Impact of patient age and comorbidity on surgeon versus oncologist preferences for adjuvant chemotherapy for stage III colon cancer

Adjuvant Chemotherapy for Older Patients With Stage III Colorectal Cancer: A Real-World Analysis of Treatment Recommendations, Treatment Administered and Impact on Cancer Recurrence

BACKGROUND

A substantial proportion of patients with stage III colorectal cancer (CRC) are older than 70 years. Optimal adjuvant chemotherapy (AC) for older patients (OP) continues to be debated, with subgroup analyses of randomized trials not demonstrating a survival benefit from the addition of oxaliplatin to a fluoropyrimidine backbone.

PATIENTS AND METHODS

We analyzed the multisite Australian ACCORD registry, which prospectively collects patient, tumor and treatment data along with long term clinical follow-up. We compared OP (≥70) with stage III CRC to younger patients ([YP] <70), including the proportion recommended AC and any reasons for not prescribing AC. AC administration, regimen choice, completion rates, and survival outcomes were also examined.

RESULTS

One thousand five hundred twelve patients enrolled in the ACCORD registry from 2005 to 2018 were included. Median follow-up was 57.0 months. Compared to the 827 YP, the 685 OP were less likely to be offered AC (71.5% vs. 96.5%, P < .0001) and when offered, were more likely to decline treatment (15.1% vs. 2.8%, P < .0001). Ultimately, 60.0% of OP and 93.7% of YP received AC (P < .0001). OP were less likely to receive oxaliplatin (27.5% vs. 84.7%, P < .0001) and to complete AC (75.9% vs. 85.7%, P < .0001). The probability of remaining recurrence-free was significantly higher in OP who received AC compared to those not treated (HR 0.73, P = .04) but not significantly improved with the addition of oxaliplatin (HR 0.75, P = .18).

CONCLUSION

OP were less likely than YP to receive AC. Receipt of AC reduced recurrences in OP, supporting its use, although no significant benefit was observed from the addition of oxaliplatin.

Mortality and morbidity after colorectal cancer resection surgery in elderly patients: a retrospective population-based study in Sweden

BACKGROUND

Colorectal cancer is primarily a condition of older adults, and surgery is the cornerstone of treatment. As life expectancy is increasing and surgical techniques and perioperative care are developing, curative surgery is often conducted even in ageing populations. However, the risk of morbidity, functional decline, and mortality following colorectal cancer resection surgery are known to increase with increasing age. This study aims to describe real-world data about postoperative mortality and morbidity after resection surgery for colorectal cancer in the elderly (≥ 70 years) compared to younger patients (< 70 years), in a Swedish setting.

METHODS

A cohort study including all patients diagnosed with colorectal cancer in a Swedish region of 1.7 million inhabitants between January 2016 and May 2020. Patients were identified through the Swedish Colorectal Cancer Registry, and all baseline and outcome variables were extracted from the registry. The following outcome measures were compared between the two age groups: 90-day mortality rates, postoperative complications, postoperative intensive care, reoperations, readmissions, and 1-year mortality. To adjust the analyses for baseline confounders in the comparison of the outcome variables, the following methods were used: marginal matching, calliper (ID matching), and logistic regression adjusted for baseline confounders.

RESULTS

The cohort consisted of 5246 patients, of which 3849 (73%) underwent resection surgery. Patients that underwent resection surgery were significantly younger than those who did not (mean ± SD, 70.9 ± 11.4 years vs 73.7 ± 12.8 years, p < 0.001). Multivariable analyses revealed that both 90-day and 1-year mortality rates were higher in older patients that underwent resection surgery (90-day mortality OR 2.12 [95% CI 1.26-3.59], p < 0.005). However, there were no significant differences in postoperative intensive care, postoperative complications, reoperations, or readmissions.

CONCLUSION

Elderly patients suffer increased postoperative mortality after resection surgery for colorectal cancer compared to younger individuals. Given the growing elderly population that will continue to require surgery for colorectal cancer, more efficient ways of determining and handling individual risk for older adults need to be implemented in clinical practice.

Adjuvant Chemotherapy Is Associated with Improved Survival for Stage III Colon Cancer When Initiated Beyond 8 Weeks

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines recommend adjuvant chemotherapy (AC) within 6-8 weeks of surgical resection for patients with stage III colon cancer. However, postoperative complications or prolonged surgical recovery may affect the receipt of AC. The aim of this study was to assess the utility of AC for patients with prolonged postoperative recovery.

METHODS

We queried the National Cancer Database (2010-2018) for patients with resected stage III colon cancer. Patients were categorized as having either normal or prolonged length of stay (PLOS: >7 days, 75th percentile). Multivariable Cox proportional hazard regression and logistic regressions were used to identify factors associated with overall survival and receipt of AC.

RESULTS

Of the 113,387 patients included, 30,196 (26.6%) experienced PLOS. Of the 88,115 (77.7%) patients who received AC, 22,707 (25.8%) initiated AC more than 8 weeks after surgery. Patients with PLOS were less likely to receive AC (71.5% vs. 80.0%, OR: 0.72, 95%CI=0.70-0.75) and displayed inferior survival (75 vs. 116 months, HR: 1.39, 95%CI=1.36-1.43). Receipt of AC was also associated with patient factors such as high socioeconomic status, private insurance, and White race (p<0.05 for all). AC within and after 8 weeks of surgery was associated with improved survival for patients with both normal LOS and PLOS (normal LOS: <8 weeks HR: 0.56, 95% CI: 0.54-0.59, >8 weeks HR: 0.68, 95% CI: 0.65-0.71; PLOS: <8 weeks HR: 0.51, 95% CI: 0.48-0.54, >8 weeks HR: 0.63, 95% CI 0.60-0.67). AC was associated with significantly improved survival if initiated up to 15 weeks postoperatively (normal LOS: HR: 0.72, 95%CI=0.61-0.85; PLOS: HR: 0.75, 95%CI=0.62-0.90), and very few patients (<3.0%) initiated AC beyond this time.

CONCLUSION

Receipt of AC for stage III colon cancer may be affected by surgical complications or otherwise prolonged recovery. Timely and even delayed AC (>8 weeks) are both associated with improved overall survival. These findings highlight the importance of delivering guideline-based systemic therapies, even after complicated surgical recovery.

Geriatric assessment and the variance of treatment recommendations in geriatric patients with gastrointestinal cancer-a study in AIO oncologists

BACKGROUND

Geriatric assessment (GA) is recommended to detect vulnerabilities for elderly cancer patients. To assess whether results of GA actually influence the treatment recommendations, we conducted a case vignette-based study in medical oncologists.

MATERIALS AND METHODS

Seventy oncologists gave their medical treatment recommendations for a maximum of 4 out of 10 gastrointestinal cancer patients in three steps: (i) based on tumor findings alone to simulate the guideline recommendation for a '50-year-old standard patient without comorbidities'; (ii) for the same situation in elderly patients (median age 77.5 years) according to the comorbidities, laboratory values and a short video simulating the clinical consultation; and (iii) after the results of a full GA including interpretation aid [Barthel Index, Cumulative Illness Rating Scale (CIRS), Geriatric 8 (G8), Geriatric Depression Scale (GDS), Mini Mental Status Examination (MMSE), Mini-Nutritional Assessment (MNA), Timed Get Up and Go (TGUG), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30), stair climb test].

