Colorectal cancer in the elderly: is palliative chemotherapy of value?

Elderly Patients with Advanced Colorectal Cancer: Tolerability and Activity of Chemotherapy

Aims and Background

Colorectal cancer is the most common gastrointestinal tumor in Western countries and is increasing in elderly patients. In recent years, new treatments based on the use of 5-fluorouracil associated with oxaliplatin or CPT-11 have shown promising activity. The aim of the present study was to analyze the tolerability and activity of chemotherapy with 5-fluorouracil plus oxaliplatin or CPT-11 in elderly patients with advanced colorectal cancer.

Methods

Patients aged 70 years or older with advanced colorectal cancer were treated with 5-fluorouracil (400 mg/m2 in bolus and 600 mg/m2 in a 22-hr continuous infusion on days 1-2) plus folinic acid (100 mg/m2) associated to oxaliplatin (85 mg/m2 on day 1, FOLFOX regimen) or CPT-11 (180 mg/m2 on day 1, FOLFIRI regimen), every 14 days.

Results

Twenty-nine patients with a median age of 76 years (range, 70-82) were treated with FOLFOX or FOLFIRI as first-line chemotherapy for metastatic disease. We observed a partial response in 8/29 (27.6%), stable disease in 11/29 (37.9%) and progressive disease in 10/29 (34.5%). Median survival was 21 months; 1-year survival probability was 89.8%. Grade III leukopenia was observed in 2/29 (7%) patients and grade III diarrhea in 1/29 patients. No other grade III-IV toxicity was observed.

Conclusions

FOLFOX and FOLFIRI appear to be active and well tolerated regimens for elderly patients with advanced colorectal cancer.

Palliative chemotherapy in advanced colorectal cancer patients 80 years of age and older

BACKGROUND

Colorectal cancer (crc) has a median diagnostic age of 68 years. Despite significant progress in chemotherapy (ctx) options, few data on outcomes or toxicity from ctx in patients 80 years of age and older are available. We investigated ctx in such patients with metastatic crc (mcrc), hypothesizing high rates of hospitalization and toxicity.

METHODS

A retrospective chart review identified patients 80 years of age and older with mcrc who initiated ctx between 2005-2010 at our institution. Patient demographics and ctx data were collected. Endpoints included rates of hospitalization, ctx discontinuation because of toxicity, and overall survival.

RESULTS

In 60 patients, ctx was initiated on 88 occasions. Median age in the cohort was 83 years; 52% were men; 72% lived with family; 53% had a modified Charlson comorbidity index of 2 or greater; and 31% were taking 6 or more prescription medications at baseline. At baseline, 33% of the patients were anemic (hemoglobin < 100 g/L), 36% had leukocytosis (white blood cells > 11×10(9)/L), and 48% had renal impairment (estimated glomerular filtration rate < 60 mL/min/1.73 m(2)). In 53%, ctx was given as first-line treatment. The initial ctx dose was adjusted in 67%, and capecitabine was the most common chemotherapeutic agent (45%). In 19 instances (22%), the patient was hospitalized during or within 30 days of ctx; in 26 instances (30%), the ctx was discontinued because of toxicity, and in 48 instances (55%), the patient required at least 1 dose reduction, omission, or delay. Median overall survival was 17.8 months (95% confidence interval: 14.3 to 20.8 months).

CONCLUSIONS

In the population 80 years of age and older, ctx for mcrc is feasible; however, most recipients will require dose adjustments, and a significant proportion will be hospitalized or stop ctx because of toxicity. Prospective research incorporating geriatric assessment tools is required to better select these older patients for ctx.

Differences in the therapeutic approach to colorectal cancer in young and elderly patients

PURPOSE

To analyze differences in the therapeutic approach to and tumor-related mortality of young and elderly colorectal cancer (CRC) patients.

PATIENTS AND METHODS

This was a descriptive study of a retrospective cohort, based on administrative databases, of all patients with CRC diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, type of treatment received, survival time, and cause of death. We compared differences between a young group (YG) (age <75 years) and an older group (OG) (age ≥75 years) and assessed the variables associated with receiving different therapeutic options (multivariate analysis) and with survival time (Cox proportional hazards models).

RESULTS

The study included 503 patients (YG, 320; OG, 183), with mean ages of 63.1 years in the YG and 81.8 years in the OG. No differences were observed between the groups in degree of differentiation, extension, tumor stage, or comorbidity. After adjustment for gender, comorbidity, and tumor localization and extension, YG patients were more likely than OG patients to receive surgery, radiotherapy, and chemotherapy and less likely to receive palliative care. After a median follow-up of 36.5 months, YG patients had a longer tumor-specific survival time than OG patients (36.41 months vs 26.05 months). After further adjustment, the YG had a lower tumor-specific mortality risk (hazard ratio, 0.66) than the OG.

CONCLUSION

In comparison with younger patients, elderly CRC patients are undertreated, mainly because of their age and not because of their tumor type or comorbidity. Elderly patients have a significantly shorter tumor-specific survival time, partially because of this undertreatment.

Bevacizumab in clinical practice: prescribing appropriateness relative to national indications and safety

The aim of this study was to describe the clinical use of bevacizumab in Lombardy (9.5 million inhabitants), Italy, during 2006-2007 in patients with metastatic colorectal cancer (mCRC) to evaluate compliance with the Italian Medicine Agency (AIFA) indications, the incidence of adverse events, and the survival rate. We performed computerized record linkage among three different Lombardy health care databases: File F registry, Regional discharge database, and Registry Office records. Patients were classified into approved and off-label uses according to the AIFA indications. Treatment with bevacizumab was administered to 780 patients, of whom 81.7% (n = 637) had mCRC. Among these, 37.8% (n = 241) of patients received the drug in observance of AIFA indications. Overall, ∼10% of patients had serious treatment-related toxicities (fistula, 3.5%; venous thromboembolism, 2.8%; hemorrhage, 1.9%; intestinal perforation and arterial thromboembolism, <1%). The 1-year survival rate was 74.3% and the 2-year survival rate was 39.2%. The median survival time was 20.5 months, and there were no meaningful differences between gender and age groups. There was a gap between the bevacizumab approved indication and clinical practice pattern: overall, less than one half of the patients received bevacizumab in observance with the regulatory indication. The main reason for nonadherence to the indication was use as a second-line or advanced line of therapy. The incidence of serious adverse events and the survival rates of mCRC patients were similar to those reported in clinical trials.

Oxaliplatin-based chemotherapy in the treatment of elderly patients with metastatic colorectal cancer (CRC)

Elderly patients constitute a subpopulation with special clinical features that differ from those of the general population and are under-represented in clinical trials. We retrospectively analyzed the toxicity and efficacy of oxaliplatin-based chemotherapy in the treatment of elderly patients affected by metastatic (m) CRC. Seventy-five consecutive patients aged 65-75 years (median age 71 years), 51 males and 24 females, with mCRC and measurable disease, were analyzed. The primary site of metastases was the liver (38.6% of patients). The majority of patients had a performance status (PS) according to the Eastern Cooperative Oncology Group (ECOG) PS before treatment of 0-1 (96%). The overall response rate was 57.3%, median progression-free survival was 7 months and median overall survival was 27 months. The main hematological and extra-hematological toxicities (grade 3 or 4) were neutropenia (20.0%), and neurological toxicity or diarrhea (6.7%), respectively. No toxic death occurred. Oxaliplatin-based chemotherapy maintains its efficacy, and safety in elderly patients with mCRC and good PS. This regimen should be considered in the treatment of this particular setting of patients.

Treatment of metastatic colorectal cancer in the elderly

OPINION STATEMENT

Metastatic colorectal cancer (CRC) is the second leading cause of cancer related mortality in the United States. The median age of patients at diagnosis is over 70, so as the American population ages, it can be expected that the incidence of CRC will also increase. There is limited prospective data regarding the safety and efficacy of chemotherapy in elderly patients with metastatic CRC. However, the data that are available suggest that elderly patients with a good performance status have a similar likelihood of response to currently available chemotherapy, though perhaps a somewhat higher likelihood of toxicities such as myelosuppression. This paper reviews the available data and recommendations for the treatment of this patient population.

First-line single-agent cetuximab in elderly patients with metastatic colorectal cancer. A phase II clinical and molecular study of the Spanish group for digestive tumor therapy (TTD)

PURPOSE

to evaluate the efficacy and safety of first-line single-agent cetuximab in fit elderly patients with metastatic colorectal cancer, as well as potential molecular predictive factors for efficacy.

PATIENTS AND METHODS

patients aged 70 or older with metastatic CRC without criteria for frailty and no prior treatment for advanced disease were treated with single-agent cetuximab 400mg/m(2) followed by weekly 250mg/m(2) until disease progression or unacceptable toxicity.

RESULTS

forty-one patients were included. Two patients achieved a complete response and 4 patients had a partial response for an overall response rate of 14.6%. Fifteen patients (36.6%) remained stable. Median time to progression was 2.9 months and median overall survival 11.1 months despite two-third of patients received chemotherapy at progression. Forty-five percent of EGFR gene copy number positive patients by FISH were progression-free at 12 weeks, in contrast with 12% of FISH negative patients (p=0.04). Grade 3 skin toxicity was reported in 5 patients (12.2%). Hypersensitivity infusion reactions were not reported and there were no toxic deaths.

CONCLUSION

cetuximab is a safe monoclonal antibody with moderate activity in first-line metastatic colorectal cancer, but the present study does not support the use of cetuximab as single-agent in first-line fit elderly patients with metastatic CRC.

Chemotherapy for colorectal cancer in the elderly: Whom to treat and what to use

The median age at diagnosis of colorectal cancer is during the seventh decade, and the incidence of the disease increases continuously with age. However, as the age increases, the possibilities of receiving adequate cancer treatment diminish and the mortality rises. So, there is a huge need for defined treatment strategies in elderly patients with colorectal carcinoma. The geriatric population is a very heterogeneous group where patients with an excellent health status coexist with the patients with both co-morbidities and functional dependency. Therefore, it is necessary to personalize each treatment according to the degree of vulnerability of the elderly patients. It is essential to set up a multidimensional geriatric assessment in order to consider not only the stage of the disease, but also all the factors that may influence the survival and interfere with the treatment. The aim of this review is to discuss the potential benefits and issues of chemotherapy in the elderly patients affected with colorectal cancer.

Cancer in older men: a gender-based review

Cancer is a common condition of the older male. Risk factors for developing a malignancy include genetic, environmental and life style features. Cancer epidemiology and prognosis differ depending on the age and gender of the population being studied. In the group of men older than 65 years, the most common malignant tumors are prostate, lung, colon and pancreatic cancer. Treatment options vary depending on the stage of the tumor when it is diagnosed, and the decision for therapeutic versus palliative interventions will depend upon the functional status, comorbidity and personal wishes of the patients.

Age and colorectal cancer with focus on the elderly: trends in relative survival and initial treatment from a Danish population-based study

PURPOSE

Elderly patients with colorectal cancer undergo surgery with curative intent less frequently than younger patients, and survival declines with increasing age. We compared relative survival of colorectal cancer among patients older than 75 years with that of younger patients in Denmark during the period 1977 to 1999. We also examined trends in choice of initial treatment.

METHODS

From the files of the nationwide population-based Danish Cancer Registry, we identified all cases of colorectal cancer diagnosed between 1977 and 1999. We then linked this data to information on survival obtained from the Danish Register of Causes of Death and from the Central Population Register.

RESULTS

During the entire study period, short-term and long-term relative survival improved for patients of all ages, but the improvement was more pronounced among elderly patients (>75 years). Radical resection was increasingly chosen as the initial treatment for elderly patients; during the 1995 to 1999 period it was performed on approximately 50 percent of such patients, almost as frequently as among younger patients.

CONCLUSIONS

Relative survival of elderly colorectal cancer patients (>75 years) improved in Denmark between 1977 and 1999. In the most recent period studied, 1995 to 1997, only minor differences in five-year relative survival were observed among younger, middle-aged, and elderly patients. A simultaneous increase in the rate of radical resection among elderly patients, reflecting more effective treatment, may underlie this finding.

Capecitabine as first-line treatment for patients older than 70 years with metastatic colorectal cancer: an oncopaz cooperative group study

PURPOSE

To determine the tolerability of capecitabine in elderly patients with advanced colorectal cancer (CRC).

