoring between elderly and younger patients.

METHODS

Hundred fifty-four patients (31 of whom are older than 75 years) with gastrointestinal cancers, who were to receive 5-FU-based regimens, were included in our study. At cycle 1 (C1), the 5-FU dose was calculated using patient's body surface area, then a blood sample was drawn to measure 5-FU concentration and 5-FU dose was adjusted at the subsequent cycles based on C1 concentration. Assessments of toxicity were performed at the beginning of every cycle.

RESULTS

Seventy-one percent of elderly patients required dose adjustments after C1, compared with 50% for younger patients. Percentages of patients within 5-FU area under the curve range at cycle 2 were 64% and 68%, respectively, for elderly and younger patients. The proportion of elderly patients experiencing severe toxicities fell from 15% at C1 to only 5% at cycle 3.

CONCLUSION

Pharmacokinetic-guided 5-FU-dosing algorithm, leading to an improved tolerability while remaining within therapeutic concentration range, is even more valuable for patients older than 75 years than in younger patients.

Early colorectal cancer: diagnosis, treatment and survivorship care

CRC is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death in the world. With advances in treatment, colorectal cancer is being transformed from a deadly disease to an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. They often suffer late/long-term side effects of therapies that may compromise their QoL such as fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. In this review, we discuss what is known about early colorectal diagnosis, staging, treatments and their long-term effects on quality of life and survivorship care.

Clinical factors associated with the therapeutic outcome of chemotherapy in very elderly cancer patients

Background

The purpose of this study was to detect background factors that might be associated with the therapeutic and curative outcome of chemotherapy in elderly cancer patients aged over 75 years.

Methods

A retrospective study was conducted for elderly cancer patients aged over 75 years who had received more than 2 courses of chemotherapy at our hospital. We analyzed the relationships between RECIST outcome and background factors, such as age, sex, clinical TNM stage, pre-treatment history, ECOG performance status, serum albumin, and Charlson comorbidity index using logistic regression analysis.

Results

A total of 103 cancer patients aged over 75 years were analyzed in this study, including 28 with hematological neoplasia, 36 with gastrointestinal tract cancers, 25 with breast cancers, and 14 with other malignancies originating in various tissues. Seventy-one patients (69.1%) had a positive clinical outcome including RECIST CR (complete response), PR (partial response) and SD (stable disease). Multivariate analysis showed that a high serum albumin level of more than 3.5 g/dl and a Charlson comorbidity index score of less than 2 points were positively correlated with a favorable therapeutic outcome.

Conclusions

The results of the current study suggested that serum albumin level and comorbidity index are the principal clinical factors affecting therapeutic outcomes in elderly cancer patients receiving chemotherapy. In the future, these factors may make chemotherapy adaptations, continuity, and effectiveness easier to predict than GA screening.

Cancer Comorbidity: Implications for Drug Safety

Cancer is primarily a disease of aging. This chapter discusses relevant aspect of the physiology of aging, medication use and toxicity, comorbidities, and specific challenges in treating older adults with cancer.

In vitro and in vivo evaluation of colon cancer targeted epichlorohydrin crosslinked Portulaca-alginate beads

The aim of this study was to formulate a novel dual crosslinked hydrogel bead using Portulaca mucilage for colon-targeted delivery of 5-fluorouracil (5-FU) and evaluate its safety, specificity and efficacy. The ionotropic gelation technique was employed to prepare the hydrogel beads of Portulaca mucilage. For this, the mucilage was initially crosslinked with alginate and calcium ions. Epichlorohydrin was employed as a crosslinker in the second crosslinking step. The formulation was subjected to in vitro and in vivo studies to evaluate morphology, size, cytotoxicity, and organ distribution. Human HT-29 colon cancer cell-line was used for in vitro assays and in vivo studies were performed in Wistar rats to assess the usefulness and effectiveness of the formulation for colon cancer therapy. Microsphere sizes ranged from 930 to 977μm and possessed a high level of drug encapsulation efficiency (ca. 78% w/w). Compared with 5-FU solution (Tmax = 1.2 h, mean resident time: MRT = 3.3h) the dual crosslinked Portulaca microspheres exhibited sustained drug release after oral administration to rats (Tmax = 16h, MRT = 14h). The relative bioavailability of 5-FU solution and the microspheres were 100 and 93.6% respectively. Tissue distribution studies indicated high concentration of 5-FU in colon. In-vitro anticancer assay demonstrated IC50 value of 11.50 μg/ml against HT-29 colon cancer cell line. The epichlorohydrin cross-linked Portulaca microspheres prepared in this study provided sustained release of 5-FU up to 16h in the colonic region and enhanced the antitumor activity of the neoplastic drug. The formulation is hence an ideal carrier system for colon-targeted drug delivery.

Treatment of Rectal Cancer in Older Adults

PURPOSE OF REVIEW

Rectal cancer is predominantly a disease of older adults but current guidelines do not incorporate the associated specific challenges leading to wide variation in the delivery of cancer care to this subset of population. Here, we will review the current data available regarding the management of rectal cancer in older adults.

