Do older patients with colorectal cancer experience more deterioration in health-related quality of life than younger patients during the first year of palliative chemotherapy? A prospective real-world observational study

INTRODUCTION

The primary aim was to evaluate changes in health-related quality of life (HRQoL) in a real-life population among younger (< 70 years) and older patients with metastatic colorectal cancer (mCRC) during the first year of palliative chemotherapy. The secondary aims were to assess the impact of chemo-break on HRQoL and to report overall survival (OS).

MATERIALS AND METHODS

Patients with newly diagnosed mCRC, ≥ 18 years, and scheduled for first line palliative chemotherapy were included in this multicentre longitudinal observational study. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (0-100) was filled in at baseline and every second month. Changes or differences in QoL scores of >20, 10-20, and 5-10 points were considered to be of large, moderate, and small clinical magnitude, respectively. Comparing means of different QoL scores between groups or over time, a threshold of 5-10 was considered the minimally important difference (MID). Treatments, patient characteristics, and tumour characteristics were prospectively registered.

RESULTS

A total of 214 patients were included, and 146 were alive after one year. Four months after start of treatment, large deteriorations in fatigue and physical functioning were reported by 40% and 25% of the patients, respectively. Changes in global QoL, physical functioning, role functioning, fatigue, pain, and nausea/vomiting were not significantly different between the age groups and reached baseline levels after one year. Patients on chemo-break reported significant improvements in several HRQoL domains. Median OS was 17.5 months [95% confidence interval 14.4-20.5] with no difference between younger and older patients.

DISCUSSION

Older patients did not experience more deterioration in HRQoL than younger patients during the first year of palliative chemotherapy. Measures to mitigate the deteriorations in fatigue and physical functioning observed during the first months of palliative treatment are warranted.

TRIAL REGISTRATION

NCT02395224, March 23, 2015, retrospectively registered.

Initial Panitumumab Plus Fluorouracil, Leucovorin, and Oxaliplatin or Plus Fluorouracil and Leucovorin in Elderly Patients With RAS and BRAF Wild-Type Metastatic Colorectal Cancer: The PANDA Trial by the GONO Foundation

PURPOSE

To verify whether both doublet chemotherapy with a modified schedule of fluorouracil, leucovorin, and oxaliplatin (mFOLFOX) and monochemotherapy with fluorouracil plus leucovorin (5-FU + LV) achieve satisfactory efficacy when both regimens are combined with panitumumab (PAN) as initial treatment of elderly patients with RAS/BRAF wild-type metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

PANDA (ClinicalTrials.gov identifier: NCT02904031) was an open-label, randomized phase II noncomparative trial in previously untreated patients age 70 years and older with unresectable RAS/BRAF wild-type mCRC. Patients were randomly assigned 1:1 to mFOLFOX + PAN (arm A) or 5-FU + LV + PAN (arm B) for up to 12 cycles, followed by PAN maintenance. The primary end point was progression-free survival (PFS). In each arm, assuming a null hypothesis of median PFS time ≤6 months and target PFS ≥9.65, 90 patients per arm were needed to achieve 90% power and 5% type I error (one-sided Brookmeyer-Crowley test).

RESULTS

Between July 2016 and April 2019, 91 patients were randomly assigned to arm A and 92 to arm B. At a median follow-up of 50.0 months (IQR, 45.6-56.4), median PFS was 9.6 and 9.0 months for arm A and B, respectively (P < .001 in each arm). Overall response rate was 69% and 52%, whereas median overall survival was 23.5 and 22.0 months in arm A and B, respectively. The overall rate of grade >2 chemotherapy-related adverse events was 60% and 37%, respectively. Baseline G8 and Chemotherapy Risk Assessment Scale for High-Age Patients scores were prognostic, but they were not associated with efficacy and safety of the two arms.

CONCLUSION

Both mFOLFOX and 5-FU + LV + PAN are reasonable options as initial therapy of elderly patients with RAS/BRAF wild-type mCRC. 5-FU + LV + PAN is associated with a better safety profile.

The oncological multidimensional prognostic index is a promising decision-making tool: A real-world analysis in older patients with metastatic colorectal cancer

BACKGROUND

Approximately 50% of colorectal cancers occur in older patients. International societies recommend geriatric tools to optimise treatment of older patients. Comprehensive Geriatric Assessment (CGA) is a multidimensional assessment used to classify patients as fit, vulnerable, or frail. The CGA-based oncological multidimensional prognostic index (onco-MPI) also classifies patients as high-, intermediate-, or low-risk based on tumour characteristics. We investigated the role of CGA and onco-MPI in older patients with metastatic colorectal cancer (mCRC) in a real-world setting.

METHODS

Data for consecutive mCRC patients aged ≥70 years were retrieved from a prospectively maintained database from 2010 to 2020. We analyzed patients' and tumours' characteristics, and the CGA domains. Onco-MPI was calculated by a validated algorithm derived from CGA domains. Pearson's test was used to verify whether onco-MPI scores and chemotherapy administration were correlated.

RESULTS

The study included 488 mCRC patients with a mean age of 76.1 years. According to CGA, 52% of patients were fit, 28% vulnerable, and 20% frail. According to onco-MPI, 9% were low, 54% intermediate, and 37% high-risk. The median OS was 22.7 months. The following factors improved OS: 0-1 ECOG PS, low onco-MPI, fit based on CGA, chemotherapy administration, and doublet regimen. Chemotherapy administration significantly correlated with onco-MPI scores, leading to a survival gain regardless of the risk subgroups. First-line regimen had no impact on survival across the CGA and onco-MPI categories.

CONCLUSION

CGA and onco-MPI scores confirmed their prognostic impact in older mCRC patients and may aid in decision-making and subgroup stratification in dedicated trials.

