Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Systemic chemotherapy for cancer in elderly persons

Stuart M Lichtman, MD
Section Editors
Paul J Hesketh, MD
Kenneth E Schmader, MD
Deputy Editor
Sadhna R Vora, MD


People 65 years or older are the fastest growing segment of the population in the United States [1]. By 2030, this group will comprise about 20 percent of the total population, and among elderly persons, the percentage of patients >75 and >85 years old will increase disproportionately. A similar aging of the population is present in Western Europe and Japan.

The importance of this demographic increase in the number of elderly persons is magnified by the sharp rise in the incidence of most types of cancer after age 60 years. Currently, approximately 50 percent of all cancers and 70 percent of cancer deaths occur in those ≥65 years old, and this fraction is expected to increase [1,2].

Despite the frequency with which cancer occurs in the elderly population, this group is significantly underrepresented in clinical trials [3-5]. Elderly patients who are enrolled in clinical trials represent a carefully selected subset. A systematic review of 345 cooperative group trials found no evidence of poorer survival or increased treatment-related mortality with experimental treatments compared with younger patients, despite concerns about an increased risk of toxicity [4].

Even when substantial numbers of older patients are included, the results cannot be extrapolated to the entire elderly population. Patients with a poor performance status or renal, hepatic, or bone marrow dysfunction generally have been excluded, thus raising questions about the general applicability of data derived from such trials. This is particularly true for patients over 80 years.

