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Chemotherapy for older persons with colon cancer?

Review
Results
Comment

There are often very good reasons why therapy of older people is different from younger people. For a start, bits drop off as we get older, and we develop more chronic conditions. Older people commonly have to take a lot of medicines. But the number and type of tablets can pose a problem when a new condition arises and new treatment needed. Difficult decisions sometimes have to be made on the balance between efficacy on the one hand and possible harm on the other, let alone which condition is the most important to treat when problems arise.

To some extent that will never go away, but for adjuvant chemotherapy after surgery for colon cancer, we can be reasonably sure that therapy is as effective and no more harmful for patients older than 70 years than those younger than 70 years [1]. The results came from looking at every patient ever entered in a randomised trial and analysing by age.

Review


Randomised trials that randomised patients to chemotherapy after surgery (usually fluorouracil plus calcium folinate) or surgery alone were sought, and authors contacted. Trialists were asked to provide data on outcomes (death, recurrence) for each patient entered, together with toxicity information. Analysis was for overall survival time and recurrence by age of patient.

Results


Information was available for seven trials with 2251 patients with stage II or stage III disease. Several trials identified had not completed follow up. Trial size was 239 to 968 patients, with median follow up of five to over eight years, and with six or twelve months of treatment in cycles. Only one trial specified an age limit of less than 75 years.

Chemotherapy was effective in increasing survival over five years, from 64% survival in untreated patients to 71% in those treated with adjuvant chemotherapy. The five-year recurrence free rate was increased from 58% in untreated patients to 69% in those treated with adjuvant chemotherapy. The likelihood of this occurring by chance was less than 1 in 1,000 in both cases.

Survival curves for patients older and younger than 70 years were very similar, and age was not important. More patients died without recurrence at older ages (Figure 1), but the proportion dying with recurrence was identical at all ages.

Figure 1: Percentage of patients with colon cancer dying with recurrence and without recurrence in different age groups



Toxicity was broadly similar for patients less than and more than 70 years. There was no difference in nausea and vomiting, or diarrhoea, or stomatitis, but rates of leucopaenia were about double in patients older than 70 years, and much higher with levamisole (31% at more than 70 years compared with 17% for younger patients) than calcium folinate (8% and 4% respectively).

Comment


Some older people having surgery for colon cancer will not be offered adjuvant chemotherapy for very good reasons. Others may not be offered chemotherapy because of perceptions of greater toxicity, or lower tolerance, or for some other reason relating to age.

This report shows that re-analysis of clinical trial information based on individual patient data can help answer the question of who benefits and who does not. Patients older than 70 years did just as well as younger patients. Important this, as people older than 70 years without cancer have a life expectancy of a decade or so.

References:

  1. DJ Sargent et al. A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients. New England Journal of Medicine 2001 345: 1091-1097.
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