RECENT FINDINGS

The greatest challenge arises in the management of stage II/III disease as it involves tri-modality treatment that can be harder to tolerate by frail older patients. Response to neoadjuvant treatment is being used as a new marker to tailor further therapy and possibly avoid surgery. Oxaliplatin can be omitted from the adjuvant treatment without compromising outcomes. Physicians should perform geriatric assessment utilizing many validated tools available to help predict treatment tolerability and outcomes in older adults that can help personalize subsequent management. Most older adults can undergo standard therapy for stages I, II, or III rectal cancer with curative intent. Increasing evidence suggests that patients with a clinical complete response to neoadjuvant treatment may be observed closely with the possibility of avoiding surgery. Studies are evaluating alternate systemic treatments for advanced metastatic disease with the hope of maintaining quality of life without compromising cancer outcomes.

The changing face of treatment for metastatic colorectal cancer

Introduction: Since late 1990's therapy of metastatic colorectal cancer (mCRC) patients has changed considerable, and the combination of doublet or triplet chemotherapy and a targeted agent are now routinely used. With the introduction of more intensified regimens, it has become even more important to identify patients that will benefit from and can tolerate therapy. Furthermore, the increasing understanding of the biology of mCRC has led to the discovery of new potential targets. Therefore, therapy of patients with mCRC has undergone considerable change from 'one strategy fits all' towards a more personalized therapy. Areas covered: We present an overview of the recent literature on approved systemic treatment of mCRC however with focus on how the treatment strategy has changed based on clinical and molecular parameters that presently are used routinely in the clinical situation. Expert commentary: The face of treatment of mCRC has changed from 'one strategy fits all' to a personalized approach in which both clinical, molecular parameters and the aim of therapy have to be taking into account when planning the optimal treatment strategy for the individual mCRC patient.

Age-related inequalities in colon cancer treatment persist over time: a population-based analysis

Background

Older people experience poorer outcomes from colon cancer. We examined if treatment for colon cancer was related to age and if inequalities changed over time.

Methods

Data from the UK population-based Northern and Yorkshire Cancer Registry on 31 910 incident colon cancers (ICD10 C18) diagnosed between 1999–2010 were obtained. Likelihood of receipt of: (1) cancer-directed surgery, (2) chemotherapy in surgical patients, (3) chemotherapy in non-surgical patients by age, adjusting for sex, area deprivation, cancer stage, comorbidity and period of diagnosis, was examined.

Results

Age-related inequalities in treatment exist after adjustment for confounding factors. Patients aged 60– 69, 70–79 and 80+ years were significantly less likely to receive surgery than those aged <60 years (multivariable ORs (95% CI) 0.84(0.74 to 0.95), 0.54(0.48 to 0.61) and 0.19(0.17 to 0.21), respectively). Age-related differences in receipt of surgery and adjuvant chemotherapy (but not chemotherapy in non-surgical patients) narrowed over time for the ’younger old’ (aged <80 years) but did not diminish for the oldest patients.

Conclusions

Age inequality in treatment of colon cancer remains after adjustment for confounders, suggesting age remains a major factor in treatment decisions. Research is needed to better understand the cancer treatment decision-making process, and how to influence this, for older patients.

Clinical Outcomes of Single-port Surgery for Colon Cancer in Octogenarians

AIM

The aim of this study was to evaluate the clinical outcomes of single-port surgery for colon cancer in octogenarians.

MATERIALS AND METHODS

A retrospective cohort study was performed on patients who underwent single-port surgery for colon cancer from 2010 to 2014 at a single institution. Patients were categorized into the following 3 groups according to age: ≤69 years (n=196), 70 to 79 years (n=143), and ≥80 years (n=86). Short-term and long-term outcomes were assessed among 3 groups.

RESULTS

The rate of overall postoperative complications in the octogenarian group did not differ significantly, compared with the other groups (20.9% in the octogenarians group vs. 14.3% in the ≤69 y group and 15.4% in the 70 to 79 y group, P=0.363). The 3-year relapse-free survival rates were similar among groups (83.9% in the octogenarians group vs. 87.8% in the ≤69 y group and 87.5% in the 70 to 79 y group, P=0.754). The 5-year overall survival rates were 79.8% in the octogenarians group, 89.9% in the ≤69 years group, and 81.7% in the 70 to 79 years group (P=0.063).

CONCLUSION

Single-port surgery is safe, feasible, and can provide satisfactory oncological outcomes in octogenarians with colon cancer.

Association Between Primary Payer Status and Survival in Patients With Stage III Colon Cancer: An National Cancer Database Analysis

BACKGROUND

Colon cancer is the third most frequent cancer diagnosis, and primary payer status has been shown to be associated with treatment modalities and survival in cancer patients. The goal of our study was to determine the between-insurance differences in survival in patients with clinical stage III colon cancer using data from the National Cancer Database (NCDB).

MATERIALS AND METHODS

We identified 130,998 patients with clinical stage III colon cancer in the NCDB diagnosed from 2004 to 2012. Kaplan-Meier curves and multivariable Cox regression models were used to determine the association between insurance status and survival.

RESULTS

Patients with private insurance plans were 28%, 30%, and 16% less likely to die than were uninsured patients, Medicaid recipients, and Medicare beneficiaries, respectively. Medicare patients were 14% were less likely to die compared with uninsured patients. Patients receiving chemotherapy were, on average, 65% less likely to die compared with the patients not receiving chemotherapy.

