Adjuvant therapy for resected colon cancer in elderly patients
- Hanna K Sanoff, MD, MPH
Hanna K Sanoff, MD, MPH
- Associate Professor
- University of North Carolina at Chapel Hill
Approximately 134,490 new cases of large bowel cancer are diagnosed each year in the United States, of which 95,270 are colon cancers; the remainder arise in the rectum . Global, country-specific incidence rates for colorectal cancer are available through the World Health Organization GLOBOCAN database.
Age is a major risk factor for colorectal cancer (figure 1) . The median age at diagnosis is 71. Approximately 70 percent of cases develop over the age of 65; 40 percent are 75 years or older. The US Census bureau projects that by the year 2030 the number of Americans over age 65 will double . As a result, the number of patients over the age of 70 presenting for colorectal cancer care is expected to rise.
Surgical resection is the only curative treatment for locoregional colon cancer, and outcome is most closely related to the extent of disease at presentation (table 1 and figure 2) . For patients who have undergone potentially curative resection, disease recurrence is thought to arise from clinically occult micrometastases that are present at the time of surgery. Postoperative (adjuvant) systemic chemotherapy is recommended for high-risk patients to eradicate these micrometastases, thereby increasing the cure rate.
This topic review will cover the benefits, risks, and choice of adjuvant chemotherapy for elderly patients with resected colon cancer. A general discussion of the benefits of adjuvant chemotherapy for resected colon and rectal cancer, surgical management and prognosis of colon cancer, chemotherapy considerations in older individuals with advanced colorectal cancer, a compilation of chemotherapy protocols for colorectal cancer, and recommendations for posttreatment follow-up are discussed separately. (See "Adjuvant therapy for resected stage III (node-positive) colon cancer" and "Adjuvant therapy for resected rectal adenocarcinoma" and "Overview of the management of primary colon cancer" and "Therapy for metastatic colorectal cancer in elderly patients and those with a poor performance status" and "Treatment protocols for small and large bowel cancer" and "Surveillance after colorectal cancer resection".)
CHALLENGES SPECIFIC TO THE ELDERLY
The essential principles of treating colon cancer in the elderly are the same as in younger patients. However, for older patients, who may have age-related organ function decline and comorbid conditions that may limit life expectancy, special attention must be paid to the risks of chemotherapy, including both treatment-related toxicity and quality of life issues.
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- CHALLENGES SPECIFIC TO THE ELDERLY
- Age-related organ function decline
- Comorbid conditions
- Quality of life issues
- Measures of physical function and reserve
- Use of physical function to guide treatment decisions
- OVERVIEW OF STANDARD ADJUVANT CHEMOTHERAPY FOR COLON CANCER
- Choice of regimen
- - Stage III
- - Stage II
- SAFETY AND EFFICACY OF ADJUVANT CHEMOTHERAPY IN THE ELDERLY
- 5-FU plus leucovorin
- - Toxicity
- Oral fluoropyrimidines
- - Capecitabine
- - UFT
- Oxaliplatin-based regimens
- Irinotecan-based regimens, bevacizumab, and cetuximab
- Summary: choice of regimen
- - Chemotherapy dosing in obese patients
- Use of web-based tools for assessing prognosis and benefit from adjuvant therapy
- POSTTREATMENT SURVEILLANCE AND SECONDARY PREVENTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS