Management of Colorectal Cancer in Older Adults

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Key points

  • Assess each colorectal cancer patient for their degree of fitness and tailor the aggressiveness of the treatment appropriately.

  • The goals of care, curative versus palliative, should guide therapeutic management.

  • Employ strategies such as intermittent oxaliplatin or omission of bolus 5-fluorouracil to improve chemotherapy tolerance for older adults.

Colorectal cancer screening

Although more than one-third of CRC cases occur in patients 75 years or older, the age at which colon cancer screening should be discontinued remains an area of debate. The U.S. Preventative Services Task Force recommends against the routine use of screening colonoscopy among patients aged 76 to 85, and recommends against any CRC screening in patients over 85 years.7 This is owing to the increased risks of colonoscopy, including perforation, gastrointestinal bleeding, and cardiopulmonary

Surgery

More than 70% of CRC cases are diagnosed at early stages (I–III) and therefore amenable to operative resection.8 Surgery for CRC is usually well-tolerated among the elderly, especially with advances in laparoscopic colectomy, which result in similar postoperative complications (death, anastomotic leak, and postoperative ileus) among younger and older patients.9 Excellent survival results can be achieved even among the oldest patients. A recent analysis of the Surveillance, Epidemiology and End

Rectal cancer

The current standard of care in the management of locally advanced rectal cancer, including lesions that have invaded through the muscularis propria and/or lymph node positive disease found on either pelvic MRI or rectal endoscopic ultrasonography, is for neoadjuvant chemotherapy with a fluoropyrimidine followed by operative resection plus 4 more months of additional chemotherapy.15 Patients over 75 years of age are at risk of early termination of treatment, treatment interruptions, and dose

Systemic therapy for colorectal cancer

The use of systemic chemotherapy improves survival after operative resection of CRC (adjuvant setting) as well as when surgery is unable to be performed (palliative setting). Multiple studies have shown that older adults with CRC are undertreated in both the adjuvant as well as the metastatic setting.5, 18, 19 Undertreating older adults with systemic chemotherapy may decrease survival outcomes in this age group. Several database studies have shown that older patients with CRC who receive

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      The surgical strategy for patients with bowel obstruction from right colon cancer differs according to the cancer location, staging, ASA score, comorbidities and the skills of the emergency surgeon [6–9]. The need for emergency surgery is more frequent in the elderly (especially in patients aged more than 75 years), and these patients are generally frail due to a significant incidence of comorbidities, thus they are affected by higher rates of postoperative morbidity and mortality [10,11]. The prognosis of patients treated in emergency setting is expectedly worse than those treated in elective setting [12–15].

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      The clinician and patient should discuss which method of screening is the best option for individualized patients. Treatment for CRC can include a single or combination of surgery, chemotherapy, or radiation.39 An observed 30% to 40% decline in liver size, blood flow, and perfusion is noted between the third and tenth decades of life.5

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    Financial Disclosure: Dr J.M. Hubbard receives research support for clinical trials from Genentech, Bayer, Boston Biomedical Inc, and Senhwa Biosciences Inc. Advisory board for Bayer (Honorarium to Mayo Clinic).

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