CONCLUSION

Private insurance and a greater socioeconomic status were associated with increased patient survival compared with other insurance plans or the lack of insurance. Future research should continue to unravel how socioeconomic status and insurance status contribute to the quality of care and survival of oncologic patients.

Combination of carcinoembryonic antigen with the American Joint Committee on Cancer TNM staging system in rectal cancer: a real-world and large population-based study

AIM

This study assessed the combination of carcinoembryonic antigen (CEA) with the American Joint Committee on Cancer (AJCC) TNM staging system, aiming to improve the AJCC TNM staging system, in terms of prognostic accuracy and clinical management of rectal cancer.

METHODS

Eligible patients (N=22,132) were selected from the Surveillance, Epidemiology, and End Results database between January 1, 2004, and December 31, 2010. Patients with elevated CEA levels were designated as "C1 stage" and those with normal CEA amounts as "C0 stage". The outcome of interest was cancer-specific survival (CSS). Cox proportional hazards regression analyses and Kaplan-Meier curves were used to identify independent prognostic factors and analyze the odds of CSS in patients with rectal cancer in different C and TNM stages, respectively.

RESULTS

C1 stage was associated with a 61.0% risk increase in cancer-specific mortality (HR=1.610, 95% CI=1.219-1.705, P<0.001). In addition, C0-stage patients showed improved CSS compared with C1-stage counterparts. In addition, CSS was improved in stage IIB-C0 patients (HR=2.478, 95% CI=1.660-3.699) compared with stage IIIB-C1 patients (HR=2.431, 95% CI=2.021-2.924) or IIIA-C1 patients (HR=1.060, 95% CI=0.823-1.366, P=0.650) and stage IIC-C0 patients (HR=4.263, 95% CI=3.308-5.493) compared with stage IIIB-C1 or IIIA-C1 counterparts.

CONCLUSION

C stage is an independent prognostic factor of rectal cancer. The improved prognostic precision of the C-TNM staging system and, thus, more individualized risk-adaptive treatments support the incorporation of C stage into the AJCC TNM staging system in rectal cancer.

Age is nothing but a number: radical en bloc resection of colon adenocarcinoma with abdominal wall reconstruction in an 81 year old

Colon adenocarcinoma is a common neoplasm, which rarely presents with full thickness invasion through the abdominal wall. Aggressive treatment is often reserved for younger patients, with many surgeons opting to consider elderly patients as non-operative candidates, especially in the setting of diffuse disease. We report a case of radical resection of a colon cancer, with full thickness abdominal wall invasion in an 81-year-old female. The patient presented with gradual abdominal swelling over multiple months. She had a CT scan revealing a mass eroding through her abdominal wall, up to the skin. Operative resection with adjuvant chemotherapy was chosen as therapy because the patient had no co-morbidities. The patient underwent en bloc resection of the abdominal wall with right hemicolectomy and resection of all structures attached to the mass. The patient has been disease free for 24 months and has had return to her baseline activities of daily living.

Do older and younger patients derive similar survival benefits from novel oncology drugs? A systematic review and meta-analysis

Background

older patients are commonly believed to derive less benefit from cancer drugs, even if they fulfil clinical trial eligibility [Talarico et al. (2004, J Clin Oncol, 22(22):4626-31)]. We aim to examine if novel oncology drugs provide differential age-based treatment outcomes for patients on clinical trials.

Methods

a systematic review of randomised control trials (RCTs) cited for clinical efficacy evidence in novel oncology drug approvals by the Food and Drug Administration, European Medicines Agency and Health Canada between 2006 and 2017 was conducted. Studies reporting age-based subgroup analyses for overall or progression-free survival (OS/PFS) were included. Hazard ratios (HRs) and confidence intervals (CIs) for age-based subgroups were extracted. Meta-analyses with random effects were conducted, examining patient subgroups <65 and ≥65 years separately and pooled HRs of studies primary endpoints (OS or PFS) compared to examine if differences existed between age-based subgroups. Sensitivity analyses were conducted for cancer type, primary endpoint and systemic treatment.

Results

one-hundred-two RCTs, including 65,122 patients, met the inclusion criteria. One study reported age-based toxicity and none reported age-based quality of life (QOL) results. Pooled HRs [95% CIs] for patients <65 and ≥65 years were 0.61 [0.57-0.65] and 0.65 [0.61-0.70], respectively, with no difference between them (P = 0.14). Sensitivity analyses revealed similar results.

Conclusion

our results suggest that older and young patients, who fulfil clinical trial eligibility, may derive similar relative survival benefits from novel oncology drugs. There is, however, a need to report age-based toxicity and QOL results to support patient discussions regarding the balance of treatment benefit and harm, to encourage informed decision-making.

The use of chemotherapy in older patients with stage II and III colon cancer: Variation by age and era of diagnosis

OBJECTIVE

We aim to examine the use and outcomes of adjuvant chemotherapy in older patients with stage II and III colon cancer.

MATERIAL AND METHODS

Using data from the SEER-Medicare database, we analyzed patients aged 66 or greater, diagnosed with stage II or III colon cancer between 1991 and 2007 who received surgery. Using Medicare claims, receipt of adjuvant chemotherapy was identified, and compared between age bands. Logistic regression modeling was performed to assess predictors of receipt of adjuvant chemotherapy, and Cox proportional hazards modeling was performed to assess predictors of mortality.