RESULTS

Data on 164 treatment recommendations were analyzed. The recommendations had a significantly higher variance for elderly patients than for 'standard' patients (944 versus 602, P < 0.0001) indicating a lower agreement between oncologists. Knowledge on GA had marginal influence on the treatment recommendation or its variance (944 versus 940, P = 0.92). There was no statistically significant influence of the working place or the years of experience in oncology on the variance of recommendations. The geriatric tools were rated approximately two times higher as being 'meaningful' (53%) and 'useful for the presented cases' (49%) than they were 'used in clinical practice' (19%). The most commonly used geriatric tool in patient care was the MNA (30%).

CONCLUSIONS

The higher variance of treatment recommendations indicates that it is less likely for elderly patients to get the optimal recommendation. Although the proposed therapeutic regimen varied higher in elderly patients and the oncologists rated the GA results as 'useful', the GA results did not influence the individual recommendations or its variance. Continuing education on GA and research on implementation into clinical practice are needed.

The association of comorbidities with administration of adjuvant chemotherapy in stage III colon cancer patients: a systematic review and meta-analysis

Background:

Chemotherapy is an established treatment for stage III colon cancer cases. Older age is known to be associated with less chemotherapy use in these patients, but there might be other relevant factors besides age that influence treatment administration. We summarized evidence on associations between comorbidity and adjuvant chemotherapy administration in stage III colon cancer patients in a systematic review and meta-analysis.

Methods:

We searched the PubMed and Web of Science databases up to 2 June 2020 for studies on comorbidities and chemotherapy use in patients with stage III colon cancer. Summary odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using random-effects models. Subgroup analyses according to year of colon cancer diagnosis, timing of comorbidity assessment, and geographical region were also conducted.

Results:

Thirty-three studies were included in this review, including 219,406 stage III colon cancer patients overall. Chemotherapy administration was 60.9% (95% CI: 56.9% to 64.9%), increasing from 57.1% before 2001 to 66.3% after 2010. There were inverse associations between comorbidities and chemotherapy administration. Compared with patients with Charlson comorbidity score 0, those with scores 1 (OR = 0.79, 95% CI = 0.72–0.87) and 2+ (OR = 0.49, 95% CI = 0.42–0.56) received chemotherapy less often. Among comorbidities, the strongest predictors of chemotherapy non-use were dementia (OR = 0.37, 95% CI = 0.33–0.54), followed by heart failure (OR = 0.44, 95% CI = 0.28–0.70) and stroke (OR = 0.56, 95% CI = 0.38–0.81).

Conclusions:

Merely 60% of stage III colon cancer patients receive chemotherapy. Comorbidities are strong predictors of chemotherapy non-use, but the association differs by comorbid condition and is strongest with dementia. Given the survival disadvantage of colon cancer patients with comorbidities, further evidence on the risk–benefit ratio of chemotherapy according to the type and severity of comorbidity and on the extent to which the survival disadvantage of comorbidity is explained by less use or lower tolerability of chemotherapy is needed to foster personalized medical care in these patients.

A lower cut-off for lymph node harvest predicts for poorer overall survival after rectal surgery post neoadjuvant chemoradiotherapy

Background

A lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. However, neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; hence, a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients.

Methods

A retrospective review of patients who underwent elective surgery for rectal cancer from 2006 to 2013 was performed. All patients with R1/2 resections and presence of metastases and those operated on for recurrence were excluded. Patient demographics, clinical features, operative details, LNH, 30-day mortality and disease-free and overall survival were recorded. P values of < 0.05 were considered significant.

Results

A total of 257 patients were studied, with 174 (68%) males and a median age of 66 years. Ninety-four (37%) patients received long-course NACRT, and 122 (48%) patients were stage 2 and below. Median LNH was 17, which was reduced in the NACRT group (14 versus 23, P < 0.01). Average length of stay was 9 ± 8 days, with a major post-operative complication rate of 4%. Using hazard ratio plots for the NACRT subgroup, LNH cut-offs of 16.5 and 8.5 were obtained for disease-free survival (DFS) and overall survival (OS) respectively. Survival analysis showed that a LNH cut-off of 8.5 was a significant predictor of OS (P < 0.001).

Conclusion

LNH is reduced in patients receiving NACRT before rectal cancer surgery. A LNH of 9 and above is associated with improved overall survival. We propose that this can be used as a tool for prognosis.

Comorbidities, timing of treatments, and chemotherapy use influence outcomes in stage III colon cancer: A population-based European study

INTRODUCTION

For stage III colon cancer (CC), surgery followed by chemotherapy is the main curative approach, although optimum times between diagnosis and surgery, and surgery and chemotherapy, have not been established.

MATERIALS AND METHODS

We analysed a population-based sample of 1912 stage III CC cases diagnosed in eight European countries in 2009-2013 aiming to estimate: (i) odds of receiving postoperative chemotherapy, overall and within eight weeks of surgery; (ii) risks of death/relapse, according to treatment, Charlson Comorbidity Index, time from diagnosis to surgery for emergency and elective cases, and time from surgery to chemotherapy; and (iii) time-trends in chemotherapy use.

RESULTS

Overall, 97% of cases received surgery and 65% postoperative chemotherapy, with 71% of these receiving chemotherapy within eight weeks of surgery. Risks of death and relapse were higher for cases starting chemotherapy with delay, but better than for cases not given chemotherapy. Fewer patients with high comorbidities received chemotherapy than those with low (P < 0.001). Chemotherapy timing did not vary (P = 0.250) between high and low comorbidity cases. Electively-operated cases with low comorbidities received surgery more promptly than high comorbidity cases. Risks of death and relapse were lower for elective cases given surgery after four weeks than cases given surgery within a week. High comorbidities were always independently associated with poorer outcomes. Chemotherapy use increased over time.

CONCLUSIONS

Our data indicate that promptly-administered postoperative chemotherapy maximizes its benefit, and that careful assessment of comorbidities is important before treatment. The survival benefit associated with slightly delayed elective surgery deserves further investigation.

Determinants of Variation in the Use of Adjuvant Chemotherapy for Stage III Colon Cancer in England

AIMS

Adjuvant chemotherapy (ACT) for stage III colon cancer is well-established. This study aimed to explore the determinants of ACT use and between-hospital variation within the English National Health Service (NHS).

MATERIALS AND METHODS

In total, 11 932 patients (diagnosed 2014-2017) with pathological stage III colon cancer in the English NHS were identified from the National Bowel Cancer Audit. Records were linked to Systemic Anti-Cancer Therapy and Hospital Episode Statistics databases. Multi-level logistic regression analyses were carried out to estimate independent factors for ACT use, including age, sex, deprivation, comorbidities, performance status, American Society of Anaesthesiologists (ASA) grade, surgical urgency, surgical access, TNM staging, readmission and hospital-level factors (university teaching hospital, on-site chemotherapy and high-volume centre). A random intercept was modelled for each English NHS hospital (n = 142). Between-hospital variation was explored using funnel plot methodology. Fully adjusted random-intercept models were fitted separately in young (<70 years) and elderly (≥70 years) patients and intra-class correlation coefficients estimated.

RESULTS

60.7% of patients received ACT. Age was the strongest determinant. Compared with patients aged <60 years, those aged 60-64 (adjusted odds ratio [aOR] 0.76, 95% confidence interval 0.63-0.93), 65-69 (aOR 0.63, 95% confidence interval 0.54-0.74), 70-74 (aOR 0.53, 95% confidence interval 0.44-0.62), 75-79 (aOR 0.23, 95% confidence interval 0.19-0.27) and ≥80 years (aOR 0.05, 95% confidence interval 0.04-0.06) were significantly less likely to receive ACT. With adjustment for other factors, ACT use was more likely in patients with higher socioeconomic status, fewer comorbidities, better performance status, lower ASA grade, advanced disease, elective resections, laparoscopic procedures and no unplanned readmissions. Hospital-level factors were non-significant. The observed proportions of ACT administration in the young and elderly were 46-100% (80% of hospitals 74-90%) and 10-81% (80% of hospitals 33-65%), respectively. Risk adjustment did not reduce between-hospital variation. Despite adjustment, age accounted for 9.9% (7.2-13.4%) of between-hospital variation in the elderly compared with 2.7% (1.2-5.7%) in the young.

CONCLUSIONS

There is significant between-hospital variation in ACT use for stage III colon cancer, especially for older patients. Advanced age alone seems to be a greater barrier to ACT use in some hospitals.

Experience with age discrimination and attitudes toward ageism in older patients with cancer and their caregivers: A nationwide Korean survey

OBJECTIVE

It is not clear whether age-related differences in treatment and treatment decision-making are the result of age discrimination or just a reflection of older patients' elevated risk and their own preferences. Therefore, it is critical to understand older patients' own views toward their care in regard to its relationship to age.

MATERIAL AND METHODS

439 older patients with cancer (age ≥ 60) and 358 family members from eleven cancer centers participated in this cross-sectional survey.

RESULTS

Almost all patients (91.2%) and caregivers (92.7%) thought that older patients should be treated equal to younger patients, across all questionnaire items. The proportions of patients who reported having experienced age discrimination according to each item were: disease information (12.3%), treatment information (11.0%), participation in treatment decision (10.7%), attention from healthcare professionals (6.2%), supportive care (5.2%), and treatment (3.2%). Increasing age was the only demographic characteristic that was associated with greater ageism experience (p < .001). Patients' ageism attitudes, as well as caregivers' ageism attitudes, were negatively associated with ageism experience. Ageism experience was associated with a higher depression score, as well as a lower quality of life.

CONCLUSION

Discrimination in treatment and the treatment decision process based on age was not justified. Interventions that address ageist attitudes in older patients, family caregivers, and healthcare professionals are needed to reduce age discrimination, and thereby improve the quality of life of older patients with cancer.

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.

Better Late than Never? Adherence to Adjuvant Therapy Guidelines for Stage III Colon Cancer in an Underserved Region

INTRODUCTION

In 2008, the American College of Surgeons Commission on Cancer (CoC) issued a quality guideline for stage III colon cancer (CC) recommending adjuvant chemotherapy (AC) within 120 days of diagnosis. We examined adherence in a healthcare system serving a region with disparities in CC outcomes.

METHODS

In a retrospective analysis of patients (2005-2014) with stage III CC in a multi-hospital healthcare system, the associations between adherence, clinicopathologic, demographic, geographic, and socioeconomic data and overall survival (OS) were examined.

RESULTS

Of 1171 CC patients, 438 (37.4%) had stage III disease with 63% (n = 276) receiving AC and 37% (n = 162) not. AC conferred a 5-year OS advantage (62.4 vs. 42.5%, p < 0.0001). Younger age independently predicted AC receipt (OR = 0.95, p < 0.0001). Of 252 AC patients < 80 years, 75.8% were CoC guideline compliant (GC) whereas 24.2% were not (nGC). Although there was no OS difference between GC and nGC, both had superior survival (p < 0.0001) compared to non-AC patients. Surgical complications trended towards independent association with non-compliance (p = 0.07) CONCLUSION: Guideline compliance in our system (63%) is lower than the CoC Estimated Performance Rate (72.4%). Age influenced absolute receipt of AC while surgical complications may impact guideline compliance. Even when administered beyond 120 days, AC was associated with a survival benefit.

Administration of adjuvant chemotherapy in older patients with Stage III colon cancer: an observational study

AIM

According to established guidelines, patients with Stage III colon cancer should receive adjuvant chemotherapy. However, a significant proportion do not. This study assessed factors associated with the administration of adjuvant chemotherapy and causes of death.

METHODS

Patients with Stage III colon cancer who underwent surgery between 2000 and 2009 were selected from two hospitals in the Netherlands. Patient characteristics including comorbidities and treatment preferences, tumour characteristics and follow-up were extracted from the medical records. The patient and tumour characteristics of patients who did receive chemotherapy were compared with those who did not using chi-squared analysis. Differences between the groups in causes of death were recorded together with the duration of follow-up.

RESULTS

A total of 348 patients were included. The median age was 73 years (range 33-93). Over half of the patients received adjuvant chemotherapy (50.6%). Patients who did not receive adjuvant chemotherapy were significantly older (P < 0.001), had more comorbidities (P < 0.001) and were more often living alone (P < 0.001). Patients who received no adjuvant chemotherapy had a reduced overall survival, and the cause of death was more often attributed to other causes (60%) than colon cancer (40%). For patients who received chemotherapy, the cause of death was usually attributed to colon cancer (71%).

CONCLUSION

Patients who did not receive adjuvant chemotherapy had a worse overall survival and the majority died due to other causes than colon cancer. In our aging society it will become even more important to develop tools to estimate remaining life expectancy in order to improve the selection of older patients for adjuvant treatments.

The Effect of Adjuvant Chemotherapy on Stoma-Related Complications After Surgery for Colorectal Cancer: A Retrospective Analysis

PURPOSE

To assess stoma-related complications of colorectal cancer patients undergoing surgery with curative intent who received adjuvant chemotherapy compared to those who underwent surgery alone.

DESIGN

A retrospective analysis of a prospectively maintained colorectal cancer clinical audit database was completed.

SUBJECTS AND SETTINGS

Patients undergoing curative surgery for colorectal cancer with the formation of a stoma (end ileostomy, loop ileostomy, end colostomy) between 1999 and 2011 at a single hospital in Lanarkshire, United Kingdom. Patients who underwent neo-adjuvant chemotherapy were excluded. Two hundred twenty-two patients comprised the study sample; 130 (59%) were male. Seventy-five (34%) patients comprised the chemotherapy group and 147 (66%) made up the surgery-only group. Patients in the chemotherapy group were younger (61.6 vs 65.4 years; P = .001) and had higher stage colorectal cancer (P < .001). There was no difference in baseline (day 10) stoma scores between the chemotherapy or surgery-only groups.