Assessing Oncologists' Adoption of Biomarker Testing in Metastatic Colorectal Cancer Using Real-World Data

BACKGROUND

Despite national guideline recommendations for universal biomarker testing (KRAS, NRAS, BRAF, and mismatch repair and microsatellite instability [MMR/MSI]) in all patients with metastatic colorectal cancer (mCRC), little is known regarding adherence to these recommendations in routine practice.

METHODS

We retrospectively reviewed patients with mCRC diagnosed between January 1, 2013, and December 27, 2018, from a de-identified electronic health record-derived database. We analyzed disparities in KRAS, NRAS, BRAF, and MMR/MSI testing by race, age, sex, and insurance status using χ2 tests and t tests. We evaluated changes in biomarker testing over time with attention to changes around dates of landmark publications and guideline updates using χ2 tests and Cochran-Armitage tests.

RESULTS

A total of 20 333 patients were identified of which 66.6% had test results for any biomarker. Rates of test results for all 4 biomarkers statistically significantly increased over time (P < .001). However, as of June 30, 2018, the rate of test results was only 46% for NRAS, 56% for KRAS, and 46% for BRAF. As of December 31, 2017, the rate of MMR/MSI testing was 59%. Higher documented testing rates were associated with younger age, lower Eastern Cooperative Oncology Group performance status, and commercial insurance. There were no clinically meaningful and/or statistically significant differences in documented testing rates by tumor sidedness, race, sex, or initial stage.

CONCLUSIONS

Increased rates of documented testing for NRAS, BRAF, and MMR/MSI in mCRC was seen between 2013 and 2018 reflecting adoption of guideline recommendations. However, the rate of documented testing remains lower than expected and warrants additional research to understand the extent to which this may represent a clinical practice quality concern.

Impact of preoperative sarcopenia on postoperative complications and survival outcomes of patients with esophageal cancer: a meta-analysis of cohort studies

The effects of preoperative sarcopenia on postoperative complications and survival outcomes of patients undergoing esophageal cancer resection are controversial. From database establishment to 16 May 2021, we systematically searched PubMed, Embase, the Cochrane Library, Web of Science, and Chinese Biomedical Literature Database to collect relevant studies investigating the effects of preoperative sarcopenia on postoperative complications, survival outcomes, and the risk of a poor prognosis of patients undergoing esophagectomy. The Newcastle-Ottawa scale was used to evaluate the quality of the included literature, and RevMan 5.3 software was used for the meta-analysis. A total of 26 studies (3 prospective cohort studies and 23 retrospective cohort studies), involving 4,515 patients, were included. The meta-analysis showed that preoperative sarcopenia significantly increased the risk of overall complications (risk ratio [RR]: 1.15; 95% confidence interval [CI]: 1.08-1.22), pulmonary complications (RR: 1.78; 95% CI: 1.48-2.14), and anastomotic leakage (RR: 1.29; 95% CI: 1.04-1.59) and reduced the overall survival rate (hazard ratio: 1.12; 95% CI: 1.04-1.20) following esophageal cancer resection. Preoperative sarcopenia increased the risks of overall postoperative and pulmonary complications in patients undergoing esophageal cancer resection. For patients with esophageal cancer, assessing the preoperative risk of preoperative sarcopenia is necessary.

Oncological liver resection in elderly - A retrospective comparative study

BACKGROUND

Due to demographic changes and higher life expectancy especially in industrial nations, the number of liver resections in patients ≥70 years is rising. It is known that older age is associated with higher postoperative morbidity and mortality after surgery under general anesthesia. The aim of this analysis is to compare the postoperative outcome after liver resections for malignancies in patients aged below and above 70 years.

MATERIALS AND METHODS

A prospectively collected electronic database of 1034 liver resections between 01/2013 and 12/2019 was retrospectively analyzed. Comparative analysis of patients <70 and ≥ 70 years receiving liver resections for malignancies included 889 operations in 703 patients. Analysis of postoperative outcome and uni- and multivariate analyses of associated risk factors were performed.

RESULTS

Median age of the whole cohort was 65 years (range 18-87 years). N = 582 liver resections (65.7%) were performed in patients <70 years with 42.8% major hepatectomies and n = 307 (34.3%) liver resections in patients ≥70 years with 50.5% major hepatectomies (p = 0.034). Relevant postoperative morbidity of the whole cohort was 27.9%. The 30-day mortality was 3.9% and re-operation rate 14.8%. Patients ≥70 years had significantly higher postoperative morbidity and mortality rates than patients <70 years. Major resections, longer operating time, need of intraoperative transfusions of blood products as well as biliodigestive anastomosis (BDA) and inferior vena cava (IVC) resection were independent risk factors for worse postoperative outcome.

CONCLUSION

Liver resections in patients ≥70 years are associated with a worse postoperative course after. Parenchyma sparing resections should be preferred in those patients.

Age and comorbidity association with survival outcomes in metastatic colorectal cancer: CALGB 80405 analysis

BACKGROUND

Little is known about the interaction of comorbidities and age on survival outcomes in colorectal cancer (mCRC), nor how comorbidities impact treatment tolerance.

METHODS

We utilized a cohort of 1345 mCRC patients enrolled in CALGB/SWOG 80405, a multicenter phase III trial of fluorouracil/leucovorin + oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) plus bevacizumab, cetuximab or both. Endpoints were overall survival (OS), progression-free survival (PFS), and grade ≥ 3 toxicities assessed using NCI CTCAE v.3.0. Participants completed a questionnaire, including a modified Charlson Comorbidity Index. Adjusted Cox and logistic regression models tested associations of comorbidities and age on the endpoints.

RESULTS

In CALGB/SWOG 80405, 1095 (81%) subjects were < 70 years and >70 250 (19%). Presence of ≥1 comorbidity was not significantly associated with either OS (HR 1.10, 95% CI 0.96-1.25) or PFS (HR 1.03, 95% CI 0.91-1.16). Compared to subjects <70 with no comorbidities, OS was non-significantly inferior for ≥70 with no comorbidities (HR 1.21, 95% CI 0.98-1.49) and significantly inferior for ≥70 with at least one comorbidity (HR 1.51, 95% CI 1.22-1.86). There were no significant associations or interactions between age or comorbidity with PFS. Comorbidities were not associated with treatment-related toxicities. Age ≥ 70 was associated with greater risk of grade ≥ 3 toxicities (OR 2.15, 95% CI 1.50-3.09, p < 0.001).

CONCLUSIONS

Among participants in a clinical trial of combination chemotherapy for mCRC, presence of older age with comorbidities was associated with worse OS but not PFS. The association of age with toxicity suggests additional factors of care should be measured in clinical trials.

Metastatic Colorectal Cancer Outcomes by Age Among ARCAD First- and Second-Line Clinical Trials

BACKGROUND

We evaluated the time to progression (TTP) and survival outcomes of second-line therapy for metastatic colorectal cancer among adults aged 70 years and older compared with younger adults following progression on first-line clinical trials.

METHODS

Associations between clinical and disease characteristics, time to initial progression, and rate of receipt of second-line therapy were evaluated. TTP and overall survival (OS) were compared between older and younger adults in first- and second-line trials by Cox regression, adjusting for age, sex, Eastern Cooperative Oncology Group Performance Status, number of metastatic sites and presence of metastasis in the lung, liver, or peritoneum. All statistical tests were 2-sided.

RESULTS

Older adults comprised 16.4% of patients on first-line trials (870 total older adults aged >70 years; 4419 total younger adults aged ≤70 years, on first-line trials). Older adults and those with Eastern Cooperative Oncology Group Performance Status >0 were less likely to receive second-line therapy than younger adults. Odds of receiving second-line therapy decreased by 11% for each additional decade of life in multivariable analysis (odds ratio = 1.11, 95% confidence interval = 1.02 to 1.21, P = .01). Older and younger adults enrolled in second-line trials experienced similar median TTP and median OS (median TTP = 5.1 vs 5.2 months, respectively; median OS = 11.6 vs 12.4 months, respectively).

CONCLUSIONS

Older adults were less likely to receive second-line therapy for metastatic colorectal cancer, though we did not observe a statistical difference in survival outcomes vs younger adults following second-line therapy. Further study should examine factors affecting decisions to treat older adults with second-line therapy. Inclusion of geriatric assessment may provide better criteria regarding the risks and benefits of second-line therapy.

Quality of Life in Vulnerable Older Patients with Metastatic Colorectal Cancer Receiving Palliative Chemotherapy-The Randomized NORDIC9-Study

Quality of life data from randomized trials are lacking in older patients with metastatic colorectal cancer (mCRC). In the randomized NORDIC9-study, reduced-dose S1+oxaliplatin (SOx) showed superior efficacy compared to full-dose S1 monotherapy. We hypothesized that treatment with SOx does not result in inferior quality of life. Patients with mCRC aged ≥70 years and that were not a candidate for standard combination chemotherapy were included and randomly assigned to receive either S1 or SOx. The EORTC QLQ-C30 questionnaire was completed at baseline, after 9, and 18 weeks. The primary endpoint was global Quality of Life (QoL) at 9 weeks. For statistical analysis, a non-inferiority design was chosen applying linear mixed effects models for repeated measurements. The results were interpreted according to statistical significance and anchor-based, clinically relevant between-group minimally important differences (MID). A total of 160 patients aged (median (Interquartile range (IQR))) 78 years (76-81) were included. The QLQ-C30 questionnaire was completed by 150, 100, and 60 patients at baseline, at 9, and 18 weeks, respectively. The difference at 9 weeks in global QoL was 6.85 (95%CI-1.94; 15.65) and 7.37 (0.70; 14.05) in the physical functioning domain in favor of SOx exceeding the threshold for MID. At 18 weeks, the between-group MID in physical functioning was preserved. Dose-reduced combination chemotherapy may be recommended in vulnerable older patients with mCRC, rather than full-dose monotherapy.

Predictors of outcome in elderly patients with metastatic colorectal cancer: the final results of a prospective phase II study of bevacizumab in combination with capecitabine as first-line treatment

In 2011, we demonstrated that bevacizumab in combination with capecitabine as first-line treatment is effective in elderly patients with metastatic colorectal cancer (mCRC). We present the final results of the study with data on tumor molecular biology, sidedness and postprogression therapy. Forty patients with mCRC aged ≥70 years, initially treated with bevacizumab and capecitabine, were followed from the start of the treatment of metastatic disease to death. Tumor tissue samples were retrospectively analyzed for RAS, BRAF and microsatellite status. After a median follow-up time of 20.5 months, the median progression-free survival (PFS) and overall survival (OS) were 9.8 and 20.5 months, respectively and the objective response rate (ORR) was 65%. Twelve patients had mutation in RAS and four patients in BRAF gene, which coexisted with MSI in two cases. Patients with the right-sided tumor had apparently, but not statistically significantly lower PFS (8.6 vs. 13 months, P = 0.14) and statistically significantly lower OS (13 vs. 23.1 months, P = 0.046). Twelve patients with one or more postprogression therapy lines had significantly better ORR (12/12 = 100% vs. 14/28 = 50%, P = 0.003), median PFS (17.2 vs. 8.5 months, P < 0.001) and median OS (42 vs. 13 months, P < 0.001) than patients who received just first-line study treatment. Elderly patients with mCRC responded favorably to bevacizumab and capecitabine, especially the subgroup with the left-sided primary tumor. In the further subset of this group, characterized by RAS/BRAF wild-type and MSS tumors, the application of postprogression therapies was feasible and resulted in significant prolongation of survival.

Impact of neutrophil-lymphocyte ratio, Glasgow Prognostic Score, and postoperative decrease in psoas muscle index on recurrence after curative gastrectomy

Aim : We investigated whether preoperative or postoperative inflammatory markers and psoas muscle index (PMI), and their change after surgery, could predict postoperative recurrence in gastric cancer (GC). Methods : Thirty-five patients who underwent curative gastrectomy for pStage II and III GC were retrospectively reviewed. The relationship between neutrophil-lymphocyte ratio (NLR), prognostic nutritional index (PNI), Glasgow Prognostic Score (GPS), and PMI, as well as postoperative recurrence, was analyzed presurgery and at 6 months after surgery. Results : In the preoperative data, there was a significant association between postoperative recurrence and high NLR, low total protein, low albumin, low PNI, and high GPS. In the data from 6 months after surgery, there was a significant association between postoperative recurrence and high NLR, high C-reactive protein, and high GPS. The reduction in PMI at 6 months after surgery relative to preoperative data was significantly greater in the cases with recurrence than in those without recurrence. No patients whose PMI increased compared with presurgery had recurrence. Conclusions : The postoperative reduction in PMI at 6 months after surgery relative to presurgery could be a predictive marker of recurrence after curative gastrectomy for patients with pStage II and III GC. J. Med. Invest. 68 : 119-124, February, 2021.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky

BACKGROUND

Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality.

METHODS

The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots.

RESULTS

A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001).

CONCLUSIONS

Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

Is specialized palliative cancer care associated with use of antineoplastic treatment at the end of life? A population-based cohort study

BACKGROUND

The use of chemotherapy in the last 14 days of life should be as low as possible.

AIM

To study the factors related to the use of chemotherapy in the last 14 days of life and the factors related to concurrent antineoplastic treatment and specialized palliative care.

DESIGN

This was a population-based cohort study. The data were collected from the Danish Register of Causes of Death, the Danish National Patient Register, and the Danish Palliative Care Database. Analyses were descriptive and multivariate logistic regression.

SETTING/PARTICIPANTS

Cancer decedents between 2010 and 2013 in the Capital Region of Denmark.

RESULTS

During the study period, 17,246 individuals died of cancer and 33% received specialized palliative care. In the last 14 days of life, 4.2% received chemotherapy. Younger patients and patients with hematological cancers were more likely to receive chemotherapy in the last 14 days of life. Receiving specialized palliative care was associated with a lower risk of receiving chemotherapy in the last 14 days of life-odds ratio 0.15 for hospices and 0.53 for palliative hospital units. A total of 8% of the population received concurrent antineoplastic treatment and specialized palliative care. Female gender, younger age, and breast and prostate cancer were significantly associated with this concurrent model.

CONCLUSION

Overall, the incidence of antineoplastic treatment in the last 14 days of life was low compared to other studies. Patients in specialized palliative care had a reduced risk of receiving chemotherapy at the end of life.

Survival after resection of colorectal liver metastases in octogenarians and sexagenarians compared to their respective age-matched national population

Background

The aim of the current study was to investigate survival after resection of colorectal liver metastases (CLM) in octogenarians. The survival of octogenarian patients was compared to the survival of the national population of octogenarians and the survival of sexagenarians, the latter representing the average-age patient undergoing resection of CLM.

Methods

Octogenarian and sexagenarian were defined as person 80-89 and 60-69 years of age, respectively. Survival analyses of patients who underwent resection of CLM between 2002 and 2014 were performed. Data from Statistics Norway were used to estimate the survival of the age-matched national population of octogenarians (ageM-Octo) and the age-matched national population of sexagenarians (ageM-Sexa).

Results

During the study period, 59 octogenarians underwent resection of CLM. The majority of patients underwent a minor liver resection (n=50). In octogenarians, the 5-year survival was 32.5% and 66.3% [difference, 33.8 percentage points (pp)] in patients and ageM-Octo, respectively. The 10-year survival was 14.1% and 31.2% (difference, 17.1 pp) in patients and ageM-Octo, respectively. In sexagenarians, the 5-year survival was 50.9% and 96.2% (difference, 45.3 pp) in patients and ageM-Sexa, respectively. The 10-year survival was 35.7% and 90.3% (difference, 54.6 pp) in patients and ageM-Sexa, respectively. The 5-year cancer-specific survival and 5-year recurrence-free survival (RFS) after resection of CLM in octogenarians were 43.1% and 32.9%, respectively.

Conclusions

After resection of CLM, the survival was poorer in octogenarians than in sexagenarians. However, the difference between the survival curves of patients and their age-matched population was smaller in octogenarians. In practice, this finding may indicate a greater benefit of resection in the elderly than the survival rates alone would suggest.

Causes of mortality in older patients with stage 3 colon cancer

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

General recommendations paper on the management of older patients with cancer: the SEOM geriatric oncology task force's position statement

Population aging is associated with greater numbers of older people with cancer. Thanks to treatment advances, not only are more seniors diagnosed with cancer, but there are also more and more older cancer survivors. This upward trend will continue. Given the heterogeneity of aging, managing older patients with cancer poses a significant challenge for Medical Oncology. In Spain, a Geriatric Oncology Task Force has been set up within the framework of the Spanish Society for Medical Oncology (SEOM). With the aim of generating evidence and raising awareness, as well as helping medical oncologists in their training with respect to seniors with cancer, we have put together a series of basic management recommendations for this population. Many of the patients who are assessed in routine clinical practice in Oncology are older. CGA is the basic tool by means of which to evaluate older people with cancer and to understand their needs. Training and the correct use of recommendations regarding treatment for comorbidities and geriatric syndromes, support care, and drug–drug interactions and toxicities, including those of antineoplastic agents, as detailed in this article, will ensure that this population is properly managed.

Competing nomograms help in the selection of elderly patients with colon cancer for adjuvant chemotherapy

PURPOSE

The extent to which ≥ 70 year patients with colon cancer benefit from adjuvant chemotherapy in the presence of competing risks remains controversial.

