Management of Primary Colon Cancer in Older Adults

Robin McLeod, MD, Division of General Surgery, Mount Sinai Hospital, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON.
Selina Schmocker, Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.
Erin Kennedy, MD, PhD, Division of General Surgery, University Health Network, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.

Colorectal cancer is the third most common cancer worldwide, and more than half of those newly diagnosed with colon cancer are over the age of 70 years. Despite the large proportion of patients over the age of 70 diagnosed with colon cancer annually, this age group is significantly underrepresented in clinical trials and, therefore, there is little high-quality evidence on which to base treatment decisions or treatment guidelines. This article reviews the management of primary colon cancer in older adults, including screening, presentation and diagnosis, treatment, and follow-up in this population.
Key words: colon cancer, colorectal cancer, screening, tumour, older adults.

Dr. Anne Horgan and Dr. Shabbir Alibhai share their views on the current status of research in Colorectal Cancer

The incidence of colorectal cancer increases with age, with approximately 60% of patients in the US (and similar numbers in Canada) older than 65 years at diagnosis and 40% over the age of 75. As highlighted by McLeod et al in this issue, the management of older patients with colorectal cancer is challenging. The prevailing difficulty is the lack of randomized trial data to support and guide treatment decisions. Pivotal trials establishing the standard of care for this disease have tended to enroll younger patients. For example, the median age of patients enrolled in phase III studies of systemic chemotherapy for metastatic colorectal cancer is commonly 60-64 years,^1,2 with fewer than 20% of patients being 70 years and older. In the large colorectal screening studies, older patients are again under-represented, with only 15-17% of randomized patients being 70 years or older.^{3, 4} Similarly, elderly patients are less likely to be enrolled in surgical trials than younger patients.⁵

With this absence of prospective data, evidence regarding safety and efficacy of interventions in older patients with colorectal cancer has come mainly from subgroup analyses or meta-analyses of large randomized clinical trials, both in the adjuvant and metastatic disease settings. These analyses suggest that older patients gain similar benefit from chemotherapy as do younger patients, with little difference in the rates of severe toxicity.⁶ This should be reassuring to clinicians.  The relation between age and outcomes from colorectal cancer surgery is more complex, however. Poorer outcomes in terms of postoperative morbidity and mortality are reported with increasing age, but these are confounded by presentation with more advanced disease stage, a greater frequency of emergency surgery and fewer curative surgeries compared to younger patients.⁷ All of these analyses suffer from selection bias with patients in these studies generally being fit and of good performance status.

Data from randomized studies will ultimately help optimize management of older patients with colorectal cancer. However, careful consideration should be given to the design of these studies.  A growing appreciation of the heterogeneity of this patient population has led to a better understanding and use of geriatric specific assessments. These assessments which evaluate functional status, comorbid medical conditions, cognitive function, psychological state, and social supports may have value in predicting postoperative complications following surgery and may help better predict tolerance to systemic therapies. Incorporation of these assessments into both the clinical trial setting and daily clinical practice is encouraged but challenging due to time constraints in busy practices. Identifying elder-specific clinical predictors of tolerability to various interventions will ultimately lead to a more tailored approach for these patients.

The essential principles of managing colon cancer in the elderly are the same as in younger patients, however, as the authors state, an individualized approach is necessary. Frameworks for determining a patient’s remaining life-expectancy, risks of toxicities and operative complications, and quality of life issues must be developed and should ultimately underlie these individualized decisions.

No competing financial interests declared.

References:
1.    Goldberg RM, Sargent DJ, Morton RF et al. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004; 22: 23-30.
2.    Seymour MT, Maughan TS, Ledermann JA et al. Different strategies of sequential and combination chemotherapy for patients with poor prognosis advanced colorectal cancer (MRC FOCUS): a randomised controlled trial. Lancet 2007; 370: 143-152.
3.    Hardcastle JD, Chamberlain JO, Robinson MH et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477.
4.    Mandel JS, Bond JH, Church TR et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328: 1365-1371.
5.    Stewart JH, Bertoni AG, Staten JL et al. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol 2007; 14: 3328-3334.
6.    Kumar A, Soares HP, Balducci L, Djulbegovic B. 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: 1272-1276.
7.    Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet 2000; 356: 968-974.

