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Ioffe D, Dotan E. Guidance for Treating the Older Adults with Colorectal Cancer. Curr Treat Options Oncol 2023; 24:644-666. [PMID: 37052812 DOI: 10.1007/s11864-023-01071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 04/14/2023]
Abstract
OPINION STATEMENT The need for evidence-based data in the rapidly growing group of older patients is vast and more elderly-specific studies are desperately needed, for which there is clear demand from both patients and providers. Notably, many of the studies discussed in this review included unplanned subset analyses based on age and/or were not originally stratified by age; therefore, these data, particularly overall survival data, need to be interpreted with some caution as they may not be statistically valid based on the initial trial design and statistical plan. As we await data from ongoing elderly-specific trials, our recommendation for managing older patients with CRC should include geriatric screening tools (e.g., CSGA, VES-13, G8, CARG, CRASH) to help guide treatment adjustments for improved tolerability without sacrificing efficacy. For patients with a positive screen for significant geriatric concerns, a full geriatric assessment is recommended to guide treatment approach and supportive care. Prior data support the use of all approved medications for CRC in older adults who are fit; however, treatment breaks and dose attenuation with potential escalation are reasonable options for these patients. Ultimately, management decisions in the care of older adults with mCRC must be made through shared decision-making with the patient with consideration for the patient's functional status, comorbidities, goals of care, social support, as well as potential toxicities and possible effect on QoL.
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Affiliation(s)
- Dina Ioffe
- Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Efrat Dotan
- Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA.
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Lakkunarajah S, Breadner DA, Zhang H, Yamanaka E, Warner A, Welch S. The Influence of Adjuvant Chemotherapy Dose Intensity on Five-Year Outcomes in Resected Colon Cancer: A Single Centre Retrospective Analysis. Curr Oncol 2021; 28:4031-4041. [PMID: 34677260 PMCID: PMC8535138 DOI: 10.3390/curroncol28050342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/04/2021] [Accepted: 09/28/2021] [Indexed: 01/22/2023] Open
Abstract
There is evidence that achieving a dose intensity > 80% in adjuvant colon cancer treatment improves survival. In total, 192 consecutive patients with resected stage III and high-risk stage II colon cancer that received adjuvant chemotherapy were retrospectively analyzed. Patients who received at least 6 weeks of adjuvant therapy were included. The primary objective was to assess the influence of dose index (DI) and relative dose intensity (RDI) on DFS and OS at 3 and 5 years in patients receiving fluorouracil-based doublet therapy with oxaliplatin (FOLFOX) (5-FU and oxaliplatin assessed separately), or capecitabine monotherapy. In the capecitabine group, DFS rates for 3 and 5 years were 66.7% and 57.6%, respectively, while OS rates were 80.3% and 66.7%, respectively. Those who received FOLFOX had DFS rates of 76.9% and 71.2% at 3 and 5 years, respectively. OS rates were 86.4% and 76.7% at 3 and 5 years, respectively. Median RDI was 73.8% for capecitabine and 76.3% and 85.6% for the oxaliplatin and 5-FU components respectively. Based on a multivariate analysis in patients receiving FOLFOX, those with an oxaliplatin DI > 80% had improvements in DFS and OS compared to those with an oxaliplatin DI of ≤80%. Otherwise, there was no significant difference in DFS or OS when comparing patients who achieved an RDI or a DI of above versus below 80% in the patients receiving adjuvant chemotherapy for resected colon cancer.
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Affiliation(s)
- Suganija Lakkunarajah
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5A5, Canada;
| | - Daniel A. Breadner
- Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5W9, Canada;
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON N6A 5W9, Canada; (E.Y.); (A.W.)
- Correspondence:
| | - Hanbo Zhang
- Department of Internal Medicine, Section of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada;
| | - Ellen Yamanaka
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON N6A 5W9, Canada; (E.Y.); (A.W.)
| | - Andrew Warner
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON N6A 5W9, Canada; (E.Y.); (A.W.)
| | - Stephen Welch
- Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5W9, Canada;
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON N6A 5W9, Canada; (E.Y.); (A.W.)