RESULTS

A total of 31,990 patients were identified: 4371 aged 66-69, 6922 (70-74), 7673 (75-79), 6807 (80-84), 4266 (85-89), and 1951 (90+). The percent starting adjuvant chemotherapy decreased by age cohort: 57% in the 66-69 age cohort, 48% (70-74), 37% (75-79), 20% (80-84), 8% (85-89), and 1% (90+). Multivariable analysis showed that stage III disease was the strongest positive predictor of chemotherapy receipt. Multivariable analysis for mortality risk showed that adjuvant chemotherapy was associated with an increased risk of mortality in stage II patients. Adjuvant chemotherapy was associated with a decreased risk of mortality in stage III patients, consistent across all age cohorts, with the exception of the 90+ cohort, in whom adjuvant chemotherapy appeared to increase mortality.

CONCLUSION

Administration of adjuvant chemotherapy for stage II/III colon cancer decreases with advancing age, but improved outcomes are seen in stage III patients under 90 years of age.

Real-World Implications of Nonbiological Factors with Staging, Prognosis and Clinical Management in Colon Cancer

Background: The present study analyzed the nonbiological factors (NBFs) together with the American Joint Committee on Cancer (AJCC) Tumor-Node-Metastasis (TNM) staging system to generate a refined, risk-adapted stage for the clinical treatment of colon cancer. Methods: Eligible patients (N = 28,818) with colon cancer between 1 January 2010 and 31 December 2014, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier curves and Cox proportional hazards regression, analyzed the probabilities of cancer-specific survival (CSS) in patients with colon cancer, with different NBF-TNM stages. Results: Insurance status, marital status, and median household income were significant prognostic NBFs in the current study (p < 0.05). The concordance index of NBF-TNM stage was 0.857 (95% confidence interval (CI) = 0.8472⁻0.8668). Multivariate Cox analyses, indicated that NBF1-stage was independently associated with a 50.4% increased risk of cancer-specific mortality in colon cancer (p < 0.001), which increased to 77.1% in non-metastatic colon cancer. NBF0-stage improved in CSS as compared to the NBF1-stage in the respective stages (p < 0.05). Conclusions: The new proposed NBF-stage was an independent prognostic factor in colon cancer. Effect of NBFs on the survival of colon cancer necessitates further clinical attention. Moreover, the incorporation of NBF-stage into the AJCC TNM staging system is essential for prognostic prediction, and clinical guidance of adjuvant chemotherapy in stage II and III colon cancer.

Oncologic outcome of colorectal cancer patients over age 80: a propensity score-matched analysis

PURPOSE

It remains unclear whether old age is a poor prognostic factor in colorectal cancer (CRC). We compared oncologic outcomes in CRC patients according to age, using 80 as the dividing point.

METHODS

CRC patients who underwent radical surgery from 2000 to 2011 were evaluated. We performed matched and adjusted analyses comparing oncologic outcomes between patients with ≥ 80 and < 80 years old.

RESULTS

Among 9562 patients, 222 were elderly. The median age was 82.0 years in elderly patients and 59.0 years in young patients. Elderly patients received less neoadjuvant or adjuvant therapy compared to young patients (p < 0.001). After recurrence, significantly fewer elderly patients received additional treatments (p < 0.001). Before matching, disease-free survival (DFS) and cancer-specific survival (CSS) were significantly lower for elderly patients compared to those for young patients (p < 0.001 and p < 0.001, respectively). After matching, DFS and CCS were not significantly different between the two groups (p = 0.400 and p = 0.267, respectively). In a multivariate analysis for prognostic factors, old age was not an independent poor prognostic factor of DFS and CCS (p = 0.619 and p = 0.137, respectively).

CONCLUSIONS

Elderly patients aged ≥ 80 years with CRC had similar oncologic outcome to young patients, and age was not an independent prognostic factor.

P-TNM staging system for colon cancer: combination of P-stage and AJCC TNM staging system for improving prognostic prediction and clinical management

AIM

This study focused on improving the American Joint Committee on Cancer TNM staging system and demonstrated an improvement in prognostic accuracy and clinical management of colon cancer using the P-TNM staging system.

PATIENTS AND METHODS

Eligible patients (N=56,800) were identified from the Surveillance, Epidemiology, and End Results database between January 1, 2010, and December 31, 2014. The P-stage (P0 or P1) was assigned to each patient based on age at diagnosis, tumor grade, and tumor size. The outcome of interest was cancer-specific survival (CSS). The Cox proportional hazards regression analyses were used to identify independent prognostic factors and analyze the CSS probabilities of patients with colon cancer having different P-TNM stages, respectively.

RESULTS

A total of 29,627 patients were assigned to P0-stage and 27,173 patients were assigned to P1-stage. The P1-stage was associated with a 98.1% increased risk of cancer-specific mortality (hazard ratio =1.981, 95% confidence interval =1.891-2.076, P<0.001), which was higher in patients with nonmetastatic colon cancer. The P1-stage patients had improvement in CSS compared with those in P0-stage in respective stages (P<0.001). Moreover, CSS decreased in stage I-P1 compared with stage IIA-P0 or IIIA-P0 (P<0.001), stage IIIA-P1 compared with stage IIA-P0 (P<0.001), stage IIB-P1 compared with stage IIIB-P0 or IIC-P0 (P<0.001), stage IIIB-P1 compared with stage IIC-P0 (P<0.001), and stage IIC-P1 compared with stage IIIC-P0 (P<0.001).

CONCLUSION

P-stage was an independent prognostic factor for colon cancer. This study strongly supported the incorporation of P-stage into the American Joint Committee on Cancer TNM staging system for a better approach to prognostication and, thus, more individualized risk-adaptive therapies in colon cancer.

Clinical pharmacology of oncology agents in older adults: A comprehensive review of how chronologic and functional age can influence treatment-related effects

Unique challenges exist when managing older adults with cancer. Associations between cancer and age-related physiologic changes have a direct impact on pharmacokinetics and pharmacodynamics of cancer therapies and can affect drug dosing, dose intensity, efficacy, safety and quality of life. The breadth and depth of these issues, however, have not been fully evaluated because the majority of clinical trials have focused on a younger and healthier population. As a consequence, little information is available to support clinicians in making evidence-based decisions regarding treatment with cancer therapies in older adults, especially those over age 75. Prior clinical pharmacology reviews summarized the literature on how age-related physiologic changes can influence and affect conventional and targeted anti-cancer treatments. Our article provides an updated review with expanded information that includes small molecule kinase inhibitors, monoclonal antibodies, immunotherapies, hormonal, conventional, and miscellaneous agents. Additionally, our article integrates how functional age, determined by the geriatric assessment (GA), can also influence treatment-related effects and health outcomes. Broadening cancer therapy trials to capture not only chronologic age but also functional age would allow clinicians to better identify subsets of older adults who benefit from treatment versus those most vulnerable to morbidity and/or mortality.

Causes of mortality in older patients with stage 3 colon cancer

OBJECTIVES

Life expectancy plays a key role in the selection of patients with stage III colon cancer for adjuvant chemotherapy, but little is known about causes of mortality in older patients with colon cancer. We aimed to examine causes of death in this population and compare these causes between patients who received chemotherapy and those who did not. Specifically, we chose to examine the rates of death related to recurrent colon cancer versus non colon cancer.

MATERIALS AND METHODS

Patients aged 50 and older diagnosed with stage III colon cancer between 2005 and 2009 were included. Patients were divided into "younger" (aged 50-69) and "older" (aged 70+). Causes of death, which were categorized into colon cancer versus non-colon cancer related.

RESULTS

1361 patients were included, 50% of whom were 70 or older. Younger patients were more likely to receive adjuvant chemotherapy (90% vs. 60%). 601 patients died in the follow up period. Deceased patients in the younger group were more likely to die from colon cancer (81% vs. 62%). The most common cause of non-colon cancer death was other primary malignancies in younger patients and cardiovascular diseases in older patients. In older patients who received chemotherapy, 41% died; 89% of these deaths were related to colon cancer. In older patients who did not receive chemotherapy 72% died, with 38% of patients ultimately dying from colon cancer.

CONCLUSIONS

Older patients remain under-treated with chemotherapy. Although non-colon cancer deaths were more frequent in older patients with cancer, colon cancer was a still a significant cause of mortality. These deaths may be preventable with adjuvant chemotherapy.

Real-World Adverse Effects of Capecitabine Toxicity in an Elderly Population

BACKGROUND

Few studies have assessed the safety and effectiveness of the numerous available chemotherapeutic therapies for geriatric oncology patients. Most safety studies are conducted in large trials, and there is some uncertainty surrounding whether the results would be the same in typical daily use.

OBJECTIVE

This retrospective study aims to assess the adverse effects of real-world capecitabine use in elderly patients.

METHODS

We reviewed the records of patients treated with capecitabine in an oncology department of a University Clinic in Nijmegen, The Netherlands. We scored adverse effects such as hand-foot syndrome and diarrhea, and dosage adjustments and the reasons for them. In total, 132 patients were included, 69 of whom were aged 70 years or below (mean age: 57 years), while 63 were aged older than 70 years (mean age: 74 years).

RESULTS

Patients aged over 70 years experienced more serious adverse effects than younger patients. Grade 2 or 3 hand-foot syndrome toxicity was experienced by 20.2% of patients aged younger than 70 years and by 34.9% of patients older than 70 years (p = 0.059). Grade 2, 3, or 4 diarrhea was experienced by 17.4% of the patients aged younger than 70 years but by 31.7% of the patients aged older than 70 years (p = 0.044). Dosage was adjusted for 27/69 patients in the younger group and 52/63 patients in the older group (p = 0.001).

CONCLUSION

The difference in observed adverse effects cannot be the sole explanation for the high incidence of observed dose adjustments. A prospective follow-up study of elderly patients using capecitabine outside clinical trials is needed to evaluate the optimum balance between adverse effects and efficacy.

Predictors of Unplanned Hospitalizations in Patients With Nonmetastatic Lung Cancer During Chemotherapy

PURPOSE/OBJECTIVES

To determine predictors of unplanned hospitalizations in patients with lung cancer to receive chemotherapy in the outpatient setting and examine the potential financial burden of these events.
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DESIGN

Retrospective, longitudinal cohort study.
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SETTING

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.
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SAMPLE

Of 104,388 incident cases of lung cancer diagnosed from 2005-2009, 2,457 cases of patients with lung cancer who received outpatient chemotherapy were identified. Patients were aged 66 years or older at diagnosis, had uninterrupted Medicare Part A and B coverage with no health maintenance organization enrollment, and received IV chemotherapy at least once.
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METHODS

Generalized estimating equations was used.
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MAIN RESEARCH VARIABLES

Patient age, sex, race, marital status, degree of residential urbanization, median income, education level, stage, receipt of radiation therapy, and comorbidities.
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FINDINGS

Younger age, non-White race, lower education, higher income, receipt of radiation therapy, and lack of preexisting comorbidity were significant predictors of the likelihood of an initial unplanned hospitalization for lung cancer. Non-White race, receipt of radiation therapy, and comorbidity were factors associated with an increased number of hospitalizations. 
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CONCLUSIONS

Unplanned hospitalizations are frequent, disruptive, and costly. This article defines areas for further exploration to identify patients at high risk for unexpected complications. 
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IMPLICATIONS FOR NURSING

This article represents a foundation for development of risk models to enable nursing evaluation of patient risk for chemotherapy treatment interruption and unplanned hospitalization.

Safety and Efficacy of Oxaliplatin Doublet Adjuvant Chemotherapy in Elderly Patients With Stage III Colon Cancer

BACKGROUND

Colon cancer is common in the elderly, but owing to under representation in clinical trials, the benefit of standard therapies is uncertain in this age group. We aimed to clarify the efficacy and complications of adjuvant oxaliplatin and fluoropyrimidine chemotherapy for patients 70 years and older with stage III colon cancer.

PATIENTS AND METHODS

All patients with stage III colon adenocarcinoma were identified from an Australian cancer registry (2006-2013). Multivariable Cox hazard regression was used to determine prognostic factors for all-cause mortality. Chemotherapy complications were quantified using discontinuation rates, hospital admissions, and mortality for 12 months after starting chemotherapy.

RESULTS

A total of 2164 patients fulfilled our inclusion criteria, including 1080 (49.9%) patients ≥ 70 years. Patients ≥ 70 years were less likely to receive adjuvant chemotherapy (60.7% vs. 89.6%) or oxaliplatin doublet chemotherapy (18.8% vs. 71.2%). Older patients receiving oxaliplatin were more likely to cease treatment early (18.7% vs. 7.6%) and require hospital admission (67.0% vs. 53.5%). The addition of oxaliplatin provided an overall survival benefit for patients < 70 years (hazard ratio, 0.44; 95% confidence interval, 0.3-0.6; P < .0001) and for patients ≥ 70 years (hazard ratio, 0.64; 95% confidence interval, 0.5-0.9; P = .005).

CONCLUSIONS

Despite a modestly increased rate of hospital admission and early chemotherapy cessation, we demonstrate a persistent survival benefit for the addition of oxaliplatin to a fluoropyrimidine as adjuvant treatment for stage III colon cancer in elderly patients.

Predictive models of adjuvant chemotherapy for patients with stage ii colorectal cancer: A retrospective study

BACKGROUND

It remains controversial whether patients with Stage II colorectal cancer would benefit from adjuvant chemotherapy after radical resection. The aim of this study was to establish two mathematical models to identify the suitable patients for adjuvant chemotherapy.

METHODS

The current study comprised of two steps. In the first step, 353 patients with Stage II colorectal cancer who underwent surgical procedures at the Third Affiliated Hospital of Sun Yat-sen University between June 2006 and December 2015 were entered and followed up for 6-120 months. Their clinical data were collected and enrolled into the database. We established two mathematical models by univariate and multivariate Cox regression analysis to identify the target patients; in the second step, 230 patients under the same standard between January 2012 and December 2016 were entered and followed up for 3-62 months to verify the two models' validation.

RESULTS

In the first step, totally 340 surgical patients with Stage II colorectal cancer were finally enrolled in this study. Statistical analysis showed that tumor differentiation (TD) (P < 0.001), lymphovascular invasion (LVI) (P < 0.001), uncertain or positive margins (UPM) (P < 0.001), and fewer lymph nodes (LNs) (<12) retrieved (P < 0.001) were correlated with the overall survival (OS) and disease free survival (DFS). We obtained two models: (1) OS risk score = 1.116 × TD + 2.202 × LVI + 3.676 × UPM + 1.438 × LN - 0.493; (2) DFS risk score = 0.789 × TD + 2.074 × LVI + 3.183 × UPM + 1.329 × LN - 0.432. According to the models and cutoff points [(0.07, 1.33) and (-0.04, 1.30), respectively], patients can be divided into three groups: low-risk, moderate-risk, and high-risk. Moreover, the high-risk group patients could benefit from adjuvant chemotherapy. In the second step, totally 221 patients were finally used to verify the models' validation. The results proved that the models were accurate and feasible (P< 0.05).

CONCLUSIONS

According to the predictive models, patients with Stage II colorectal cancer in the high-risk group are strongly recommended for adjuvant chemotherapy, thus facilitating the individualized and precise treatment.