METHODS

Postoperative stoma-related complications were serially assessed using a stoma complication scoring tool; scores were calculated at 10 days and 3 months postoperatively. Scores of patients receiving adjuvant chemotherapy were compared to scores of participants who underwent surgery alone.

INSTRUMENT

A composite stoma function score was calculated for each patient after assessment of stoma-related complications. The overall score included a global assessment of stoma quality (stoma retraction, prolapse, stenosis, parastomal hernia, skin changes) and patient-reported stoma function (leakage, soiling, nighttime emptying, odor).

RESULTS

At 3 months, the mean loop ileostomy stoma function score was poorer among the chemotherapy group when compared to the surgery-only group (4.55 vs 1.53; P = .041). No differences were found when colostomy (2.00 vs 2.62; P = .411) or end ileostomy (1.00 vs 2.00; P = .170) function scores were compared at 3 months.

CONCLUSION

Patients undergoing curative surgery for colorectal cancer resulting in a loop ileostomy who received adjuvant chemotherapy had higher stoma complication scores at 3 months compared to those who underwent surgery with no chemotherapy. This difference was not seen in patients with colostomies or end ileostomies. Patients, WOC nurses, and medical staff must be alert to the potential of increased loop ileostomy-related complications with adjuvant chemotherapy. Fully informed patient consent coupled with timely support and advice may reduce stoma-related morbidity and improve quality of life for such patients.

Decision-making in geriatric oncology: systemic treatment considerations for older adults with colon cancer

Colon cancer is common and can be considered a disease of older adults with more than half of cases diagnosed in patients aged over 70 years. Decision-making about treatment with chemotherapy for older adults may be complicated by age-related physiological changes, impaired functional status, limited social supports, concerns regarding the occurrence of and ability to tolerate treatment toxicity, and the presence of comorbidities. This is compounded by a lack of high quality evidence guiding cancer treatment decisions for older adults. Areas covered: This narrative review evaluates the evidence for adjuvant and palliative systemic therapy in older adults with colon cancer. The value of an adequate assessment prior to making a treatment decision is addressed, with emphasis on the geriatric assessment. Guidance in making a treatment decision is provided. Expert commentary: Treatment decisions should consider goals of care, a patient's treatment preferences, and weigh up relative benefits and harms.

Chemotherapy treatment decision-making experiences of older adults with cancer, their family members, oncologists and family physicians: a mixed methods study

Purpose

Although comorbidities, frailty, and functional impairment are common in older adults (OA) with cancer, little is known about how these factors are considered during the treatment decision-making process by OAs, their families, and health care providers. Our aim was to better understand the treatment decision process from all these perspectives.

Methods

A mixed methods multi-perspective longitudinal study using semi-structured interviews and surveys with 29 OAs aged ≥70 years with advanced prostate, breast, colorectal, or lung cancer, 24 of their family members,13 oncologists, and 15 family physicians was conducted. The sample was stratified on age (70–79 and 80+). All interviews were analyzed using thematic analysis.

Results

There was no difference in the treatment decision-making experience based on age. Most OAs felt that they should have the final say in the treatment decision, but strongly valued their oncologists’ opinion. “Trust in my oncologist” and “chemotherapy as the last resort to prolong life” were the most important reasons to accept treatment. Families indicated a need to improve communication between them, the patient and the specialist, particularly around goals of treatment. Comorbidity and potential side-effects did not play a major role in the treatment decision-making for patients, families, or oncologists. Family physicians reported no involvement in decisions but desired to be more involved.

Conclusion

This first study using multiple perspectives showed neither frailty nor comorbidity played a role in the treatment decision-making process. Efforts to improve communication were identified as an opportunity that may enhance quality of care.

Condensed abstract

In a mixed methods study multiple perspective study with older adults with cancer, their family members, their oncologist and their family physician we explored the treatment decision making process and found that most older adults were satisfied with their decision. Comorbidity, functional status and frailty did not impact the older adult’s or their family members’ decision.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3476-8) contains supplementary material, which is available to authorized users.

Role of surgery for colorectal cancer in the elderly

The prevalence of subjects with colorectal cancer is expected to grow in the next future decades and surgery represents the most successful treatment modality for these patients. Anyway, currently elderly subjects undergo less elective surgical procedures than younger patients mainly due to the high rates of postoperative morbidity and mortality. Some authors suggest extensive surgery, including multistage procedures, as carried out in younger patients while others promote less aggressive surgery. In older patients, laparoscopic-assisted colectomy showed a number of advantages compared to conventional open surgery that include lower stress, higher rate of independency after surgery, quicker return to prior activities and a decrease in costs. The recent advances in chemotherapy and the introduction of new surgical procedures such as the endoluminal stenting, suggest the need for a revisitation of surgical practice patterns and the role of palliative surgery, mainly for patients with advanced disease. In this article, we discuss the current role of surgery for elderly patients with colorectal cancer.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

Why adjuvant chemotherapy for stage III colon cancer was not given: Reasons for non-recommendation by clinicians or patient refusal

Aim

The aim of our study was to evaluate stage III colon cancer patients discussed at a multidisciplinary team meeting to identify reasons for clinicians not recommending adjuvant chemotherapy and reasons for patients declining recommended chemotherapy.

Methods

A retrospective, single institution Australian study was conducted on all surgically managed stage III colon cancer patients diagnosed at the regional cancer centre at Toowoomba Hospital between July 2010 and December 2014. Reasons why adjuvant chemotherapy was not recommended by the multidisciplinary team or following referral to a medical oncologist and patients’ reasons for refusing chemotherapy despite medical oncology recommendation were determined.

Results

One hundred and nine patients were suitable for evaluation. Overall, 72 (66.1%) received adjuvant chemotherapy. Chemotherapy was not recommended in 25 (23.4%) of patients, with the majority (68%) having more than one cited reason. Multiple comorbidities and advanced age were the most common reasons for non-recommendation ( p < 0.01). Age alone was not a reason for not recommending chemotherapy. Twelve (11%) patients declined offered chemotherapy. The reasons for refusal were not detailed in the majority of patient charts (63.6%). Travel distance was not a factor in accepting or refusing chemotherapy.

Conclusion

Discussion at a multidisciplinary team meeting facilitates the identification of patients unsuitable for adjuvant treatment. The reasons for declining offered chemotherapy need to be assessed fully to ensure that patients’ treatment preferences are balanced against the proven benefits of chemotherapy. Attendance at a regional cancer centre provides the opportunity for high standard care in the management of stage III colon cancer.

The effect of comorbidity on the use of adjuvant chemotherapy and type of regimen for curatively resected stage III colon cancer patients

Postsurgical chemotherapy is guideline-recommended therapy for stage III colon cancer patients. Factors associated with patients not receiving adjuvant chemotherapy were identified in numerous studies; comorbidity was recognized as an important factor besides patient's age. We assessed the association between comorbidity and the use of adjuvant chemotherapy and type of chemotherapy regimen. Stage III colon cancer patients who underwent surgical resection were obtained from ten Centers for Disease Control and Prevention (CDC)-NPCR Specialized Registries which participated in the Comparative Effectiveness Research (CER) project. Comorbidity was classified into no comorbidity recorded, Charlson, non-Charlson comorbidities, number, and severity of Charlson comorbidity. Pearson chi-square test and multivariable logistic regression were employed. Of 3180 resected stage III colon cancer patients, 64% received adjuvant chemotherapy. After adjusting for patient's demographic and tumor characteristics, there were no significant differences in receipt of chemotherapy between Charlson and non-Charlson comorbidity. However, patients who had two or more Charlson comorbidities or had moderate to severe disease were significantly less likely to have chemotherapy (ORs 0.69 [95% CI, 0.51-0.92] and 0.62 [95% CI, 0.42-0.91], respectively) when compared with those with non-Charlson comorbidity. In addition, those with moderate or severe comorbidities were more likely to receive single chemotherapy agent (P < 0.0001). Capecitabine and FOLFOX were the most common single- and multi-agent regimens regardless of type of comorbidity grouping. Both the number and severity of comorbidity were significantly associated with receipt of guideline-recommended chemotherapy and type of agent in stage III resected colon cancer patients. Better personalized care based on individual patient's condition ought to be recognized.

Development and psychometric validation of a brief comprehensive health status assessment scale in older patients with hematological malignancies: The GAH Scale

OBJECTIVES

The purpose of this study was to develop a new brief, comprehensive geriatric assessment scale for older patients diagnosed with different hematological malignancies, the Geriatric Assessment in Hematology (GAH scale), and to determine its psychometric properties.

MATERIALS AND METHODS

The 30-item GAH scale was designed through a multi-step process to cover 8 relevant dimensions. This is an observational study conducted in 363 patients aged≥65years, newly diagnosed with different hematological malignancies (myelodysplasic syndrome/acute myeloblastic leukemia, multiple myeloma, or chronic lymphocytic leukemia), and treatment-naïve. The scale psychometric validation process included the analyses of feasibility, floor and ceiling effect, validity and reliability criteria.

RESULTS

Mean time taken to complete the GAH scale was 11.9±4.7min that improved through a learning-curve effect. Almost 90% of patients completed all items, and no floor or ceiling effects were identified. Criterion validity was supported by reasonable correlations between the GAH scale dimensions and three contrast variables (global health visual analogue scale, ECOG and Karnofsky), except for comorbidities. Factor analysis (supported by the scree plot) revealed nine factors that explained almost 60% of the total variance. Moderate internal consistency reliability was found (Cronbach's α: 0.610), and test-retest was excellent (ICC coefficients, 0.695-0.928).

CONCLUSION

Our study suggests that the GAH scale is a valid, internally reliable and a consistent tool to assess health status in older patients with different hematological malignancies. Future large studies should confirm whether the GAH scale may be a tool to improve clinical decision-making in older patients with hematological malignancies.

Consideration of comorbidity in treatment decision making in multidisciplinary cancer team meetings: a systematic review

BACKGROUND

Comorbidity is very common among patients with cancer. Multidisciplinary team meetings (MDTs) are increasingly the context within which cancer treatment decisions are made internationally. Little is known about how comorbidity is considered, or impacts decisions, in MDTs.

METHODS

A systematic literature review was conducted to evaluate previous evidence on consideration, and impact, of comorbidity in cancer MDT treatment decision making. Twenty-one original studies were included.

RESULTS

Lack of information on comorbidity in MDTs impedes the ability of MDT members to make treatment recommendations, and for those recommendations to be implemented among patients with comorbidity. Where treatment is different from that recommended due to comorbidity, it is more conservative, despite evidence that such treatment may be tolerated and effective. MDT members are likely to be unaware of the extent to which issues such as comorbidity are ignored.

CONCLUSIONS

MDTs should systematically consider treatment of patients with comorbidity. Further research is needed to assist clinicians to undertake MDT decision making that appropriately addresses comorbidity. If this were to occur, it would likely contribute to improved outcomes for cancer patients with comorbidities.

A retrospective cohort study of patients with stomach and liver cancers: the impact of comorbidity and ethnicity on cancer care and outcomes

Background

Comorbidity has an adverse impact on cancer survival partly through its negative impact on receipt of curative treatment. Comorbidity is unevenly distributed within populations, with some ethnic and socioeconomic groups having considerably higher burden. The aim of this study was to investigate the inter-relationships between comorbidity, ethnicity, receipt of treatment, and cancer survival among patients with stomach and liver cancer in New Zealand.

Methods

Using the New Zealand Cancer Registry, Māori patients diagnosed with stomach and liver cancers were identified (n = 269), and compared with a randomly selected group of non-Māori patients (n = 255). Clinical and outcome data were collected from medical records, and the administrative hospitalisation and mortality databases. Logistic and Cox regression modelling with multivariable adjustment were used to examine the impacts of ethnicity and comorbidity on receipt of treatment, and the impact of these variables on all-cause and cancer specific survival.

Results

More than 70% of patients had died by two years post-diagnosis. As comorbidity burden increased among those with Stage I-III disease, the likelihood that the patient would receive curative surgery decreased (e.g. C3 Index score 6 vs 0, adjusted OR: 0.32, 95% CI 0.13-0.78) and risk of mortality increased (e.g. C3 Index score 6 vs 0, adjusted all-cause HR: 1.44, 95% CI 0.93-2.23). Receipt of curative surgery reduced this excess mortality, in some cases substantially; but the extent to which this occurred varied by level of comorbidity. Māori patients had somewhat higher levels of comorbidity (34% in highest comorbidity category compared with 23% for non-Māori) and poorer survival that was not explained by age, sex, site, stage, comorbidity or receipt of curative surgery (adjusted cancer-specific HR: 1.36, 95% CI 0.97-1.90; adjusted all-cause HR: 1.33, 95% CI 0.97-1.82). Access to healthcare factors accounted for 25-36% of this survival difference.

Conclusions

Patients with comorbidity were substantially less likely to receive curative surgery and more likely to die than those without comorbidity. Receipt of curative surgery markedly reduced their excess mortality. Despite no discernible difference in likelihood of curative treatment receipt, Māori remained more likely to die than non-Māori even after adjusting for confounding and mediating variables.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-821) contains supplementary material, which is available to authorized users.

Does patient age still affect receipt of adjuvant therapy for colorectal cancer in New South Wales, Australia?

OBJECTIVES

To investigate the effect of patient age on receipt of stage-appropriate adjuvant therapy for colorectal cancer in New South Wales, Australia.