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Antonio M, Carmona-Bayonas A, Saldaña J, Navarro V, Tebé C, Salazar R, Borràs JM. Factors Predicting Adherence to a Tailored-Dose Adjuvant Treatment on the Basis of Geriatric Assessment in Elderly People With Colorectal Cancer: A Prospective Study. Clin Colorectal Cancer 2017; 17:e59-e68. [PMID: 29054805 DOI: 10.1016/j.clcc.2017.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 09/20/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Selecting elderly people with colorectal cancer (CRC) for adjuvant chemotherapy is challenging. Comprehensive geriatric assessment (CGA) can help by classifying them according to their frailty profile. The supposed benefit of chemotherapy is on the basis of the rate of treatment adherence. In this study we evaluated tolerance and adherence to tailored-dose adjuvant therapy on the basis of CGA in a cohort of older patients with high-risk stage II and stage III CRC. PATIENTS AND METHODS This was a prospective study in 193 consecutive patients aged 75 years or older. On the basis of CGA results, we classified patients as fit, medium fit, or unfit, administering standard therapy, adjusted treatment, and best supportive care, respectively. We recorded planned chemotherapy, toxicity, and completion of the treatment. A logistic multivariate analysis was carried out. RESULTS Seventeen (15%) of the 141 candidates for chemotherapy (n = 86 fit and n = 55 medium fit) refused treatment; associated factors included polypharmacy (odds ratio [OR], 5.34; 95% confidence interval [CI], 1.55-18.40) and rectal location (OR, 5.61; 94% CI, 1.45-21.49). Of the 105 (74%) patients receiving chemotherapy, 20 (27%) fit and 4 (13%) medium fit patients experienced Grade 3 to 4 toxicity (P = .11) without association to explanatory variables. Approximately 55% of patients treated with chemotherapy received at least 80% of the planned dose (55% fit and 58% medium fit patients; P = .7). Factors associated with completion of chemotherapy were the absence of toxicity (OR, 7.67; 95% CI, 2.41-24.43) and social support (OR, 2.29; 95% CI, 0.08-1.04). CONCLUSION CGA is useful for selecting elderly patients for adjuvant chemotherapy, adapting the dose to their frailty profile, and identifying adherence-related factors amenable to modification through CGA-based interventions.
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Affiliation(s)
- Maite Antonio
- Medical Oncology Department, Institut d'Investigació Biomèdica de Bellvitge, Institut Català d'Oncologia-Hospital Duran i Reynals, University of Barcelona, Barcelona, Spain.
| | | | - Juana Saldaña
- Medical Oncology Department, Institut d'Investigació Biomèdica de Bellvitge, Institut Català d'Oncologia-Hospital Duran i Reynals, University of Barcelona, Barcelona, Spain
| | - Valentí Navarro
- Research Clinical Unit, Institut Català d'Oncologia-Hospital Duran I Reynals, Barcelona, Spain
| | - Cristian Tebé
- Statisical Assessment Service, Institut d'Investigació Biomèdica de Bellvitge and Universitat Rovira i Virgili, Barcelona, Spain
| | - Ramon Salazar
- Medical Oncology Department, Institut d'Investigació Biomèdica de Bellvitge, Institut Català d'Oncologia-Hospital Duran i Reynals, University of Barcelona, Barcelona, Spain
| | - Josep Maria Borràs
- Department of Clinical Sciences, University of Barcelona and Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
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Aspinall SL, Good CB, Zhao X, Cunningham FE, Heron BB, Geraci M, Passero V, Stone RA, Smith KJ, Rogers R, Shields J, Sartore M, Boyle DP, Giberti S, Szymanski J, Smith D, Ha A, Sessions J, Depcinski S, Fishco S, Molina I, Lepir T, Jean C, Cruz-Diaz L, Motta J, Calderon-Vargas R, Maland J, Keefe S, Tague M, Leone A, Glovack B, Kaplan B, Cosgriff S, Kaster L, Tonnu-Mihara I, Nguyen K, Carmichael J, Clifford L, Lu K, Chatta G. Adjuvant chemotherapy for stage III colon cancer: relative dose intensity and survival among veterans. BMC Cancer 2015; 15:62. [PMID: 25884851 PMCID: PMC4352567 DOI: 10.1186/s12885-015-1038-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/23/2015] [Indexed: 12/17/2022] Open
