Treatment of Colorectal Cancer in Older Patients: International Society of Geriatric Oncology (SIOG) Consensus Recommendations 2013

D. Papamichael; R. A. Audisio; B. Glimelius; A. de Gramont; R. Glynne-Jones; D. Haller; C.-H. Köhne; S. Rostoft; V. Lemmens; E. Mitry; H. Rutten; D. Sargent; J. Sastre; M. Seymour; N. Starling; E. Van Cutsem; M. Aapro

Disclosures

Ann Oncol. 2015;26(3):463-476. 

In This Article

Abstract and Introduction

Abstract

Colorectal cancer (CRC) is one of the most commonly diagnosed cancers in Europe and worldwide, with the peak incidence in patients >70 years of age. However, as the treatment algorithms for the treatment of patients with CRC become ever more complex, it is clear that a significant percentage of older CRC patients (>70 years) are being less than optimally treated. This document provides a summary of an International Society of Geriatric Oncology (SIOG) task force meeting convened in Paris in 2013 to update the existing expert recommendations for the treatment of older (geriatric) CRC patients published in 2009 and includes overviews of the recent data on epidemiology, geriatric assessment as it relates to surgery and oncology, and the ability of older CRC patients to tolerate surgery, adjuvant chemotherapy, treatment of their metastatic disease including palliative chemotherapy with and without the use of the biologics, and finally the use of adjuvant and palliative radiotherapy in the treatment of older rectal cancer patients. An overview of each area was presented by one of the task force experts and comments invited from other task force members.

Introduction

Colorectal cancer (CRC) is one of the most commonly diagnosed cancers worldwide.[1] There are marked differences in incidence trends between countries, with the total number of cases affected both by changes in individual risk at a given age (the age-standardized rate, ASR) and by the changing age demographic of the population.

In the USA, the ASR fell by over 30% between 1975 and 2010, perhaps reflecting lifestyle changes and the uptake of opportunistic screening,[2] while rates in Canada, New Zealand and elsewhere were broadly stable.[3] However, over the same period the ASR in the UK, although remaining unchanged in women, rose by 30% in men.[4] Changes in ASRs do not, however, represent the overall burden of disease. The age-specific risk rises markedly with age, and as mortality from heart disease and other non-cancer causes reduces, this leaves an elderly population at high risk of developing bowel cancer. This has major implications for the organization of cancer services: for example, in the UK, the number of new cases of bowel cancer diagnosed in patients >75 years rose by 30%, from 13 400 elderly patients in 1993 to 17 300 in 2010.[5] And, even countries with a stable ASR may see a rising number of cases of CRC in the elderly.

Oncologists and surgeons managing patients with CRC must recognize that ~60% of their patients are >70 years of age and 43% >75 years,[5] that these proportions may increase further, and that many of these older patients will have problems of frailty and comorbidity which demand careful patient assessment and, if necessary, individualized treatment approaches.[6,7]

Currently, the majority of patients with stage I or II CRC are treated and cured by surgery.[8,9] For patients with stage III colon cancer, the standard treatment is surgery followed by adjuvant chemotherapy, whereas for those patients with metastatic CRC (mCRC) systemic chemotherapy alone or in combination with targeted biologics is usually the treatment of choice. Also, increasingly, patients with mCRC are managed within multidisciplinary teams (MDTs) and being considered for surgical resection of their metastatic disease wherever possible.[10] For patients with rectal cancer, treatment may involve surgery alone, preoperative short-course radiation therapy (SCPRT), or chemoradiotherapy (CRT) with surgical resection followed by postoperative adjuvant chemotherapy in selected patients.

Comorbidity, functional dependency, and older age are associated with early postoperative mortality in patients with gastrointestinal malignancies, with 30-day postoperative mortality rates underestimating postoperative mortality in older patients.[11] The International Society of Geriatric Oncology (SIOG) previously recommended that CRC patients >65 years of age requiring surgery should undergo a preoperative whole patient evaluation of the most common physiological side-effects of aging, physical and mental ability, and social support.[12] Furthermore, for those patients assessed as having physical or psychological comorbidities, it was recommended that 'a geriatrician was involved in patient management'.[12]

One of the major challenges is the physiological heterogeneity of the older patient population with frequent discrepancies between physiological and chronological age coupled with the additional complications of coexisting medical conditions and the potential psychological and social care issues alluded to above. Defining old or elderly patients is challenging. The patient's biological age should ideally be established through a comprehensive geriatric assessment in order to aid therapeutic decisions. There is a paucity of clinical trial data for these patients in terms of their poor functional reserves, major comorbidities, and frailty. Indeed, there is a huge debate in the literature about how to define frail patients and how to differentiate frailty from comorbidity and disability.[13–16] Experts anticipate that, by distinguishing the fit from the more vulnerable older patients, treatment can be adjusted to maximize its effectiveness, avoid complications, and better meet the individual requirements of the older patient. It is against this backdrop that SIOG convened a task force meeting to review and update their existing recommendations for the treatment of older patients with CRC,[12] based on recent publications and personal experience.

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