MATERIALS AND METHODS

A linked population-based dataset was used to examine the records of 580 people with lymph node-positive colon cancer and 498 people with high-risk rectal cancer who underwent surgery following diagnosis in 2007/2008. Multilevel logistic regression models were used to determine whether age remained an independent predictor of adjuvant therapy utilisation after accounting for significant patient, surgeon and hospital characteristics.

RESULTS

Overall, 65-73% of eligible patients received chemotherapy and 42-53% received radiotherapy. Increasing age was strongly associated with decreasing likelihood of receiving chemotherapy for lymph node-positive colon cancer (p<0.001) and radiotherapy for high-risk rectal cancer (p=0.003), even after adjusting for confounders such as Charlson comorbidity score and ASA health status. People aged over 70years for chemotherapy and over 75years for radiotherapy were significantly less likely to receive treatment than those aged less than 65. Emergency resection, intensive care admission, and not having a current partner also independently predicted chemotherapy nonreceipt. Other predictors of radiotherapy nonreceipt included being female, not being discussed at multidisciplinary meeting, and lower T stage. Adjuvant therapy rates varied widely between hospitals where surgery was performed.

CONCLUSION

There are continuing age disparities in adjuvant therapy utilisation in NSW that are not explained by patients' comorbidities or health status. Further exploration of these complex treatment decisions is needed. Variation by hospital and patient characteristics indicates opportunities to improve patient care and outcomes.

Effect of the 12-gene colon cancer assay results on adjuvant treatment recommendations in patients with stage II colon cancer

INTRODUCTION

The 12-gene colon cancer Recurrence Score assay is a clinically validated predictor of recurrence risk in stage II colon cancer patients. A survey was performed characterizing the assay's impact on treatment recommendations for these patients.

METHODS

US medical oncologists (n = 346) who ordered the assay for ≥3 stage II colon cancer patients were asked to complete a web-based survey regarding their most recent such patient. Physicians surveyed represented users of the assay within the first 2 years of commercial availability which may include 'early adopters'.

RESULTS

Most of 116 eligible physicians were in community practice (86%), with median 14.5 years' experience (range = 2-40). Mean patient age was 61 years (range = 32-85); 81% had T3 disease, and 38% had comorbidities. Of 76 patients tested for mismatch-repair/microsatellite-instability (MMR/MSI), 13 (17%) were MMR-deficient/MSI-high; 46 (61%) MMR-proficient/MSI-low; and 17 (22%) unknown. Most patients (84%) had ≥12 nodes examined. Median Recurrence Score result was 20 (range = 1-77). Before assay, treatment recommendations were specified for 92 (79%) patients, with no recommendation for 24 (21%). Of the 92 with pre-assay recommendations, chemotherapy was planned for 52 (57%) and observation for 40 (43%); the assay changed recommendations for 27 (29%). Treatment intensity decreased for 18 (67%) and increased for nine (33%) patients; it was more likely to decrease for lower Recurrence Score values and increase for higher values (p < 0.001).

CONCLUSION

For stage II colon cancer patients receiving Recurrence Score testing, 29% of treatment recommendations were changed. Use of the assay may lead to reductions in treatment intensity. Study limitations include retrospective design, data gathering during the first 2 years of assay availability only, and potential non-representativeness of respondents.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

Adjuvant chemotherapy for colorectal cancer: age differences in factors influencing patients' treatment decisions

PURPOSE

Older colorectal cancer patients are significantly less likely than younger patients to receive guideline-recommended adjuvant chemotherapy. Previous research has indicated that patient refusal of treatment is a contributing factor. This study aimed to identify potential barriers to adjuvant chemotherapy use in older patients by examining the associations between patient age, factors influencing chemotherapy treatment decisions, and preferences for information and decision-making involvement.

PATIENTS AND METHODS

Sixty-eight patients who underwent surgery for colorectal cancer in Sydney, Australia, within the previous 24 months completed a self-administered survey.

RESULTS

Fear of dying, health status, age, quality of life, and understanding treatment procedures and effects were significantly more important to older patients (aged ≥65 years) than younger patients in deciding whether to accept chemotherapy (all P < 0.05). Reducing the risk of cancer returning and physician trust were important factors for all patients. Practical barriers such as traveling for treatment and cost were rated lowest. Older patients preferred less information and involvement in treatment decision making than younger patients. However, 60% of the older group wanted detailed information about chemotherapy, and 83% wanted some involvement in decision making. Those preferring less information and involvement still rated many factors as important in their decision making, including understanding treatment procedures and effects.

CONCLUSION

A range of factors appears to influence patients' chemotherapy decision making, including, but not limited to, survival benefits and treatment toxicity. For older patients, balancing the risks and benefits of treatment may be made more complex by the impact of emotional motivators, greater health concerns, and conflicts between their need for understanding and their information and decision-making preferences. Through greater understanding of perceived barriers to treatment and unique motivators for treatment choice, physicians may be better able to support older patients to make informed decisions about their care.

Treatment and complications in elderly stage III colon cancer patients in the Netherlands

BACKGROUND

We evaluated which patient factors were associated with treatment tolerance and outcome in elderly colon cancer patients.

DESIGN

Population-based data from five regions included in the Netherlands Cancer Registry were used. Patients with resected stage III colon cancer aged ≥75 years diagnosed in 1997-2004 who received adjuvant chemotherapy (N = 216) were included as well as a random sample (N = 341) of patients who only underwent surgery.

RESULTS

The most common motives for withholding adjuvant chemotherapy were a combination of high age, co-morbidity and poor performance status (PS, 43%) or refusal by the patient or family (17%). In 57% of patients receiving chemotherapy, adaptations were made in treatment regimens. Patients who received adjuvant chemotherapy developed more complications (52%) than those with surgery alone (41%). For the selection of patients who had survived the first year after surgery, receiving adjuvant chemotherapy resulted in better 5-year overall survival (52% versus 34%), even after adjustment for differences in age, co-morbidity and PS.

CONCLUSION

Despite high toxicity rates and adjustments in treatment regimens, elderly patients who received chemotherapy seemed to have a better survival. Prospective studies are needed for evaluating which patient characteristics predict the risks and benefits of adjuvant chemotherapy in elderly colon cancer patients.

Increased adjuvant treatment and improved survival in elderly stage III colon cancer patients in The Netherlands

BACKGROUND

We determined to what extent patients with colon cancer stage III ≥ 75 years received adjuvant chemotherapy and the impact on overall and disease-specific survival.

PATIENTS AND METHODS

Data from The Netherlands Cancer Registry on all 8051 patients with colon cancer stage III ≥ 75 years diagnosed in 1997-2009 were included. Trends in adjuvant chemotherapy administration were analysed and multivariable overall and disease-specific survival analyses were performed.

RESULTS

The proportion of stage III colon cancer patients ≥ 75 years who received adjuvant chemotherapy increased from 12%in 1997-2000 to 23% in 2007-2009 (P < 0.0001), with a marked age gradient and large geographic variation. Five-year overall survival increased over time from 28% in 1997-2000 to 35% in 2004-2006 (P < 0.0001). Sixty percent of patients died of colorectal cancer. Adjuvant chemotherapy was the strongest positive predictor of survival in this retrospective study (hazard ratio = 0.5; 95% confidence interval: 0.4-0.5).