METHODS

18,937 patients ≥ 70 years with high-risk stage II and stage III colon cancer were retrospectively reviewed from SEER database. Propensity score matching (PSM) was used to adjust for potential baseline confounding. The nomograms were developed based on the competing model to describe the individual probability of colon cancer-specific death (CCSD) and non-CCSD. The subpopulation treatment-effect pattern plot (STEPP) was used to estimate the treatment-effect heterogeneity.

RESULTS

In the high-risk stage II subgroup, compared to the non-recipients, the hazard ratios (HR) of overall mortality for recipients were 0.83 (P = 0.001). The subdistribution hazard ratio (SHR) of CCSD for receipts was 1.22 (P = 0.021). The SHR of non-CCSD was 0.63 (P < 0.001). In the stage III subgroup, compared to non-recipients, the HR of the overall mortality for the recipients was 0.62 (P < 0.001). The SHR of CCSD was 0.77 (P < 0.001). The SHR of non-CCSD was 0.58 (P < 0.001). The chemotherapy efficacy differed significantly by risk score of non-CCSD (non-CCSD-RS) (P < 0.001). Recipients with high non-CCSD-RS had a rate of CCSD comparative to that of non-recipients (SHR 0.90, P = 0.150) in the stage III subgroup.

CONCLUSIONS

A survival analysis based on the overall mortality did not correctly interpret the effect of chemotherapy. Adjuvant chemotherapy did not provide an additional benefit to patients with high-risk stage II or patients with stage III at high risk of non-cancer death.

The PANDA study: a randomized phase II study of first-line FOLFOX plus panitumumab versus 5FU plus panitumumab in RAS and BRAF wild-type elderly metastatic colorectal cancer patients

BACKGROUND

Few data are available regarding the treatment of metastatic colorectal cancer elderly patients with anti-EGFR agents in combination with chemotherapy. FOLFOX plus panitumumab is a standard first-line option for RAS wild-type metastatic colorectal cancer. Slight adjustments in chemo-dosage are commonly applied in clinical practice to elderly patients, but those modified schedules have never been prospectively tested. Clinical definition of elderly (≥70 years old) patients that may deserve a more or less intensive combination therapy is still debated. Several geriatric screening tools have been developed to predict survival and risk of toxicity from treatment. Among those, the G8 screening tool has been tested in cancer patients showing the strongest prognostic value for overall survival, while the CRASH score can stratify patients according to an estimated risk of treatment-related toxicities.

METHODS

The PANDA study is a prospective, open-label, multicenter, randomized phase II trial of first-line therapy with panitumumab in combination with dose-adjusted FOLFOX or with 5-fluorouracil monotherapy, in previously untreated elderly patients (≥70 years) with RAS and BRAF wild-type unresectable metastatic colorectal cancer. RAS and BRAF analyses are centralized. Geriatric assessment by means of G8 and CRASH score is planned at baseline and G8 will be re-evaluated at disease progression. The primary endpoint is duration of progression-free survival in both arms. Secondary endpoints include prospective evaluation of the prognostic role of G8 score and the correlation of CRASH risk categories with toxicity.

DISCUSSION

The PANDA study aims at exploring safety and efficacy of panitumumab in combination with FOLFOX or with 5FU/LV in elderly patients affected by RAS and BRAF wild-type metastatic colorectal cancer, to identify the most promising treatment strategy in this setting. Additionally, this is the first trial in which the prognostic role of the G8 score will be prospectively evaluated. Results of this study will drive further experimental developments for one or both combinations.

TRIAL REGISTRATION

PANDA is registered at Clinicaltrials.gov : NCT02904031 , July 11, 2016. PANDA is registered at EudraCT-No.: 2015-003888-10, September 3, 2015.

Personalizing Adjuvant Therapy for Stage II/III Colorectal Cancer

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

The impact of frailty and sarcopenia on postoperative outcomes in older patients undergoing gastrectomy surgery: a systematic review and meta-analysis

BACKGROUND

Gastric cancer is a major health problem, and frailty and sarcopenia will affect the postoperative outcomes in older people. However, there is still no systematic review to determine the role of frailty and sarcopenia in predicting postoperative outcomes among older patients with gastric cancer who undergo gastrectomy surgery.

METHODS

We searched Embase, Medline through the Ovid interface and PubMed websites to identify potential studies. All the search strategies were run on August 24, 2016. We searched the Google website for unpublished studies on June 1, 2017. The data related to the endpoints of gastrectomy surgery were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled to estimate the association between sarcopenia and adverse postoperative outcomes by using Stata version 11.0. PRISMA guidelines for systematic reviews were followed.

RESULTS

After screening 500 records, we identified eight studies, including three prospective cohort studies and five retrospective cohort studies. Only one study described frailty, and the remaining seven studies described sarcopenia. Frailty was statistically significant for predicting hospital mortality (OR 3.96; 95% CI: 1.12-14.09, P = 0.03). Sarcopenia was also associated with postoperative outcomes (pooled OR 3.12; 95% CI: 2.23-4.37). No significant heterogeneity was observed across these pooled studies (Chi² = 3.10, I² = 0%, P = 0.685).

CONCLUSION

Sarcopenia and frailty seem to have significant adverse impacts on the occurrence of postoperative outcomes. Well-designed prospective cohort studies focusing on frailty and quality of life with a sufficient sample are needed.

Neurotoxicity Outcomes in a Population-based Cohort of Elderly Patients Treated With Adjuvant Oxaliplatin for Colorectal Cancer

BACKGROUND

The addition of oxaliplatin to adjuvant treatment regimens for colorectal cancer has been shown to improve overall survival at the expense of increased toxicity. The incidence and severity of toxicity might be greater among older patients who might also derive less benefit from oxaliplatin. We evaluated the association between adjuvant oxaliplatin-based chemotherapy and neurotoxicity outcomes in an elderly cohort of patients.