Abstract
Background Given the paucity of information on dose intensity, the objective of this study is to describe the use of adjuvant chemotherapy for stage III colon cancer, focusing on relative dose intensity (RDI), overall survival (OS) and disease-free survival (DFS). Methods Retrospective cohort of 367 patients diagnosed with stage III colon cancer in 2003–2008 and treated at 19 VA medical centers. Kaplan-Meier curves summarize 5-year OS and 3-year DFS by chemotherapy regimen and RDI, and multivariable Cox proportional hazards regression was used to model these associations. Results 5-fluorouracil/leucovorin (FU/LV) was the most commonly initiated regimen in 2003 (94.4%) and 2004 (62.7%); in 2005–2008, a majority of patients (60%-74%) was started on an oxaliplatin-based regimen. Median RDI was 82.3%. Receipt of >70% RDI was associated with better 5-year OS (p < 0.001) and 3-year DFS (P = 0.009) than was receipt of ≤70% RDI, with 5-year OS rates of 66.3% and 50.5%, respectively and 3-year DFS rates of 66.1% and 52.7%, respectively. In the multivariable analysis of 5-year OS, oxaliplatin + 5-FU/LV (versus 5-FU/LV) (HR = 0.55; 95% CI = 0.34-0.91), >70% RDI at the first year (HR = 0.58; 95% CI = 0.37-0.89) and married status (HR = 0.66; 95% CI = 0.45-0.97) were associated with significantly decreased risk of death, while age ≥75 (versus 55–64) (HR = 2.06; 95% CI = 1.25-3.40), Charlson Comorbidity Index (HR = 1.17; 95% CI = 1.06-1.30), T4 tumor status (versus T1/T2) (HR = 5.88; 95% CI = 2.69-12.9), N2 node status (HR = 1.68; 95% CI = 1.12-2.50) and bowel obstruction (HR = 2.32, 95% CI = 1.36-3.95) were associated with significantly increased risk. Similar associations were observed for DFS. Conclusion Patients with stage III colon cancer who received >70% RDI had improved 5-year OS. The association between RDI and survival needs to be examined in studies of adjuvant chemotherapy for colon cancer outside of the VA. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1038-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sherrie L Aspinall
- VA Pharmacy Benefits Management Services, Hines, IL, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA. .,University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA.
| | - Chester B Good
- VA Pharmacy Benefits Management Services, Hines, IL, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA. .,University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, USA. .,University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.
| | | | | | - Mark Geraci
- VA Pharmacy Benefits Management Services, Hines, IL, USA.
| | - Vida Passero
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Roslyn A Stone
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA. .,University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Kenneth J Smith
- Division of Clinical Modeling and Decision Sciences, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Renee Rogers
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Jenna Shields
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Megan Sartore
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | | | | | | | - Doug Smith
- Martinsburg VA Medical Center, Martinsburg, WV, USA.
| | - Allen Ha
- Richmond VA Medical Center, Richmond, VA, USA.
| | | | | | - Shane Fishco
- James A. Haley Veterans Hospital, Tampa, FL, USA.
| | | | | | | | | | | | | | | | - Sean Keefe
- Kansas City VA Medical Center, Kansas City, MO, USA.
| | | | - Alice Leone
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
| | | | - Blair Kaplan
- Jesse Brown VA Medical Center, Chicago, IL, USA.
| | | | | | | | | | | | | | - Kan Lu
- Sacramento VA Medical Center, Mather, CA, USA.
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