CONCLUSION

There has been an increase in administration of adjuvant chemotherapy to elderly patients with stage III colon cancer in The Netherlands since 1997. Survival of elderly patients with stage III colon cancer increased over time, at least partly due to stage migration. The large effect of adjuvant chemotherapy on survival in this study is likely to be associated with the selection of fitter patients for adjuvant treatment.

Doublet chemotherapy in the elderly patient with ovarian cancer

The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.

Surgical treatment of colon cancer in patients aged 80 years and older : analysis of 31,574 patients in the SEER-Medicare database

BACKGROUND

Age-related disparities in colon cancer treatment exist, with older patients being less likely to receive recommended therapy. However, to the authors' knowledge, few studies to date have focused on receipt of surgery. The objective of the current study was to describe patterns of surgery in patients aged ≥ 80 years with colon cancer and examine outcomes with and without colectomy.

METHODS

Medicare beneficiaries aged ≥ 80 years with colon cancer who were diagnosed between 1992 and 2005 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariable logistic regression analysis was used to assess factors associated with nonoperative management. Kaplan-Meier survival analysis determined 1-year overall and colon cancer-specific survival.

RESULTS

Of 31,574 patients, 80% underwent colectomy. Approximately 46% were diagnosed during an urgent/emergent hospital admission, with decreased 1-year overall survival (70% vs 86% for patients diagnosed during an elective admission) noted among these individuals. Factors found to be most predictive of nonoperative management included older age, black race, more hospital admissions, use of home oxygen, use of a wheelchair, being frail, and having dementia. For both operative and nonoperative patients, the 1-year overall survival rate was lower than the colon cancer-specific survival rate (operative patients: 78% vs 89%; nonoperative patients: 58% vs 78%).

CONCLUSIONS

The majority of older patients with colon cancer undergo surgery, with improved outcomes noted compared with nonoperative management. However, many patients who are not selected for surgery die of unrelated causes, reflecting good surgical selection. Patients undergoing surgery during an urgent/emergent admission have an increased short-term mortality risk. Because the earlier detection of colon cancer may increase the percentage of older patients undergoing elective surgery, the findings of the current study may have policy implications for colon cancer screening and suggest that age should not be the only factor driving cancer screening recommendations.

Reasons physicians do not recommend and patients refuse adjuvant chemotherapy for stage III colon cancer: a population based chart review

Background

Surgery followed by adjuvant chemotherapy has been the standard of care for the treatment of stage III colon cancer since the early 1990’s. Despite this, large proportions of patients do not receive adjuvant chemotherapy. We aimed to identify physicians’ and patients’ reasons for treatment decisions.

Methods

A retrospective population based study was conducted that included all surgically treated stage III colon cancer patients diagnosed in Alberta between 2002 and 2005 who had an oncologist-consult to discuss post-surgical treatment options. Patient demographics and stage were obtained from the Alberta Cancer Registry. Chart reviews were conducted to extract treatment details, the oncologists’ reasons for not recommending chemotherapy, and patients’ reasons for refusing chemotherapy. The number and proportion of patients who were not recommended or refused chemotherapy were calculated.

Results

A total of 613 patients had surgery followed by an oncologist-consult. Overall, 168 (27%) patients did not receive chemotherapy. It was not recommended for 111 (18%) patients; the most frequent reason was presence of one or more co-morbidities (34%) or combination of co-morbidity and age or frailty (22%). Fifty-eight (9%) patients declined chemotherapy, 22% of whom declined due to concerns about toxicity.

Conclusion

Some co-morbidities are clinical indications for not receiving adjuvant chemotherapy, however, the high percentage of patients who were not recommended adjuvant chemotherapy due to co-morbidities according to clinical notes but who had a low Charlson co-morbidity score suggests variation in practice patterns of consulting oncologists. In addition, patients’ reasons for refusing treatment need to be systematically assessed to ensure patients’ preferences and treatment benefits are properly weighed when making treatment decisions.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006

BACKGROUND

With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated.

PURPOSE

To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients.

METHODS

Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years.

RESULTS

Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life.

CONCLUSION

Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

The post-treatment experience of cancer survivors with pre-existing cardiopulmonary disease

PURPOSE

The purpose of this study was to explore the cancer experience of survivors with pre-existing diagnoses of heart and/or lung disease following active treatment.

METHOD

The Lance Armstrong Foundation recruited cancer survivors throughout the United States to complete a web-based survey to provide insight into post-treatment supportive care needs. Experts in survey methodology and oncology, as well as cancer survivors, provided input into the survey.

RESULTS

Among the 2,307 respondents, 137 individuals had been told by their physicians that they had heart or lung problems. They were 50 years old on average, and most were more than 5 years past active treatment. Two thirds of these respondents reported pain for long periods, and 20% of them agreed that they now need help with everyday tasks that they did not need help with before their cancer. Among those who were tired, had no energy, or had trouble sleeping and/or resting, less than half (47%) agreed that they had received help with this problem. One third of these respondents indicated that they had decreased their physical activity since their cancer diagnosis because of fatigue, and 26% decreased their activities because of pain. More respondents indicated that their needs were met during their cancer treatment than afterwards.

CONCLUSIONS

Researchers and healthcare providers are urged to consider the unmet supportive care needs of cancer survivors with co-morbid conditions following active treatment, particularly the necessity for careful monitoring of their complex health conditions.

Older patients and adjuvant therapy for colorectal cancer: surgeon knowledge, opinions, and practice

BACKGROUND

Increasing patient age independently predicts nonreferral and nonreceipt of adjuvant therapy among patients with colorectal cancer.

OBJECTIVE

This study aimed to identify factors affecting surgeons' decisions to refer older patients for adjuvant therapy.

DESIGN/SETTINGS/PARTICIPANTS

A self-administered survey was sent to all Australian and New Zealand colorectal surgeons (n = 146).

MAIN OUTCOME MEASURES

The survey consisted of 3 sections: 1) knowledge of research evidence, 2) opinions on evidence and adjuvant therapy in older patients, and 3) self-reported practice, or likelihood of patient referral in different scenarios. Demographic information was also obtained.

RESULTS

Seventy percent of surgeons responded. Surgeons were significantly less likely to refer older patients than younger patients for adjuvant therapy in all scenarios (P < .001). The difference in referral recommendations was greatest when patients lived a long way from treatment, had a comorbid condition, or had little social support. There was greater variation in referral recommendations for older patients, and marked disagreement between surgeons in knowledge and opinion questions. Surgeon age was the only significant predictor of survey responses. Greater knowledge and more positive opinions predicted similar referral recommendations for older and younger patients (P = .02, P = .01).

LIMITATIONS

Although decreased referral and receipt of adjuvant therapy among older patients is most likely multifactorial, this survey focused on the views of one physician group and a number of specific scenarios.