PATIENTS AND METHODS

A population-based cohort of patients aged > 65 years with stage II and III colorectal cancer treated with adjuvant therapy in Ontario, Canada was identified using the Ontario Cancer Registry. Cause-specific hazard models were used to estimate the effect of oxaliplatin exposure on the cause-specific hazard ratio (CHR) of peripheral neuropathy after accounting for the competing risk of death.

RESULTS

We identified 3607 patients aged > 65 years with stage II and III colorectal cancer. Of these patients, 1541 (43%) had been treated with an oxaliplatin-based regimen. Compared with subjects receiving non-oxaliplatin-based regimens, patients aged ≥ 70 years at the time of cancer diagnosis who are subsequently treated with oxaliplatin were more likely to develop peripheral neuropathy (CHR, 2.3; 95% confidence interval [CI], 1.53-3.35; P < .0001). This association was not significant in patients aged 66 to 69 years (CHR, 0.93; 95% CI, 0.50-1.72; P = .812). Formal interaction testing confirmed that the effect of oxaliplatin on neuropathy was more pronounced in patients aged ≥ 70 years compared with patients aged 66 to 69 years (P = .03).

CONCLUSION

Colorectal cancer patients aged ≥ 70 years at the time of cancer diagnosis who are subsequently treated with oxaliplatin have a significant risk of developing peripheral neuropathy. This should be considered in clinical decision making, especially because of the limited data supporting an oxaliplatin benefit in this age group.

[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]

Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.

Decreasing skeletal muscle as a risk factor for mortality in elderly patients with sepsis: a retrospective cohort study

Background

Older patients account for the majority of patients with sepsis. The objective of this study was to determine if decreased skeletal muscle mass is associated with outcomes in elderly patients with sepsis.

Methods

Patients (60 years and older) who were admitted to a tertiary medical center intensive care unit with a primary diagnosis of sepsis between January 2012 and February 2016 were included. Patients who had not undergone abdominal computed tomography on the day of admission, had cardiopulmonary arrest on arrival, or had iliopsoas abscess were excluded from the analyses. Cross-sectional muscle area at the 3rd lumber vertebra was quantified, and the relation to in-hospital mortality was analyzed. Multivariable logistic regression analysis that included sex and APACHE II score as explanatory variables was performed. The optimal cutoff value to define decreased muscle mass (sarcopenia) was calculated using receiver operating characteristic curve analysis, and the odds ratio for in-hospital mortality was determined.

Results

There were 150 elderly patients with sepsis (median age, 75 years) enrolled; in-hospital mortality and median APACHE II score were 38.7 and 24%, respectively. The skeletal muscle area of deceased patients was significantly lower than that of the survival group (P < 0.001). The multivariable logistic regression analysis demonstrated that decreased muscle mass was significantly associated with increased mortality (odds ratio = 0.94, 95% confidence interval = 0.90 to 0.97, P < 0.001). The optimal cutoff value of skeletal muscle area to predict in-hospital mortality was 45.2 cm² for men and 39.0 cm² for women. With these cutoff values, the adjusted odds ratio for decreased muscle area was 3.27 (95% CI, 1.61 to 6.63, P = 0.001).

Conclusions

Less skeletal muscle mass is associated with higher in-hospital mortality in elderly patients with sepsis. The results of this study suggest that identifying patients with low muscularity contributes to better stratification in this population.

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.

Prevalence and survival benefit of adjuvant chemotherapy in stage III colon cancer patients: Comparison of overall and age-stratified results by multivariable modeling and propensity score methodology in a population-based cohort

BACKGROUND

Few population-based studies have assessed the effectiveness of adjuvant chemotherapy (ACT) in stage III colon cancer patients according to age. We sought to quantify the prevalence of ACT use and the absolute and relative survival benefit of ACT overall and by age in a population-based cohort.

METHODS

Stage III patients with adenocarcinoma of the colon identified by the Georgia Comprehensive Cancer Registry for the years 2000-07 were eligible (final N=3057). We utilized Poisson regression to obtain adjusted mortality rates (MR) and Cox proportional hazards models to obtain adjusted hazard ratios (HRs) for 5-year overall survival. We evaluated control of confounding by comparing HRs obtained via multivariable modeling (MM), propensity score weighting (PSW), and propensity score matching (PSM).

RESULTS

Just over one-third of colon cancer patients did not receive ACT, and the proportion increased with age. Overall, receipt of ACT conferred an absolute (MR difference [No ACT rate-ACT rate] 25.4 deaths/1000 person-years [py], 95% confidence interval [CI]: 19.1-32.7 deaths/1000 py) and relative (MM HR=0.67, 95% CI: 0.59-0.76) survival benefit. The survival benefit was demonstrated across age groups. MM and propensity score methods yielded highly similar HRs.

CONCLUSION

Unless contraindicated, efforts to ensure receipt of ACT for stage III colon cancer patients up to 84 years of age are needed to improve the prognosis of patients with node-positive disease.

Patterns of Biologics Use Across Treatment Lines in Elderly (Age >65) Medicare Patients With Metastatic Colon Cancer

BACKGROUND

We explored biologics receipt in metastatic colon cancer.

METHODS

We used Surveillance, Epidemiology, and End Results-Medicare data of 4,545 elderly patients diagnosed with incident metastatic colon cancer from 2003 to 2009, treated with chemotherapy and/or biologics, and followed up through 2010.

RESULTS

A total of 2,504 (55%) patients received a biologics-containing regimen. Treatment with biologics fluctuated between 46% and 63% of first-line regimens and 67% and 73% of second-line regimens. Bevacizumab accounted for 95% of first-line and 68% of second-line biologics use. Cetuximab accounted for 33% of second-line and 48% of third-line use. Panitumumab accounted for 5% of second-line and 27% of third-line use. The adjusted odds of biologics receipt decreased rapidly with age, resulting in a threefold difference between the youngest and the oldest study participants in the sample (odds ratio [OR] 0.35, p < .01). African Americans (OR 0.77, p = .03) and patients with Charlson Comorbidity Index of 1 (OR 0.83, p = .02) or >1 (OR 0.75, p < .01) were considerably less likely to receive biologics therapy. Medicare state buy-in was associated with 2% lower odds of receiving biologics (OR 0.98, p = .04).