Challenges specific to older patients with advanced cancer and the treatment of common malignancies in the elderly population will be reviewed here. Detailed discussions of the therapy of specific malignancies are presented separately, and additional information on specific chemotherapy drugs can be found in the UpToDate drug database.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 23, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Yancik R, Ries LA. Cancer in older persons: an international issue in an aging world. Semin Oncol 2004; 31:128.
  2. Lichtman SM. Therapy insight: Therapeutic challenges in the treatment of elderly cancer patients. Nat Clin Pract Oncol 2006; 3:86.
  3. Yee KW, Pater JL, Pho L, et al. Enrollment of older patients in cancer treatment trials in Canada: why is age a barrier? J Clin Oncol 2003; 21:1618.
  4. Kumar A, Soares HP, Balducci L, et al. Treatment tolerance and efficacy in geriatric oncology: a systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups. J Clin Oncol 2007; 25:1272.
  5. Scher KS, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol 2012; 30:2036.
  6. Sawhney R, Sehl M, Naeim A. Physiologic aspects of aging: impact on cancer management and decision making, part I. Cancer J 2005; 11:449.
  7. Sehl M, Sawhney R, Naeim A. Physiologic aspects of aging: impact on cancer management and decision making, part II. Cancer J 2005; 11:461.
  8. Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 1998; 147:755.
  9. Kim TN, Yang SJ, Yoo HJ, et al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: the Korean sarcopenic obesity study. Int J Obes (Lond) 2009; 33:885.
  10. Rolland Y, Lauwers-Cances V, Cristini C, et al. Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: the EPIDOS (EPIDemiologie de l'OSteoporose) Study. Am J Clin Nutr 2009; 89:1895.
  11. Yancik R, Ries LA. Cancer in older persons. Magnitude of the problem--how do we apply what we know? Cancer 1994; 74:1995.
  12. Yancik R, Wesley MN, Ries LA, et al. Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study. Cancer 1998; 82:2123.
  13. Yellen SB, Cella DF, Leslie WT. Age and clinical decision making in oncology patients. J Natl Cancer Inst 1994; 86:1766.
  14. Sanoff HK, Goldberg RM, Pignone MP. A systematic review of the use of quality of life measures in colorectal cancer research with attention to outcomes in elderly patients. Clin Colorectal Cancer 2007; 6:700.
  15. Launay-Vacher V, Chatelut E, Lichtman SM, et al. Renal insufficiency in elderly cancer patients: International Society of Geriatric Oncology clinical practice recommendations. Ann Oncol 2007; 18:1314.
  16. Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med 2003; 163:356.
  17. Launay-Vacher V, Oudard S, Janus N, et al. Prevalence of Renal Insufficiency in cancer patients and implications for anticancer drug management: the renal insufficiency and anticancer medications (IRMA) study. Cancer 2007; 110:1376.
  18. Egorin MJ. Cancer pharmacology in the elderly. Semin Oncol 1993; 20:43.
  19. Baker SD, Grochow LB. Pharmacology of cancer chemotherapy in the older person. Clin Geriatr Med 1997; 13:169.
  20. Schrijvers D, Highley M, De Bruyn E, et al. Role of red blood cells in pharmacokinetics of chemotherapeutic agents. Anticancer Drugs 1999; 10:147.
  21. Partridge AH, Wang PS, Winer EP, Avorn J. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol 2003; 21:602.
  22. Partridge AH, Avorn J, Wang PS, Winer EP. Adherence to therapy with oral antineoplastic agents. J Natl Cancer Inst 2002; 94:652.
  23. Partridge AH, LaFountain A, Mayer E, et al. Adherence to initial adjuvant anastrozole therapy among women with early-stage breast cancer. J Clin Oncol 2008; 26:556.
  24. Hamerman D. Toward an understanding of frailty. Ann Intern Med 1999; 130:945.
  25. Lichtman SM, Wildiers H, Launay-Vacher V, et al. International Society of Geriatric Oncology (SIOG) recommendations for the adjustment of dosing in elderly cancer patients with renal insufficiency. Eur J Cancer 2007; 43:14.
  26. Lichtman SM, Cirrincione CT, Hurria A, et al. Effect of Pretreatment Renal Function on Treatment and Clinical Outcomes in the Adjuvant Treatment of Older Women With Breast Cancer: Alliance A171201, an Ancillary Study of CALGB/CTSU 49907. J Clin Oncol 2016; 34:699.
  27. Baraldi-Junkins CA, Beck AC, Rothstein G. Hematopoiesis and cytokines. Relevance to cancer and aging. Hematol Oncol Clin North Am 2000; 14:45.
  28. Dees EC, O'Reilly S, Goodman SN, et al. A prospective pharmacologic evaluation of age-related toxicity of adjuvant chemotherapy in women with breast cancer. Cancer Invest 2000; 18:521.
  29. Gómez H, Mas L, Casanova L, et al. Elderly patients with aggressive non-Hodgkin's lymphoma treated with CHOP chemotherapy plus granulocyte-macrophage colony-stimulating factor: identification of two age subgroups with differing hematologic toxicity. J Clin Oncol 1998; 16:2352.
  30. Schild SE, Stella PJ, Geyer SM, et al. The outcome of combined-modality therapy for stage III non-small-cell lung cancer in the elderly. J Clin Oncol 2003; 21:3201.
