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Clinical Conundrum: When, how to treat colorectal cancer in the elderly

elderly researchingEven as scientists plumb deep into cells and molecules to understand cancer, there are many immediate and “real-life” questions that researchers and clinicians are discussing at the 2013 annual ASCO meeting (American Society of Clinical Oncology).

One of the biggest puzzles for colorectal cancer is how to best treat the elderly, especially those with stages II or III (non-metastatic) cancer. It’s a huge question: today, 40 percent of colorectal cancer patients are elderly, and by the year 2030, more than 70 percent of non-inherited colorectal cancer will be among those 65 or older.

Currently, 70 years old is the median age at diagnosis, with fully 40 percent of diagnoses made in people over age 75. Yet when oncologists must consider, and explain, the risks versus benefits for treating colorectal cancer—especial stages II or III—in the elderly, there’s not enough research evidence to back informed decisions in that age group.

Lack of evidence, but elderly get chemo less often

Colorectal cancer clinical trials only enroll a minority of over-65s—and with the way current trials are designed, those probably  are the healthiest of seniors, wrote Dr. Richard Goldberg, a member of Fight Colorectal Cancer’s Medical Advisory Board, and his colleague Dr. Christina Wu also from Ohio State University, in a careful review of existing evidence. Their article, “Managing Choices for Older Patient with Colon Cancer,” one of just 133 articles among the hundreds selected for the 2013 ASCO Educational Book.

We do know that elderly patients get chemotherapy significantly less often than younger patients, according population-wide studies of patients in community practices, the authors wrote. One study found that only 58% of older-65s received chemo, compared to 84% of patients under 65.

But “it’s a disservice to classify patients based on their ..age alone,” Drs. Wu and Goldberg wrote. Doctors and patients must consider physiologic differences that can affect tolerance for chemo (e.g. body fat vs. muscle body composition; heart, liver and kidney function). Common medications (e.g. blood-thinners) can interact with chemo. Seniors who have neuropathy (i.e., numbness in feet) from diabetes or spinal stenosis perhaps shouldn’t try Eloxitin® (oxaliplatin) in the FOLFOX chemo regimen.

Life quality–and length

elderly working outFor elderly patients, other facts affecting treatment choices include social support—such as whether a person lives alone, and can drive or get a ride to treatments—and especially the individual’s desires for quality versus length of life.

Another paper presented at 2013 ASCO notes considerations of life-expectancy—how long the patient might expect to live—might challenge some stereotypes among both doctors and patients. In 65-year-old people (a common age for diagnosis), women have an average 18 more years of life, and men have about 14 more years. And an individual’s level of basic fitness makes a huge difference, the authors note: A healthy, fit 75-year-old man has a life expectancy of more than 14 years compared to barely 5 years for a frail 75-year-old man.

In their summary, Drs. Wu and Goldberg concluded:

“Analyses of available data in older patients…show that, as a group, they may not benefit from adjuvant chemotherapy regimens containing [Eloxitin] oxaliplatin, or at least benefit as much as younger patients. Although older patients do appear to benefit from adjuvant FOLFOX in stage III disease…the benefit is less than that observed in younger patients….It is likely that some of the fit elderly will gain value from oxaliplatin-based regimens. In advising patients, clinicians should remember that the incremental benefit from 5FU-based adjuvant therapy overshadows the incremental benefit from adding oxaliplatin to those regimens, while avoiding long-term issues with peripheral neuropathy.”

 Dr. Goldberg told Fight Colorectal Cancer, “It is particularly important for older patients to maintain very close communication with their medical team with regard to goals and priorities, as well as treatment-related side effects so that prompt and effective management of side effects can be instituted to avert modest effects from transforming into potentially serious and treatment-limiting issues. Enrollment in clinical trials is needed to help us understand management issues in older patients better. “

Patient take-away

If you are a senior, or have a parent diagnosed with colorectal cancer, know that especially for stage II and some stage III cancers, you should take time with your oncologist to balance risks and benefits, based on your personal level of fitness irrespective of age, plus other conditions, medicines, and especially personal goals.

Sources:

 Disclosure: Fight Colorectal Cancer has accepted funding for projects and educational programs from sanofi-aventis in the form of unrestricted educational grants. Fight Colorectal Cancer has ultimate authority over website content. See the Fight Colorectal Cancer Funding Policy and Disclosure.

 

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