Colorectal cancer (CRC) is one of the most common cancers worldwide. Approximately 60% of patients are older than 70 years of age and more than 40% are older than 75 years of age, and these rates are likely to increase in the future.
These patients often have other co-morbidities and are frail. Due to the lack of evidence-based medical evidence, treatments that are considered “standard” may not be appropriate for this group of patients.
For this reason, the International Society of Geriatric Oncology (SIOG) group meeting was updated based on recent literature and personal experience, and on existing consensus on the treatment of elderly colorectal cancer patients.
The discussion at this working group meeting focused on five areas: 1. patient assessment; 2. surgical treatment; 3. adjuvant chemotherapy; 4. palliative chemotherapy; and 5. preoperative or palliative radiotherapy for rectal cancer. The relevant content of the consensus was published in the Annals of Oncology in July 2014.
I. Patient assessment.
Geriatric assessment includes the patient’s functional status, concomitant diseases, multiple medications, nutritional status, cognitive function, emotional function, and social support. The consensus is that geriatric assessment may benefit patients, but the specific role of geriatric assessment in cancer care needs further study.
II. Surgical treatment
Surgical treatment is the main treatment modality for colorectal cancer. The improvement in survival of colorectal cancer patients is largely attributed to the reduction in postoperative mortality, which also includes the resection of liver metastases in selected patients.
Compared to younger patients, older patients have less survival benefit. This difference is mainly due to the higher early postoperative mortality in elderly patients, and therefore the treatment of elderly colorectal cancer patients requires an emphasis on perioperative care and the first postoperative year.
It is also particularly important to choose the optimal surgical approach based on the physical and mental status of the elderly individual and the surgical risk factors.
Therefore the recommendations for elderly colorectal cancer patients undergoing surgery are updated as follows.
Programs should determine which patients require geriatric specialist involvement and which patients have concomitant disease and frailty factors that pose a risk.
A formal geriatric status assessment should be considered, and if this is not feasible, a tool for rapid screening to evaluate frailty can be used.
Preoperative rehabilitation should be considered and may include correction of malnutrition, if necessary, to optimize treatment of concomitant diseases such as cardiopulmonary and medication use.
For patients requiring preoperative rehabilitation, larger resections should be postponed and emergency surgery should be avoided.
Emergency surgery should be performed minimally, and when obstructive disease is encountered, alternative means such as fistula or stent placement must be considered if a cure cannot be achieved.
The location of the fistula opening and the consequences of fistula must be carefully considered.
Avoid the combination of emergency operations and major resections or combination treatments in a short period of time.
Patients (especially high-risk patients) and their families need to be informed of the risks of treatment, possible functional impairment and tumor outcome before they consent to treatment.
Alternative treatment options should be offered to high-risk patients, ranging from non-tumor-controlling treatment to palliative care to complete treatment. Ideally, the patient’s preferred treatment options in the event of serious complications are discussed in advance.
III. Adjuvant chemotherapy
According to three adjuvant studies (MOSAIC, NSABP-C-07 and XELOXA), oxaliplatin-based combination chemotherapy is considered the standard of care for patients with stage III colon cancer.
However, based on the available data, it is difficult to draw definitive conclusions about the use of oxaliplatin-based adjuvant chemotherapy in elderly patients. Certainly, the assessment of remaining survival years (recurrence-free) and its impact on the cost/benefit ratio of adjuvant therapy in elderly patients needs to be considered. What is clear is that.
XELOX and FOLFOX are considered standard adjuvant therapy for stage III colon cancer, but there is no clear evidence of benefit for their use in patients over 70 years of age.
Given the increased incidence of serious adverse events associated with combination chemotherapeutic agents, the application of combination therapy including oxaliplatin or fluoropyrimidine monotherapy in elderly patients should depend on the clinical judgment of the treating physician and the patient’s risk of recurrence. The benefit of combination oxaliplatin is limited and most of the efficacy remains with fluoropyrimidine.
The application of fluoropyrimidine monotherapy, fluorouracil/calcium folinic acid or capecitabine, is an appropriate adjuvant regimen for many patients over 70 years of age.
The efficacy of adjuvant chemotherapy in patients with stage II colon cancer is controversial in all age groups.
It is important to emphasize that adjuvant chemotherapy data are from clinical trials in which patients are not necessarily universally representative.
IV. Palliative chemotherapy
In elderly colorectal cancer patients, the survival benefit from different drugs or drug combinations is very limited. However, the cumulative survival benefit from the combination or sequential application of different drugs is more important at different ages. The application of fluorouracil (fluorouracil/calcium folinic acid or capecitabine) may provide a clear benefit in older patients.
The addition of irinotecan, oxaliplatin, and targeted agents provided very limited benefit due to dose intensity limitations and poor benefit/risk ratios. Further analysis revealed that these limited benefits were mainly generated in older patients with a better general condition. The data showed that.
Older patients in better health can benefit from systemic cytotoxic combination therapy.
Age should not be used as a separate exclusion criterion when applying new targeted agents in the treatment of patients with metastatic colorectal cancer.
Elderly patients enrolled in clinical trials after the use of bevacizumab or cetuximab plus full-dose combination chemotherapy performed comparably to younger patients in terms of RR and PFS. However, there is a lack of data on whether this translates into significant patient-related benefits, such as improved survival with acceptable quality of life.
For older patients who are not suitable for the above treatment regimens, low intensity regimens such as reduced dose oxaliplatin combined with 5-FU or low dose capecitabine combined with bevacizumab can be applied.
V. Rectal cancer: preoperative or palliative radiotherapy
Both preoperative radiotherapy and preoperative short-course radiotherapy are standard preoperative treatments for intermediate-risk or locally advanced rectal cancer, and adjuvant chemotherapy may be applied in selected patients after surgery. Since radical surgery is more rarely performed in older patients, palliative radiotherapy is used more often than preoperative radiotherapy.
However, if radical surgery is planned, the following points need to be considered.
Immediate surgery (2-3 days) after a short course of radiotherapy (5 x 5 Gy) or a long course of radiotherapy before 6-8 weeks of surgery is required to rule out rectal mesenteric fascia (<1 mm) invasion based on MRI 3D reconstruction graphic prediction. < span="">
Although preoperative long-term radiotherapy alone is not as effective as long-term radiotherapy for local control, it can still be used as an alternative if the safety of chemotherapy is taken into account.
For tumors that are not locally resectable radically, or where MRI predicts invasion of the rectal mesenteric fascia, long course radiotherapy may be a treatment option.
If the tumor needs to shrink and leave the mesenteric fascia after radiotherapy, a sufficient time interval is needed to wait for the efficacy to be achieved. Although the optimal time interval has not been defined, 6-12 weeks is often considered to be appropriate.
For very old or frail patients, preoperative 5 x 5 Gy radiation therapy followed by a delay of 6-8 weeks (or more) for surgery may be an option.
In the palliative treatment of advanced tumors, external radiation radiotherapy can be used to treat non-operative patients with low-grade rectal cancer (all stages).
For elderly rectal cancer patients, high-dose-rate short-distance radiation therapy or contact therapy are promising, but not for anal canal cancer.