  31. Crivellari D, Bonetti M, Castiglione-Gertsch M, et al. Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breast cancer: the International Breast Cancer Study Group Trial VII. J Clin Oncol 2000; 18:1412.
  32. Smith TJ, Khatcheressian J, Lyman GH, et al. 2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 24:3187.
  33. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  34. Anía BJ, Suman VJ, Fairbanks VF, et al. Incidence of anemia in older people: an epidemiologic study in a well defined population. J Am Geriatr Soc 1997; 45:825.
  35. Chaves PH, Ashar B, Guralnik JM, Fried LP. Looking at the relationship between hemoglobin concentration and prevalent mobility difficulty in older women. Should the criteria currently used to define anemia in older people be reevaluated? J Am Geriatr Soc 2002; 50:1257.
  36. Anía BJ, Suman VJ, Fairbanks VF, Melton LJ 3rd. Prevalence of anemia in medical practice: community versus referral patients. Mayo Clin Proc 1994; 69:730.
  37. Hershman DL, McBride RB, Eisenberger A, et al. Doxorubicin, cardiac risk factors, and cardiac toxicity in elderly patients with diffuse B-cell non-Hodgkin's lymphoma. J Clin Oncol 2008; 26:3159.
  38. Carver JR, Schuster SJ, Glick JH. Doxorubicin cardiotoxicity in the elderly: old drugs and new opportunities. J Clin Oncol 2008; 26:3122.
  39. Vestal RE. Aging and pharmacology. Cancer 1997; 80:1302.
  40. Kivistö KT, Kroemer HK, Eichelbaum M. The role of human cytochrome P450 enzymes in the metabolism of anticancer agents: implications for drug interactions. Br J Clin Pharmacol 1995; 40:523.
  41. Tam-McDevitt J. Polypharmacy, aging, and cancer. Oncology (Williston Park) 2008; 22:1052.
  42. Partridge AH. Non-adherence to endocrine therapy for breast cancer. Ann Oncol 2006; 17:183.
  43. Chrischilles EA, Pendergast JF, Kahn KL, et al. Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer. J Clin Oncol 2010; 28:620.
  44. Rockwood K, Stadnyk K, MacKnight C, et al. A brief clinical instrument to classify frailty in elderly people. Lancet 1999; 353:205.
  45. Repetto L, Comandini D, Mammoliti S. Life expectancy, comorbidity and quality of life: the treatment equation in the older cancer patients. Crit Rev Oncol Hematol 2001; 37:147.
  46. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146.
  47. Balducci L, Stanta G. Cancer in the frail patient. A coming epidemic. Hematol Oncol Clin North Am 2000; 14:235.
  48. Rodin MB, Mohile SG. A practical approach to geriatric assessment in oncology. J Clin Oncol 2007; 25:1936.
  49. Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 2007; 25:1824.
  50. Goldberg RM, Tabah-Fisch I, Bleiberg H, et al. Pooled analysis of safety and efficacy of oxaliplatin plus fluorouracil/leucovorin administered bimonthly in elderly patients with colorectal cancer. J Clin Oncol 2006; 24:4085.
  51. Freyer G, Geay JF, Touzet S, et al. Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: a GINECO study. Ann Oncol 2005; 16:1795.
  52. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer 2012; 118:3377.
  53. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011; 29:3457.
  54. Extermann M, Bonetti M, Sledge GW, et al. MAX2--a convenient index to estimate the average per patient risk for chemotherapy toxicity; validation in ECOG trials. Eur J Cancer 2004; 40:1193.
  55. Ramjaun A, Nassif MO, Krotneva S, et al. Improved targeting of cancer care for older patients: a systematic review of the utility of comprehensive geriatric assessment. J Geriatr Oncol 2013; 4:271.
  56. Hurria A, Mohile S, Gajra A, et al. Validation of a Prediction Tool for Chemotherapy Toxicity in Older Adults With Cancer. J Clin Oncol 2016; 34:2366.
  57. Soubeyran P, Fonck M, Blanc-Bisson C, et al. Predictors of early death risk in older patients treated with first-line chemotherapy for cancer. J Clin Oncol 2012; 30:1829.
  58. Carlson RW, Moench S, Hurria A, et al. NCCN Task Force Report: breast cancer in the older woman. J Natl Compr Canc Netw 2008; 6 Suppl 4:S1.
  59. Rougier P, Van Cutsem E, Bajetta E, et al. Randomised trial of irinotecan versus fluorouracil by continuous infusion after fluorouracil failure in patients with metastatic colorectal cancer. Lancet 1998; 352:1407.
  60. Fuchs CS, Moore MR, Harker G, et al. Phase III comparison of two irinotecan dosing regimens in second-line therapy of metastatic colorectal cancer. J Clin Oncol 2003; 21:807.
  61. Hardy D, Liu CC, Cormier JN, et al. Cardiac toxicity in association with chemotherapy and radiation therapy in a large cohort of older patients with non-small-cell lung cancer. Ann Oncol 2010; 21:1825.
  62. Pallis AG, Shepherd FA, Lacombe D, Gridelli C. Treatment of small-cell lung cancer in elderly patients. Cancer 2010; 116:1192.
  63. Chan KK, Siu E, Krahn MD, et al. Cost-utility analysis of primary prophylaxis versus secondary prophylaxis with granulocyte colony-stimulating factor in elderly patients with diffuse aggressive lymphoma receiving curative-intent chemotherapy. J Clin Oncol 2012; 30:1064.
Topic Outline