CONCLUSIONS

Chronological age alone appears to impact colorectal surgeons' decisions to refer patients for adjuvant therapy. Sociodemographic and physiological factors further decrease the likelihood of referral of older patients. A lack of consensus among surgeons suggests that more research is needed both to predict how older patients with cancer will react to treatment, and to determine how information from emerging evidence can be best used to assist physicians' treatment decisions.

Association between receipt and timing of adjuvant chemotherapy and survival for patients with stage III colon cancer in Alberta, Canada

BACKGROUND

Surgery followed by adjuvant chemotherapy has been standard treatment for stage III colon cancer since 1990. However, to date, clinical trials have not been conducted to determine the definitive outer time limit by which adjuvant chemotherapy should be received for optimal survival benefit. The objective of the current study was to assess the association between the receipt/timing of adjuvant chemotherapy and patient survival in clinical practice.

METHODS

Residents of Alberta who were diagnosed with stage III colon adenocarcinoma in years 2000 to 2005 who underwent surgery were included in the study. Patients were identified from the Alberta Cancer Registry and were linked to hospital data and neighborhood-level socioeconomic data from the 2001 Canadian Census. Cox proportional hazards models were used to estimate hazard ratios of death according to the timing of chemotherapy.

RESULTS

There were 1053 patients in the study; 648 (61%) initiated adjuvant chemotherapy within 16 weeks of surgery. There was no difference in overall survival or colon cancer-specific survival between those who received adjuvant chemotherapy from 8 to 12 weeks postsurgery compared with those who received it within 8 weeks. However, those who received chemotherapy 12 to 16 weeks after surgery and those who either received it >16 weeks after surgery or received no treatment had a 43% and 107% greater risk of dying, respectively, than those who received chemotherapy within 8 weeks of surgery (hazard ratio, 1.43 [95% confidence interval, 0.96-2.13] and hazard ratio, 2.07 [95% confidence interval, 1.56-2.76], respectively). Analyses were controlled for age, year, and region of residence at diagnosis; sex; neighborhood-level socioeconomic factors; and number of comorbidities.

CONCLUSIONS

The results from this study were consistent with current guideline recommendations in Alberta that patients with stage III adenocarcinoma should receive chemotherapy within 12 weeks of surgery.

Impact of Comorbidity on Chemotherapy Use and Outcomes in Solid Tumors: A Systematic Review

Background

The treatment of cancer in patients with comorbidities can be challenging as these individuals are underrepresented in clinical trials. We conducted a systematic review to determine the impact of comorbidity on chemotherapy use, delivery, tolerability, and survival among patients with solid tumors to summarize current data and provide recommendations for future research.

Methods

All English-language articles from 1990 to 2009 that explored the association between comorbidity and chemotherapy were identified from MEDLINE and EMBASE. Abstracts were reviewed for eligibility, and data on study design and results were extracted.

Results

Thirty-four articles met the inclusion criteria. Study populations and design were heterogeneous, and the quality of reporting was generally poor. Most studies were retrospective (76%), were based on a cancer registry linked with administrative data (47%), and assessed the overall effect of comorbidity using an index score (76%). Sixteen studies (47%) investigated chemotherapy use, and 29 (85%) addressed survival. The majority reported decreased chemotherapy use (75%) and inferior survival (69%) for patients with comorbidities compared to those without. In 11 of 14 studies, inferior survival was independent of treatment. Of the few studies that addressed chemotherapy tolerability, seven of 10 reported an increased rate of severe toxicity, and three of five reported increased treatment delays for patients with comorbidity.

Conclusion

Chemotherapy use and outcomes among cancer patients with comorbidities are generally inferior, but the existing evidence is limited and of insufficient quality to determine the relationship between decreased use and inferior survival. Further studies that are prospective and site and stage specific are warranted.

The Benefit of Adjuvant Chemotherapy in Elderly Patients with Stage III Colorectal Cancer is Independent of Age and Comorbidity

OBJECTIVES: To determine the combined effect of age and comorbidity on receipt of chemotherapy and its impact on survival in elderly patients with stage III colorectal cancer (CRC). MATERIALS AND METHODS: All patients over age 65 with Stage III CRC diagnosed 1996-2006 were identified from the Barnes-Jewish Hospital Oncology Data Services registry. An age/comorbidity staging system was created using the ACE-27 comorbidity index and data from both Stage II and III CRC. The staging system was then applied to patients with Stage III CRC. Odds of receiving chemotherapy were calculated, and survival analyses determined the impact of chemotherapy on overall survival in each age/comorbidity stage. RESULTS: 435 patients with Stage III CRC were evaluated [median age 75 years (range 65-99)]. Advancing age/comorbidity stage (Alpha, Beta, Gamma) was associated with decreasing odds of receiving chemotherapy for Stage III CRC [Odds Ratio 0.83 (95% CI, 0.51-1.35) for Beta and 0.14 (95% CI, 0.08-0.24) for Gamma, compared to Alpha]. Chemotherapy was associated with lower risk of death in each of the age/comorbidity stages, compared to those who underwent surgery only. The hazard ratio for death in patients who did not receive chemotherapy, relative to those who did, within each age/comorbidity stage was 1.8 [95%CI 1.06-3.06] for Alpha, 2.24 [95%CI 1.38-3.63] for Beta and 2.10 [95% CI 1.23-3.57] for Gamma. CONCLUSION: While stage III CRC patients with increasing age and comorbidity are less likely to receive chemotherapy, receipt of chemotherapy is associated with a lower risk of death.

How does older age influence oncologists' cancer management?

BACKGROUND

Over half of new cancer cases occur in patients aged > or = 65 years. Many older patients can benefit from intensive cancer therapies, yet evidence suggests that this population is undertreated.

METHODS

To assess preferences and influential factors in geriatric cancer management, practicing U.S. medical oncologists completed a survey containing four detailed vignettes exploring colon, breast, lung, and prostate cancer treatment. Participants were randomly assigned one of two surveys with vignettes that were identical except for patient age (<65 years or >70 years).

RESULTS

Physicians in each survey group (n = 200) were demographically similar. Intensive therapy was significantly less likely to be recommended for an older than for a younger, but otherwise identical, patient in two of the scenarios. For a woman with metastatic colon cancer (Eastern Cooperative Oncology Group [ECOG] score, 1) for whom chemotherapy was recommended, nearly all oncologists chose an intensive regimen if the patient's age was 63; but if her age was 85, one fourth of the oncologists chose a less intensive treatment. Likewise, for stage IIA breast cancer (ECOG score, 0), 93% recommended intensive adjuvant treatment for a previously healthy patient aged 63; but only 66% said they would do so if the patient's age was 75. Oncologists commonly identified patient age as an influence on treatment choice, but were even more likely to cite performance status as a determining factor.

CONCLUSIONS

Advanced age can deter oncologists from choosing intensive cancer therapy, even if patients are highly functional and lack comorbidities. Education on tailoring cancer treatment and a greater use of comprehensive geriatric assessment may reduce cancer undertreatment in the geriatric population.