CONCLUSION

After controlling for sociodemographic and clinical differences, age, race, comorbidities, and low income had a statistically significantly negative effect on the likelihood of receiving biologics among treated patients. Use of biologics varied over time, across the treatment continuum, and by chemotherapy regimen. Bevacizumab was most frequently used in both first- and second-line treatment. Cetuximab was the second most prescribed biologic. Panitumumab use was mostly limited to third-line treatment.

IMPLICATIONS FOR PRACTICE

It is well-known that patients in the "real world" receive cancer treatments that do not reflect the strict treatment protocols of clinical trials. This is particularly true for complex and elderly patients with metastatic disease, who are frequently underrepresented in clinical trials. Although this article does not provide any additional evidence about the effectiveness of one treatment regimen or treatment sequence over another, it enhances our understanding of oncology practice outside of the clinical trial setting and provides useful information for future health services and health economics research in metastatic colon cancer.

PIK3CA Mutation, Aspirin Use after Diagnosis and Survival of Colorectal Cancer. A Systematic Review and Meta-analysis of Epidemiological Studies

AIMS

Regular aspirin use has been associated with inhibition of the whole spectrum of colorectal carcinogenesis, including prevention of metastases and reduced total mortality in colorectal cancer. Preclinical data show that aspirin down-regulates PI3 kinase (PI3K) signalling activity through cyclo-oxygenase-2 (COX-2) inhibition, leading to the hypothesis that the effect of aspirin might be different according to PIK3CA mutational status, but epidemiological studies have led to conflicting results. The aim of this study was to assess the relationship between PIK3CA status and the efficacy of regular use of aspirin after diagnosis on overall survival in colorectal cancer patients.

MATERIALS AND METHODS

We identified studies that compared post-diagnosis aspirin efficacy in colorectal cancer patients identified by PIK3CA status. Hazard ratios for overall survival were meta-analysed according to PIK3CA status by inverse variance weighting. A pooled test for treatment by PIK3CA status interaction was carried out by weighted linear meta-regression. All statistical tests were two-sided.

RESULTS

The overall effect of aspirin was not significant (summary risk estimate = 0.82; 95% confidence interval 0.63-1.08, P = 0.16; I(2) = 57%). In PIK3CA mutant disease (n = 588), aspirin use reduced total mortality by 29% (summary risk estimate = 0.71; 95% confidence interval 0.51-0.99, P = 0.04; I(2) = 0%), whereas in PIK3CA wild-type disease (n = 4001), aspirin use did not reduce overall mortality (summary risk estimate = 0.93; 95% confidence interval 0.61-1.40; P = 0.7; I(2) = 80%) (P interaction = 0.39). There was a beneficial trend for aspirin on cancer-specific survival in PI3KCA mutated subjects (summary risk estimate = 0.37, 95% confidence interval 0.11-1.32, P = 0.1), albeit with high heterogeneity (Q chi-squared = 3.41, P = 0.07, I(2) = 70.7%).

CONCLUSION

These findings suggest that the benefit of post-diagnosis aspirin treatment on overall mortality in colorectal cancer may be more marked in PIK3CA mutated tumours, although the low number of studies prevents definitive conclusions. Trials addressing this issue are warranted to assess the efficacy of aspirin in the adjuvant setting.

Intensity of adjuvant chemotherapy regimens and grade III-V toxicities among elderly stage III colon cancer patients

PURPOSE

The aim of this study was to provide insight in the use, intensity and toxicity of therapy with capecitabine and oxaliplatin (CAPOX) and capecitabine monotherapy (CapMono) among elderly stage III colon cancer patients treated in everyday clinical practice.

METHODS

Data from the Netherlands Cancer Registry were used. All stage III colon cancer patients aged ≥70 years diagnosed in the southeastern part between 2005 and 2012 and treated with CAPOX or CapMono were included. Differences in completion of all planned cycles, cumulative dosages and toxicity between both regimens were evaluated.

RESULTS

One hundred ninety-three patients received CAPOX and 164 patients received CapMono; 33% (n = 63) of the patients receiving CAPOX completed all planned cycles of both agents, whereas 55% (n = 90) of the patients receiving CapMono completed all planned cycles (P < 0.0001). The median cumulative dosage capecitabine was lower for patients treated with CAPOX (163,744 mg/m(2), interquartile range [IQR] 83,397-202,858 mg/m(2)) than for patients treated with CapMono (189,195 mg/m(2), IQR 111,667-228,125 mg/m(2), P = 0.0003); 54% (n = 105) of the patients treated with CAPOX developed grade III-V toxicity, whereas 38% (n = 63) of the patients treated with CapMono developed grade III-V toxicity (P = 0.0026). After adjustment for patient and tumour characteristics, CapMono was associated with a lower odds of developing grade III-V toxicity than CAPOX (odds ratio 0.54, 95% confidence interval 0.33-0.89). For patients treated with CAPOX, the most common toxicities were gastrointestinal (29%), haematological (14%), neurological (11%) and other toxicity (13%). For patients treated with CapMono, dermatological (17%), gastrointestinal (13%) and other toxicity (11%) were the most common.

CONCLUSION

CAPOX is associated with significantly more grade III-V toxicities than CapMono, which had a pronounced impact on the cumulative dosage received and completion of all planned cycles. In this light, CapMono seems preferable over CAPOX.

Capecitabine in the routine first-line treatment of elderly patients with advanced colorectal cancer--results from a non-interventional observation study

Background

The purpose of this observational study was to evaluate feasibility, efficacy results and toxicity observations of capecitabine in routine first line treatment of patients with metastatic colorectal cancer, with particular regard of elderly patients (>75 years of age).