Managing Cancer in Older Adults

I am someone who believes fervently in screening for colon cancer, and have had two colonoscopies (separated by 5 years). Even those at normal risk seem to benefit from some form of screening, and I have been particularly concerned because I have had close relatives afflicted by the disease. However, it is clear that many people who should know better refuse to be screened. Even simple screening tests such as fecal occult blood testing require people to endure relatively unpleasant activities, and colonoscopy prep is hardly fun.

Independent of my views, it is obvious that the rising prevalence of cancer of all types in Canada is a result of the aging of our population and the relative decline in cardiovascular mortality. Many of today’s cancer patients are relatively frail, or become so while getting treatment, and attention to geriatric medicine principles in these patients is important. Most oncology training programs in the United States incorporate a geriatric module to cover these issues. We are lagging a bit behind in Canada in this respect, but I am proud to say that one of the nation’s outstanding leaders in the field of geriatric oncology is our own senior editor, Dr. Shabbir Alibhai. The focus of this month’s edition is how cancer management is altered in older adults.

Our continuing education article, “Management of Primary Colon Cancer in Older Adults,” is by Dr. Robin McLeod, Selina Schmocker, and Dr. Erin Kennedy. Obviously, I hope never to have to worry about this because I have a commitment to screening! The very common ( and currently in the press) topic of “Multiple Myeloma in Older Adults: An Update” is written by Dr. Madappa N. Kundranda and Dr. Joseph Mikhael. The commonest cancer in older individuals is addressed in the article “Basal Cell Carcinoma” by Dr. Christian A. Murray and Dr. Erin Dahlke.

As well, we have our usual collection of articles on varied topics. Our Cardiovascular column is an “Update on the Management of Atrial Fibrillation in Older Adults” by Dr. Hatim Al Lawati, Dr. Fatemeh Akbarian, and Dr. Mohammad Ali Shafiee. Our Dementia article is on a common and difficult topic, “Withholding and Withdrawing Life-Sustaining Treatment in Advanced Dementia: How and When to Make These Difficult Decisions,” by Dr. Dylan Harris. In the area of nutrition, we have the article “Nutrition Guidelines for Cancer Prevention: More Than Just Food for Thought” by Kristen Currie, Sheri Stillman, Susan Haines, and Dr. John Trachtenberg. This is a natural extension from our focus this month. Our Community Care article is “Community-Based Health Care for Frail Seniors: Development and Evaluation of a Program” by Dr. Douglas C. Duke and Teresa Genge. Finally we feature one of Canada’s most prominent physicians in our “I Am a Geriatrician” column, namely Dr. Howard Bergman.

Enjoy this issue,
Barry Goldlist

Basal Cell Carcinoma

Erin Dahlke, MD, Dermatology Resident, University of Toronto, Toronto, ON.
Christian A. Murray, MD, FRCPC, Assistant Professor of Medicine and Dermatology, University of Toronto; Co-director of Dermatologic Surgery, Women’s College Hospital, Toronto, ON.

Basal cell carcinoma (BCC) is a common, slow-growing malignant skin tumour that only very rarely metastasizes. The main subtypes of BCC are nodular, superficial, and sclerosing. The most important risk factors for the development of BCC include fair skin, extensive sun exposure as a child, past personal history of skin cancer, and advanced age. Basal cell carcinoma is the most common human malignancy, and its incidence is increasing worldwide. There are a number of different treatm ent modalities for BCC including topical therapies, cryotherapy, electrodesiccation and curettage, surgical excision, radiotherapy, and Mohs’ micrographic surgery. Treatment should be tailored to the individual situation, and advanced age does not typically alter the management choice or reduce the expectation of an excellent outcome, including cure.
Key words: basal cell carcinoma, nonmelanoma skin cancer, risk factors, epidemiology, treatment.

Multiple Myeloma in Older Adults: An Update

Madappa N. Kundranda, MD, PhD, Department of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ, USA.
Joseph Mikhael, MD, Department of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ, USA.

Multiple myeloma (MM) is an uncommon malignant plasma cell disorder that often presents in older adults. An accurate diagnosis is critical as a spectrum of plasma cell disorders have been defined, including monoclonal gammopathy of undetermined significance, smouldering/asymptomatic multiple myeloma, multiple myeloma, and plasma cell leukemia. Although multiple myeloma is incurable disease, survival over 7 years is possible, during which patients can enjoy a good quality of life. Many therapeutic options now exist for individuals with MM who are ineligible for autologous stem cell transplantation; these include adding thalidomide, bortezomib, and lenalidomide to the current standard of melphalan and prednisone.
Key words: multiple myeloma, MGUS, older adults, plasma cell leukemia, supportive care.

