I. Surgical treatment
Updates to the recommendations for older CRC patients undergoing surgery include the following.
1. Programs should identify patients who require geriatric specialist involvement and those for whom co-morbidities and frailty factors pose a risk.
2. Formal genetic evaluation should be considered, and if not feasible, a rapid screening tool for frailty could be used.
3. Pre-rehabilitation treatment should be considered, which may include correction of malnutrition if necessary, optimal treatment of cardiovascular and pulmonary co-morbidities, and medication use.
4. For patients requiring rehabilitation, major resection should be postponed and emergency surgery avoided.
5.Emergency surgery should be performed minimally. In case of obstructive disease, alternative means such as respiratory hole or stent construction must be considered if cure is not the goal.
6, The location of the breathing hole and the results after construction must be carefully considered.
7, An emergency operation combined with a major resection or combination therapy should be avoided within a short time frame.
8.Patients (especially high-risk patients) and their families need to be informed of the risks, possible functional impairment and oncological outcomes of a treatment plan before agreeing to it.
9. Alternative treatment plans should be offered to high-risk patients, ranging from treatment for uncontrolled tumors to palliative care to complete treatment. Ideally, if serious complications occur, the patient’s preferred option should be discussed.
II. Adjuvant chemotherapy
It is difficult to draw a clear conclusion from clinical data regarding the use of oxaliplatin-based adjuvant therapy in elderly patients. Certainly, the assessment of the remaining life span (without recurrence), and the cost/benefit ratio of adjuvant chemotherapy are factors to be considered. What is clear is that.
1. for adjuvant treatment of stage III colon cancer, XELOX and FOLFOX are used as standard treatment options. However, there is uncertainty about the use of this drug for patients older than 70 years of age.
Given the increase in serious adverse events (AEs) associated with combination chemotherapeutic agents, the use of combination therapy including oxaliplatin or fluoropyrimidine alone in elderly patients should depend on the clinical judgment of the treating physician and the individual patient’s risk of recurrence. The use of oxaliplatin has had little effect, and most of the effect continues to come from fluoropyrimidines.
Fluoropyrimidine, 5-FU/LV or capecitabine alone is an appropriate adjuvant therapy for many patients aged 70 years and older.
4, The effectiveness of adjuvant chemotherapy for stage II colon cancer is controversial for patients of all ages.
5. It is worth emphasizing that adjuvant chemotherapy data from clinical trials are not always representative of the older patients seen in clinical practice every day.
III. Palliative chemotherapy
The data suggest that.
1, specific elderly patients can benefit from systemic cytotoxic combination therapy.
2. In the treatment of patients with mCRC, age should not be used as a separate criterion to exclude new targeted agents.
3, After using bevacizumab or cetuximab plus full-dose combination chemotherapy, those older patients included in clinical trials performed similarly to younger patients in terms of levels of RR and PFS. However, there is a lack of data to confirm whether this yields significant patient-related efficacy, such as prolonged survival with an acceptable quality of life.
4. For elderly patients who are not suitable for the above treatment regimens, low-intensity regimens such as reduced-dose oxaliplatin plus 5-FU, or low-dose capecitabine should be used.
4. Rectal cancer: preoperative and palliative radiotherapy for elderly patients
If radical surgery is planned, the following points should be taken into consideration.
1, RT (5 x 5 Gy) and immediate surgery (2-3 days), or long-term CRT 6-8 weeks prior to cancer surgery, such cases require 3D graphic reconstruction MRI-based prediction that the tumor is < span="">not a threat to the rectal mesenteric fascia (<1 mm).
Although preoperative long-term RT alone is not as effective as long-term CRT for local control, it can still be used as an alternative treatment when the safety of chemotherapy is taken into account.
Long-term CRT can be a therapeutic option for appropriate older adults if the tumor cannot be eradicated locally or if MRI predicts a threat to the rectal mesenteric fascia.
4, If CRT is followed by tumor shrinkage and departure from MRF, sufficient time interval is needed to generate an adequate response. Although the optimal time interval is not determined, most cases consider 6-12 weeks to be a reasonable time interval.
5. In elderly or frail patients, 5 x 5 Gy preoperative radiotherapy with a delay of 6-8 weeks (or longer) for surgery.
6. In the case of advanced tumors, EBRT can be used to manage non-surgical patients with low-grade rectal cancer (all stages).
7. For elderly patients with rectal cancer, HDR-short-range radiation therapy or contact therapy are promising technical tools. But it cannot be used for anal canal cancer.
V. Summary conclusions and recommendations
Based on the updated data in the article, the SIOG working group summarizes and gives the following recommendations to elderly patients with colorectal cancer.
1. The inclusion of the concept of individual therapy is absolutely necessary for further improvement in these patients.
2. Combination chemotherapy is the key to individualized treatment for elderly patients.
The treatment of many elderly patients with colorectal cancer is challenging, and it is particularly important to use some comprehensive genetic evaluation to inform clinical decisions.
Guidelines are urgently needed to support surgical, medical, and radiation oncology treatment of older patients, including a formal assessment of the risk/benefit of multiple therapeutic interventions.
Whenever possible, tailored information needs to be provided in an acceptable manner for patients to support and participate in the initial decision making process in order to achieve optimal treatment.
6. In the event of serious complications or treatment failure, the likelihood of death and treatment options should be discussed in advance.
7. Investigators should not only be encouraged to design trials of less toxic treatments so that such treatments can maintain most of the effects of full-dose therapy, but also to establish patient-centered evaluation systems and expand evidence-based databases of older colorectal cancer patients.