CT colonography (virtual colonoscopy) found more than twice the rate of large polyps or cancer in patients 65 and older compared to everyone being screened for colorectal cancer using the radiology-based test.

About one in six older patients was referred for an optical colonoscopy based on findings from the scans.

There were no major complications including colon perforations or bleeding, from either the CT procedure or the follow-up colonoscopy.

Researchers at the University of Wisconsin reviewed results of 577 people from 65 to 79 tested in the university’s CT colonography screening program and found either an advanced adenoma or cancer in 44 (7.6 percent).  There were 5 cancers detected.

The rate of advanced neoplasia (advanced adenoma or cancer) for all the patients screened in the program, young and old, was 3.2 percent.

The percentage of older patients who were referred for an optical colonoscopy was about twice that of those under 65 — 15.3 percent of patients 65 and older, 7.6 percent of younger people.  Optical colonoscopy confirmed the positive CT findings in all but 4 percent of cases, not verifying 3.6 percent of smaller polyps measuring 6 to 10 mm and 2.1 percent of those larger than 10 mm.

The scans also found potential problems outside the colon in 89 patients, 45 of whom needed additional medical studies.  Workups discovered 21 previously undetected abnormalities including a lung cancer and 18 aneurysms.

The authors point out the the study was retrospective, looking back at experience in their program, and that negative findings were not verified by an optical colonoscopy.

Last year, the Centers for Medicare and Medicaid Services (CMS) declined coverage of screening colonoscopy for Medicare beneficiaries, stating lack of evidence for its effectiveness in people 65 and older.  CMS was also concerned that CT colonography identifies issues outside the colon which require additional medical follow-up and may not be serious medical problems.

David H. Kim, MD and his colleagues at the University of Wisconsin concluded,

CT colonography is a safe and effective screening modality for the older population.

SOURCE:  Kim et al., Radiology, Volume 254, pp 493-500, February 2010.

Update from 2010 GI Cancers Symposium

Colon cancer patients over 70 actually had a greater reduction in disease-free survival than did younger ones with a new regimen of Xeloda® and oxaliplatin compared to older IV 5-FU treatments according to a new analysis reported at the GI Cancers Symposium in Orlando.

With the bolus IV 5-FU and leucovorin regimens, stage III colon cancer patients over 70 had about a 60 percent chance of being alive and free from cancer three years after surgery. With a combination of Xeloda (capecitabine) and oxaliplatin in a treatment called XELOX, their three-year disease-free survival was 66 percent.

Younger patients had about a 3 percent absolute improvement between the two treatments from 69 percent to 72 percent.

The Xeloxa clinical trial compared the oral drug Xeloda plus intravenous oxaliplatin to then standard IV 5-FU and leucovorin regimens after surgery for stage III colon cancer. The trial (NO16968) enrolled nearly 1,900 patients, including more than 400 who were age 70 and over.

After three years, there was a six percentage point increase in disease-free survival in the older patients. The spread remained true when the cut-off age was dropped to 65. Patients 65 and older had a 62 percent chance of disease-free survival at three years on the older 5-FU treatments compared to 68 percent on the XELOX regimen.

Speaking during a GI Symposium press briefing, Daniel G Haller, MD, of the University of Pennsylvania, said,

XELOX is a new standard of care for patients with early colon cancer, regardless of age. Patients receiving XELOX immediately after surgery live disease-free for longer, and there is a trend towards superior overall survival with XELOX.

SOURCE: Haller et al., Efficacy findings from a randomized phase III trial of capecitabine plus oxaliplatin versus bolus 5-FU/LV for stage III colon cancer (NO16968): No impact of age on disease-free survival (DFS), Abstract #284, 2010 GI Cancers Symposium.

Disclosure: C3 has accepted funding for projects and educational programs from Roche and sanofi-aventis in the form of unrestricted educational grants. C3 has ultimate authority over website content.

Briefly

Factors related to the patient, year of surgery, and tumor itself and not surgeons or pathologists explain low lymph node counts after colon and rectal surgery.  Lack of colorectal cancer screening leads to emergency surgery and complications and death among the elderly.