New horizons in systemic anti-cancer therapy in older people

Cancer is a disease associated with ageing. Increased life expectancy means that cancer in older adults is becoming an increasingly common problem. There are unique issues to consider when making decisions about cancer treatment in older populations. Unfortunately, however, this group is still under-represented in clinical trials for new cancer therapies meaning there are less evidence-based data to guide management. This article aims to look at how we can optimise the cancer treatment for older patients with a focus on systemic anti-cancer therapy and addressing particular issues around patient selection, improving treatment tolerance and use of newer agents with different toxicity profiles.

Geriatric Assessment and Tools for Predicting Treatment Toxicity in Older Adults With Cancer

Cancer is a disease of older adults, and the majority of new cancer cases and deaths occur in people 65 years or older. However, fewer data are available regarding the risks and benefits of cancer treatment in older adults, and commonly used assessments in oncology fail to adequately evaluate factors that affect treatment efficacy and outcomes in the older patients. The geriatric assessment is a multidisciplinary evaluation that provides detailed information about a patient's functional status, comorbidities, psychological state, social support, nutritional status, and cognitive function. Among older patients with cancer, geriatric assessment has been shown to identify patients at risk of poorer overall survival, and geriatric assessment-based tools are significantly more effective in predicting chemotherapy toxicity than other currently utilized measures. In this review, we summarize the components of the geriatric assessment and provide information about existing tools used to predict treatment toxicity in older patients with cancer.

Management of locally advanced rectal cancer in the elderly: a critical review and algorithm

Colorectal cancer incidence and death rates have been declining over the past 10 years. However, it remains the second leading cause of death in men ages 60-79 and the third leading cause of death in men over 80 and in women over 60 years old. However, there is little data specific to the treatment of the elder patient, since few of these patients are included in trials. With the advent of improved therapies, there are many alternative options available. Still, no definitive consensus or guidelines have been defined for this particular patient population. The goal of this study is to review the literature on the management of rectal cancer in the elderly and to propose treatment algorithms to help the oncology team in treatment decision-making.

Costs of Cancer Care Across the Disease Continuum

Using SEER‐Medicare data, this article demonstrates that considerable differences exist in expenditures across phases of care and varying patient characteristics. These findings can help to provide a better understanding of the drivers of payment variation across patient and tumor characteristics to inform efforts to decrease costs and increase quality of cancer care.

Purpose.

The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity.

Materials and Methods.

We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis.

Results.

We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year.

Conclusion.

Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care.

Implications for Practice.

Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.

Effect of Comorbidities in Stage II/III Colorectal Cancer Patients Treated With Surgery and Neoadjuvant/Adjuvant Chemotherapy: A Single-Center, Observational Study

BACKGROUND

Comorbidity has a detrimental effect on cancer survival, however, it is difficult to disentangle its direct effect from its influence on treatment choice. In this study we assessed the effect of comorbidity on survival in patients who received standard treatment for resected stage II and III colorectal cancer (CRC).

PATIENTS AND METHODS

In total, 230 CRC patients, 68 rectal (29.6%) and 162 colon cancer (70.4%) treated with surgical resection and neoadjuvant/adjuvant chemotherapy from December 2002 to December 2009 at Humanitas Cancer Center were retrospectively reviewed. The key independent variable was the Charlson Comorbidity Index (CCI) score, measured as a continuous variable. The differences between groups for categorical data were tested using the χ² test. Actuarial survival curves were generated using the Kaplan-Meier method.

RESULTS

Median follow-up was 113 (range, 8.2-145.0) months. Median age was 63 (range, 37-78) years. In univariate analysis CCI score was significantly associated with poorer disease-free survival (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.52-1.80; P < .001), and overall survival (OS; HR, 1.55; 95% CI, 1.41-1.71; P < .001). Factors associated with poorer outcome also included (stage III vs. stage II, P < .029) and age (age >70 vs. ≤70 years, P < .001). After adjusting for these factors, a significant negative prognostic role of CCI score was still observed (adjusted HR for OS, 1.59; 95% CI, 1.43-1.76; P < .001).

CONCLUSION

Among CRC patients who underwent surgical resection and chemotherapy, a higher CCI score was associated with poorer outcome and might predict long-term survival.

The Role of Fluoropirimidines in Gastrointestinal Tumours: from the Bench to the Bed

PURPOSE

Gastrointestinal tumours are one of the most common types of cancer. Therapeutic options include surgery, radiotherapy, local ablation techniques, targeted agents, and chemotherapy. Fluoroprimidines are one of the most active drug families in digestive tumours and remains the cornerstone of the most commonly used chemotherapy schemes.

METHODS

We review the molecular basis of thymidylate synthase inhibition and the mechanisms of action of 5-fluorouracil, next generation oral fluoropyrimidines (capecitabine, tegafur and the latest S-1 and TAS-102) and antifolates.

RESULTS

In addition, mechanisms and biomarkers of resistance and toxicity are explored. Finally, new fluoropyrimidines development and clinical trials ongoing in digestive tumours are reviewed.

CONCLUSIONS

Further research is necessary to avoid resistance mechanisms, improve clinical outcomes and continue reducing toxicities. Until new drugs become available, the optimization of current therapies should be a priority.