Methods

Patients with colorectal cancer receiving capecitabine as part of their first-line treatment were recorded until detection of disease progression or up to a maximum of 12 cycles on standardized evaluation forms. Additional information on long-term outcomes, progression-free survival, and overall survival were retrieved at two follow-up time points. Obtained data were analyzed with regard to age up to 75 and >75 years of age. There were no specific requirements for patient selection and conduct of therapy, corresponding to the non-interventional nature of the study.

Results

In total, 1249 evaluable patients were enrolled in Germany. The median age of the study population was 74 years (range: 21–99). Capecitabine-based combination was administered in 56 % of patients in the overall population. The median treatment duration was about 5 months. Severe toxicities occurred rarely without any difference regarding age groups. The most common hematological toxicity was anemia. Gastrointestinal side effects and hand-food-syndrome (HFS) were the most frequent non-hematologic toxicities. Overall response rate (ORR) was significantly higher in the patient group <=75 years compared to patients >75 years of age (38 vs. 32 %, p=0.019). Median progression free survival (PFS 9.7 vs. 8.2 months, p=0.00021) and overall survival (OS 31.0 vs. 22.6 months, p<0.0001) was decreased in elderly patients.

Conclusion

Efficacy and tolerability of capecitabine treatment either as single drug or in various combination regimens, as proven in randomized studies, could be confirmed in a clinical routine setting. Patients older than 75 years may derive a relevant benefit by first line capecitabine-based treatment with good tolerability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2113-8) contains supplementary material, which is available to authorized users.

Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery

According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.

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.

Trends in colorectal cancer in the elderly in Denmark, 1980-2012

BACKGROUND

Colorectal cancer (CRC) is a disease of the older population. The current demographic ageing leads to more elderly patients and is expected to further increase the number of patients with CRC. The objective of the present paper is to outline incidence, mortality and prevalence from 1980 to 2012 and survival data from 1968 to 2012 in Danish CRC patients focusing on the impact of ageing.

MATERIAL AND METHODS

Data were derived from the NORDCAN database with comparable data on cancer incidence, mortality, prevalence and relative survival in the Nordic countries, where the Danish data are delivered from the Danish Cancer Registry and the Danish Cause of Death Registry with follow-up for death or emigration until the end of 2013. This study focuses on the elderly population categorized in six age groups.

RESULTS

The incidence of CRC has increased over the past three decades. Incidence rate has increased in patients with colon cancer, but showed a decreasing trend in the oldest patients with rectal and anal cancer. Mortality has diminished in younger patients with colon cancer, but increased with increasing age. However, mortality did not increase proportionally to incidence. In rectal and anal cancer mortality has decreased, except among the oldest patients. This correlates to a decreasing incidence rate. Prevalence is widely increasing mainly because of increased incidence and longer survival, which is reflected in the increasing one- and five-year age-specific relative survival after a diagnosis of colon, rectal and anal cancer.

CONCLUSION

The incidence of CRC is increasing, especially in older citizens, and mortality increases with older age. There is limited knowledge on how to optimize treatment in older CRC patients and future focus must be how to select and tailor the treatment for older CRC patients.

An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients

The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.

Outcomes with multimodal therapy for elderly patients with rectal cancer

BACKGROUND

Treatment guidelines for stage II and III rectal cancer include neoadjuvant chemoradiotherapy, surgery and postoperative adjuvant chemotherapy. Although data support this recommendation in younger patients, it is unclear whether this benefit can be extrapolated to elderly patients (aged 75 years or older).

METHODS

This was a retrospective review of patients aged at least 75 years with stage II or III rectal cancer who underwent surgery with curative intent from 1996 to 2013 at the Mayo Clinic. Kaplan-Meier analysis and log rank test were used to compare overall survival between therapy groups. Cox proportional hazards model was used to estimate the independent effect of treatment group on survival.

RESULTS

A total of 160 elderly patients (median age 80 years) with stage II (66) and stage III (94) rectal cancer underwent surgical resection. Only 30·0 and 33·8 per cent received neoadjuvant or adjuvant therapy respectively. Among patients with stage II disease, there was no significant difference in 60-month survival between patients who received any additional therapy and those who had surgery alone (55 versus 38 per cent respectively; P = 0·184), whereas additional therapy improved survival in patients with stage III tumours (58 versus 30 per cent respectively; P = 0·007). Multivariable analysis found a survival benefit for additional therapy in elderly patients with stage III disease (hazard ratio 0·58, 95 per cent c.i. 0·34 to 0·98).

CONCLUSION

A multimodal approach in elderly patients with stage III rectal cancer improved oncological outcomes.

Distance as a Barrier to Cancer Diagnosis and Treatment: Review of the Literature

The burden of travel from a patient's residence to health care providers is an important issue that can influence access to diagnosis and treatment of cancer. Although several studies have shown that the travel burden can result in delays in diagnosis and treatment of many common cancers, its role appears underestimated in the treatment of patients in clinical practice. Therefore, we performed a review of the published data on the role of travel burden influencing four items: delay of diagnosis, adequate treatment of cancer, outcome, and quality of life of cancer patients. Forty-seven studies published up to December 2014 were initially identified. Twenty studies were excluded because they did not regard specifically the four items of our review. Twenty-seven studies formed the basis of our study and involved 716,153 patients. The associations between travel burden and (a) cancer stage at diagnosis (12 studies), (b) appropriate treatment (8 studies), (c) outcome (4 studies), and (d) quality of life (1 study) are reported. In addition, in two studies, the relation between travel burden and compliance with treatment was examined. The results of our review show that increasing travel requirements are associated with more advanced disease at diagnosis, inappropriate treatment, a worse prognosis, and a worse quality of life. These results suggest that clinical oncologists should remember the specific travel burden problem for cancer patients, who often need health care services every week or every month for many years.