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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Managing older patients with colorectal cancer

Colorectal cancer (CRC) is predominantly a disease of older persons, and our population is aging. Physicians and their older patients commonly face the dilemma of whether or not to give/receive systemic chemotherapy for CRC. Evidence supports the safety and efficacy of systemic chemotherapy in fit older patients motivated enough to enroll onto clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and may not benefit from chemotherapy. However, the majority of patients are neither fit nor frail, and current evidence is insufficient to either quantify or qualify the benefit of chemotherapy for this intermediate group of patients. Thus, treatment decisions must be individualized based on each older person's physical state (eg, their function and degree of comorbidity) and values. Despite a growing body of data, a great deal of work is still needed to establish optimal strategies to care for patients diagnosed with cancer later in life.

Systemic Therapy for Metastatic Colorectal Cancer: Current Options, Current Evidence

Combination chemotherapy regimens including irinotecan and oxaliplatin markedly improve response rate and prolong median survival over fluorouracil with leucovorin (FU/LV), and have supplanted FU/LV as the standard systemic approach for metastatic colorectal cancer. The recent availability of five active chemotherapeutic agents has doubled the median overall survival for metastatic colorectal cancer from 10 to 20 months, and though the optimal strategy for incorporation of all drugs is still unclear, current data support the use of chemotherapy doublets in first-line rather than sequential single-agent therapy. Multidrug regimens increase both response rate and the proportion of patients able to undergo potentially curative resection. In addition, as many as 20% to 30% of patients never receive second-line chemotherapy. When used as single agents, bolus and infusional FU/LV and capecitabine are similarly effective but have differing toxicity. Chemotherapy combinations that incorporate infusion of FU are less toxic and more effective than those using bolus FU dosing. Capecitabine is under study as an alternative dosing method for use in combination regimens; however, the optimal dose has not been defined and final safety and efficacy outcomes are being addressed in ongoing phase II and III investigations. Three combinations have shown excellent first-line efficacy in phase III trials—IFL with bevacizumab, FOLFOX, and FOLFIRI—but neither of these combinations is clearly superior. Sound clinical judgment must continue to guide treatment decisions while we await data regarding the optimal combination and sequence of fluorouracil, irinotecan, oxaliplatin, bevacizumab, and cetuximab.