Americans without health insurance are more likely to die, even when factors like overall health, smoking, and income are considered, and cancer patients who have support from family and friends at diagnosis are much more likely to look on the entire experience as a chance for positive growth years later.

Finally, FDA has a good video to help people avoid health care frauds.

Happy Holidays.  Enjoy family, friends, and lights.

Research Highlights

• Why are too few colon cancer lymph nodes tested?  Is it the surgeon removing too few or the pathologist not examining them all?  Or something entirely different?  Reviewing lymph node reports from 430 colon cancer patients operated on in one large hospital in a period just over four years from 2003 through 2007, researchers found no difference among 18 surgeons nor any difference that could be attributed to 10 pathologists or 3 pathology assistants.  Instead, the age of the patient, the site of the tumor, the stage of the cancer, and the year the surgery was done contributed to inadequate lymph node counts.  James W. Jakub, MD, and his team reported their study in the Archives of Surgery, December 2009.
• Lack of colorectal cancer screening leaves elderly patients at risk for emergency surgery when growing cancer blocks or perforates the colon.  About a third (30 percent) of 292 emergency colorectal surgeries in a large university hospital were due to either colon obstruction or perforation.  Fifteen percent of all patients older than 65 who had emergency colorectal surgery died, and 35 percent had at least one serious complication.   In their conclusion in the December 2009 Archives of Surgery, Edward A. McGillicuddy, MD and the Yale University team point out, “These procedures frequently involve locally advanced colorectal cancer, emphasizing the need for improved colorectal cancer screening.”
• When cancer patients receive emotional support in the three months after their diagnosis, they are much more likely to look on their cancer experience as an opportunity for positive growth many years later.  Eight years after diagnosis, cancer survivors who got reassurance, comforting, and help with problem solving from family and friends reported positive outcomes from their illness, what researchers termed posttraumatic growth. Maya J. Schroevers and her team discuss their study in Psycho-Oncology, January 2010.
• Lack of health insurance increases risk of dying, even when other factors like smoking, obesity, income, and overall health are taken into account.   Americans from 17 to 64 who are uninsured are twice as likely to die.  When the Boston research team adjusted their analysis to include race, ethnicity, income, education, body mass index, exercise, smoking, alcohol use, and how both individuals and their doctors rated their health, the uninsured were 40 percent more likely to die than the general population.  The December 2009 issue of the American Journal of Public Health reports the analysis by Andrew P. Wilper, MD, MPH and colleagues.

Other Headlines

• The FDA has a good video to help consumers become aware of health fraud. The Consumer Update shows Internet users how to spot and avoid unproven and unsafe treatments for cancer and increasing fraudulent products to prevent or treat H1N1 flu.  FDA 101: Health Fraud Awareness has more detailed information on common types of health fraud and how to avoid becoming a victim of them.

Colorectal cancer patients 65 and older without other serious medical problems benefitted when Avastin® (bevacizumab) was added to chemotherapy.

Combining results of four randomized clinical trials of Avastin and chemotherapy in patients with advanced colorectal cancer, researchers found that adding Avastin increased both the time older patients lived and the time before their cancer got worse.

Patients who were 70 and older had similar improvements.

There were more serious problems caused by blood clots (thromboembolic events) in patients who got Avastin, mostly related to arterial events.  However, other serious side effects were no more common in older patients than in those who were younger than 65.

Although two-thirds of patients with advanced colorectal cancer are 65 or older and four out of ten are older than 74, older patients are not well represented in clinical trials.  Even when there are no age limits on trials, they may not be enrolled because of other medical problems or a conservative approach to treatment of the elderly.

Therefore, to get a clearer idea of how adding Avastin to chemotherapy affects patients 65 and older, the research team combined information from three first-line and one second-line trial of Avastin and chemotherapy together including 1,100 patients who were 65 or older.

They found that both progression-free survival and overall survival improved when Avastin was added to chemo, and that age made little difference in benefits.

Progression-free survival time with and without Avastin was:

• For those under 65:  6.7 months vs 9.5 months
• Those 65 and older:  6.9 months vs 9.3 months
• Those 70 and older:  6.4 months vs 9.2 months

Overall survival time with and without Avastin was:

• For under 65: 16.5 months vs 19.9 months
• 65 and older:  15.0 months vs 17.9 months
• 70 and older:  14.1 months vs 17.4 months

As patients got older arterial thromoembolytic events (ATE) such as heart attack, stroke, TIA’s, and angina increased with the addition of Avastin.

• Under 65:  no difference in ATEs was found — 2 percent in both Avastin and non-Avastin groups
• 65 and older: 5.7 percent ATE for Avastin compared to 2.5 in non-Avastin group
• 70 and older: 6.7 percent ATE for Avastin, 3.2 with no Avastin

Age made no difference in other serious side effects including bleeding, hypertension, and gastrointestinal perforations.

The study authors point out that patients in clinical trials are carefully chosen and may not reflect the health of a patients in the general population.  They warn that overall health should be carefully assessed before beginning treatment.

James Cassidy and his colleagues wrote,

In conclusion, this pooled analysis of data from phase II and III metastatic colorectal cancer studies demonstrates that bevacizumab in combination with chemotherapy had a similar impact on PFS and OS in protocol-eligible older versus younger patients. Careful patient selection, however, remains important and should include an objective assessment of the patient’s physical and mental status.

SOURCE: Cassidy et al., Journal of Cancer Research and Clinical Oncology, Online First November 10, 2009.
Disclosure: C3 has accepted funding for projects and educational programs from Genentech in the form of unrestricted educational grants. C3 has ultimate authority over website content.

Last week I had a consultation with an older gentleman who is 84 years old. Interestingly, the role of age in the treatment of colon cancer has changed. During my training in Germany in the nineteen eighties when someone came in with metastatic cancer and was older than 65, we rarely gave chemotherapy because we were afraid to make those patients sicker than cancer did.

We have a perception that when someone is old we should be much more gentle and we should adapt treatment not only using less aggressive chemotherapy cocktails but also lower doses.. These perceptions go back to the history of chemotherapy when chemotherapy drugs made most patients very sick and weak. With less toxic chemotherapeutic therapies and much better drugs against nausea and vomiting, our perception needs to be reevaluated.

We have come a long way. We all live longer We can treat many diseases that used to lead to death such as strokes and heart disease, and we have developed much more successful therapies which are often smart drugs not causing the same “old” side effects we often associate with chemotherapy. Many recent studies in Europe and the USA clearly show that patients over 65 or 70 or 75 have the same benefit from chemotherapy that younger patients do, and they do not have more side effects. This clearly shows that treatment options should be discussed with patients of any age.

More and more we talk about biological age. Some patients in their fifties with metastatic cancer are in as good shape as a 85- year- old patient with the same diagnosis. The problem with age is that patients are more likely to have comorbidities such as hypertension, diabetes, or coronary artery disease. These make treatment decisions more complicated, not the age alone. Many of my consultations reflect that patients in their seventies are treated less aggressively based on a perception which is no longer true. Our life expectancy has increased, our treatment options have changed, and we need to include this into our treatment recommendations.

My oldest patient, who was treated with aggressive chemotherapy,was 94 years old. He had no side effects and lived 2 years with controlled disease.

Don’t let age be a decision factor for therapy.

Colon and rectal cancer patients 75 years old and older who are treated with chemotherapy or radiation don’t report any poorer quality of life than older patients who don’t have such therapy.  Patients who had chemotherapy said that their physical functioning was better than that reported by those who didn’t receive chemo.

French patients who were at least 75 responded to questionnaires about their quality of life and emotional health three, six, and twelve months after their diagnoses.  Overall health and emotional functioning improved between the first questionnaire at three months and the twelve month survey for people with colon cancer.  For rectal cancer patients, scores improved between six months and twelve months.

Anne-Marie Bouvier, MD, PhD and her team at the Burgundy Digestive Cancer Registry wrote,

To the authors’ knowledge, the current study is the first to examine trends over time with regard to the influence of adjuvant treatments for colon and rectal cancers on quality of life (QoL) in a general aged population. Providing evidence that adjuvant chemotherapy for colon cancer has no negative impact on the QoL of elderly patients is of great significance in encouraging clinicians to treat this population.

SOURCE: Bouvier et al.,Cancer, Volume 113, Number 4, August 15, 2008.