PATIENTS AND METHODS

Fifty-one patients with advanced CRC who were >/= 70 years and considered ineligible for combination chemotherapy received oral capecitabine 1,250 mg/m(2) twice daily on days 1 to 14 every 3 weeks. Patients with a creatinine clearance of 30 to 50 mL/min received a dose of 950 mg/m(2) twice daily.

RESULTS

A total of 248 cycles of capecitabine were administered (median, five cycles; range, one to eight cycles). The overall response rate was 24% (95% CI, 15% to 41%), including two complete responses (CR; 4%) and 10 partial responses (PR; 20%). Disease control (CR + PR + stable disease) was achieved in 67% of patients. The median times to disease progression and overall survival were 7 months (95% CI, 6.4 to 9.5 months) and 11 months (95% CI, 8.6 to 13.3 months), respectively. Of the 35 patients evaluated for clinical benefit response, 14 (40%; 95% CI, 24% to 58%) showed clinical benefit. Capecitabine was well tolerated. Treatment-related grade 3 and 4 adverse events were observed in only six patients (12%), and the most common events were diarrhea, hand-foot syndrome, and thrombocytopenia. One patient (2%) had an episode of angina, but no treatment-related deaths were reported.

CONCLUSION

Our findings suggest that capecitabine is effective and well tolerated in elderly patients with advanced CRC who are considered ineligible for combination chemotherapy.

Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic

Colorectal cancer is predominantly a disease of elderly people, since over 70% of cases occur in those aged 65 years or older. Clinicians have to frequently decide whether major surgery is justified in elderly patients with a limited life expectancy. Our retrospective study was aimed to compare outcomes of primary surgery for colorectal cancer in the elderly patient population. The evaluated data were collected from the 1st Department of Surgery, Charles University, and from all over the Czech Republic. Patients were divided into three groups: the young-old (21-59 years), the older-old (60-69 years), and the oldest-old (>69 years) patients. In the collective data the youngest and the oldest groups differ significantly in the rate of early postoperative complications (12.3% versus 17.6%, p<0.001). The number of complications associated with the emergency procedures was twice as high compared to elective surgery in all groups (p<0.001). There was no correlation between age and length of hospital stay in the single surgery department. These data suggest that major oncology procedures may be undertaken in older patients in whom operative risk is reasonable, with acceptable rates of complications.

New systemic frontline treatment for metastatic colorectal carcinoma

Options for first-line chemotherapy in patients with metastatic colorectal carcinoma have broadened considerably with the introduction of irinotecan and oxaliplatin. Furthermore, the oral fluoropyrimidine capecitabine has demonstrated efficacy in Phase III trials and recently was approved for first-line treatment in Europe and the United States. Capecitabine yielded similar median times to disease progression and median survival rates compared with bolus 5-fluorouracil (5-FU)/leucovorin (LV) (Mayo Clinic/North Central Cancer Treatment Group regimen), with superior and similar response rates, respectively. However, its role as a first-line, single-agent substitute for intermittent infusional 5-FU/LV remains to be defined. The addition of irinotecan or oxaliplatin to 5-FU/LV resulted in improved response rates and progression-free survival in large, randomized trials; moreover, irinotecan-containing regimens resulted in improved overall survival. Prevalent regimens of irinotecan/5-FU/LV and oxaliplatin/5-FU/LV have been compared in two randomized Phase III trials. One study demonstrated the statistical superiority of oxaliplatin/infusional 5-FU/LV over irinotecan/bolus 5-FU/LV in terms of response, time to disease progression, and median survival; however, those advantages may have been attributable to infusional administration or to major differences in second-line therapy. A randomized Phase III study comparing irinotecan and oxaliplatin in combination with the same infusional 5-FU/LV regimens and crossover in case of disease progression showed equivalent efficacy for both schedules in the first-line setting, but the irinotecan combination proved beneficial in terms of safety. New molecular targeted agents, such as angiogenesis-modulating compounds (e.g., bevacizumab) and epidermal growth factor receptor inhibitors (e.g., cetuximab), are under clinical investigation. This review updates current systemic frontline treatments and future perspectives for patients with advanced colorectal carcinoma.