New-Onset Cardiovascular Morbidity in Older Adults With Stage I to III Colorectal Cancer

Purpose

We sought to determine the long-term risk of cardiovascular disease (CVD)—stroke and myocardial infarction—and congestive heart failure (CHF) in older patients with colorectal cancer, as well as to understand the roles that preexisting comorbidities and cancer therapy play in increasing this risk.

Patients and Methods

We evaluated individuals from the SEER-Medicare database with incident stage I to III colorectal cancer at age older than 65 years between January 1, 2000, and December 31, 2011 (n = 72,408) and compared these patients with a matched cohort of Medicare patients without cancer (n = 72,408).

Results

Median age at diagnosis of colorectal cancer was 78 years (range, 66 years to 106 years), and median follow-up was 8 years since diagnosis. The 10-year cumulative incidence of new-onset CVD and CHF were 57.4% and 54.5% compared with 22% and 18% for control, respectively ( P < .001). The interaction between hypertension and chemotherapy was significant ( P < .001) for CVD, and that between diabetes and chemotherapy was significant ( P < .001) for CHF. Within the first 2 years since diagnosis, exposure to capecitabine alone increased CHF hazard (hazard ratio [HR], 3.6; 95% CI, 12.76 to 4.38) compared with exposure to fluorouracil alone. Conversely, patients who were treated with fluorouracil alone had a higher CVD hazard at < 2 years and > 2 years since diagnosis compared with patients who received capecitabine alone (< 2 years HR, 0.63; 95% CI, 0.53 to 0.75; > 2 years HR, 0.72; 95% CI, 0.62 to 0.84).

Conclusion

Older patients with colorectal cancer are at increased risk of developing CVD and CHF. Diabetes and hypertension interact with chemotherapy to increase the risk of cardiovascular morbidity. Future studies should assess the potential for personalized therapeutic options for those with preexisting morbidities and for structured monitoring for patients with a history of exposure to chemotherapy regimens, as well as explore the management of preexisting comorbidities to address long-term cardiovascular morbidity.

What Every Oncologist Should Know About Geriatric Assessment for Older Patients With Cancer: Young International Society of Geriatric Oncology Position Paper

Aging is a heterogeneous process. Most newly diagnosed cancers occur in older adults, and it is important to understand a patient's underlying health status when making treatment decisions. A geriatric assessment provides a detailed evaluation of medical, psychosocial, and functional problems in older patients with cancer. Specifically, it can identify areas of vulnerability, predict survival and toxicity, assist in clinical treatment decisions, and guide interventions in routine oncology practice; however, the uptake is hampered by limitations in both time and resources, as well as by a lack of expert interpretation. In this review, we describe the utility of geriatric assessment by using an illustrative case and provide a practical approach to geriatric assessment in oncology.

Effects of Preoperative Radiochemotherapy with Capecitabine for Resectable Locally Advanced Rectal Cancer in Elderly Patients

Aims and background

Rectal cancer is a common disease of elderly people. However, patients over 70 years of age are often not included in clinical trials. There is a lack of data concerning the use of radiochemotherapy with capecitabine in elderly patients. The aim of this study was to retrospectively evaluate the impact of preoperative radiochemotherapy with capecitabine on downstaging and sphincter preservation and to assess treatment compliance and toxicity in elderly patients.

Methods

Twenty-six patients with resectable locally advanced rectal cancer (stage II-III/TNM) aged >70 years received preoperative radiotherapy and concurrent oral capecitabine 825 mg/m2 twice daily during the whole period of radiotherapy. Two patients who refused surgery after chemoradiation therapy were excluded from the analysis.

Results

Eighty-one percent of patients underwent anterior resection and 18.1% underwent abdominoperineal resection. Overall tumor downstaging, considering both T and N categories, was observed in 18/24 patients (75%). Treatment compliance was good and toxicity rates were similar to those of younger people.

Conclusions

Age is not a contraindication to any therapy and elderly patients who can tolerate radiochemotherapy should be treated like younger patients. Preoperative radiochemotherapy with capecitabine for patients aged >70 years has a good impact on tumor downstaging, increases the feasibility of sphincter-preserving surgery, and is also safe and well tolerated.

Personalizing Adjuvant Therapy for Stage II/III Colorectal Cancer

This review focuses on three areas of interest with respect to the treatment of stage II and III colon and rectal cancer, including (1) tailoring adjuvant therapy for the geriatric population, (2) the controversy as to the optimal adjuvant therapy strategy for patients with locoregional rectal cancer and for patients with colorectal resectable metastatic disease, and (3) discussion of the microenvironment, molecular profiling, and the future of adjuvant therapy. It has become evident that age is the strongest predictive factor for receipt of adjuvant chemotherapy, duration of treatment, and risk of treatment-related toxicity. Although incorporating adjuvant chemotherapy for patients who have received neoadjuvant chemoradiation and surgery would appear to be a reasonable strategy to improve survivorship as an extrapolation from stage III colon cancer adjuvant trials, attempts at defining the optimal rectal cancer population that would benefit from adjuvant therapy remain elusive. Similarly, the role of adjuvant chemotherapy for patients after resection of metastatic colorectal cancer has not been clearly defined because of very limited data to provide guidance. An understanding of the biologic hallmarks and drivers of metastatic spread as well as the micrometastatic environment is expected to translate into therapeutic strategies tailored to select patients. The identification of actionable targets in mesenchymal tumors is of major interest.