Psychosocial Oncology for Older Adults in the Primary Care Physician’s Office

Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Barry D. Bultz, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.

Geriatric care is undoubtedly complex. A cancer diagnosis in itself creates significant concerns, irrespective of age, for the patient, and these concerns may be compounded by stresses related to moving into later life. Despite the scarce literature on geriatric oncology, the numerous challenges are acknowledged. Substantial evidence is offered on the benefits to the patient as well as the treating institution (cost off-sets, for example) on the benefits of psychosocial care. However, psychosocial care does not necessarily begin only at the cancer centre. Screening for the sixth vital sign, emotional distress, should begin at the primary care physician’s office. This not only benefits the primary care practice but also enables the tertiary referral centre to streamline resources to the specific needs of the patient, thereby ultimately improving the patient experience across the disease trajectory.
Key words: geriatric, chronic disease, emotional distress, screening, sixth vital sign.

Palliative Care in the Primary Care Setting

Sandy Buchman, MD, CCFP, FCFP, Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON; and McMaster University, Hamilton,ON; Palliative Care Physician, The Temmy Latner Centre for Palliative Care and The Baycrest Geriatric Health System, Toronto, ON.
Anthony Hung, MD, FRCPC, Fellow in Palliative Care, University of Toronto, Toronto, ON.
Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network, Toronto, ON; Associated Medical Services Fellow in End of Life Care Education, University of Toronto, Toronto, ON.

The principle of “cradle-to-grave” care is fundamental to the discipline of family medicine. This includes palliative care. However, many physicians are not comfortable providing care at the end of life. Challenges include logistical support and proficiency and comfort in the specific skills required, such as pain and other symptom management. The following case presents an example of successful palliative care, provided in the primary care setting, from diagnosis of a life-threatening illness to death in a palliative care unit.
Key words: palliative care, end of life, primary care, family medicine, longitudinal care.

Supporting and Treating the Older Adult with Cancer: It Starts in Primary Care

As I rapidly advance towards the geriatric age group, fears of cancer, in my case colon cancer because of a positive family history, start to increase. As a result, the unpleasantness of a recent colonoscopy was greatly alleviated later on by learning that I had no polyps or tumours. I am not alone in my concern about cancer, and the increasing prevalence of cancer as our population ages (and as age-corrected cardiovascular mortality declines) make these concerns quite legitimate. This high prevalence of cancer means that nearly all physicians--specialists as well as family physicians--who cares for adult patients will be caring for individuals with cancer in their practice. This issue’s focus on cancer in older adults allows us to address some of the learning needs of physicians caring for older adults with cancer.

Before her untimely death from breast cancer, a colleague of mine at the University Health Network wrote poignantly about the fatigue she experienced with her cancer. This taught me that as important as relieving pain is in cancer, many other symptoms are equally distressing for the patient. Our continuing education article this month is on some of these symptoms, and is titled “Fatigue, Pain, and Depression among Older Adults with Cancer: Still Underrecognized and Undertreated” by Dr. Manmeet Aluwhalia. An overview for supportive care of patients with cancer is addressed in the article ”Psychosocial Oncology for Older Adults in the Primary Care Physician’s Office” by Dr. Bejoy Thomas and Dr. Barry Bultz. Finally, in the same vein, is the article “Palliative Care in the Primary Care Setting” by Dr. Sandy Buchman, Dr. Anthony Hung, and Dr. Hershl Berman.

Our Cardiovascular Disease column this month is on “Diabetes and Cardiovascular Disease among Older Adults: An Update on the Evidence” by Dr. Pamela Katz and Dr. Jeremy Gilbert. Our Dementia column is on “Managing Non-Alzheimer’s Dementia with Drugs” by Dr. Kannayiram Alagiakrishnan and Dr. Cheryl Sadowski. One of the most important problems facing older adults, “Age-Related Hearing Loss,” is addressed by Dr. Christopher Hilton and Dr. Tina Huang. Urinary incontinence is usually considered a concern for older women; however, men are not exempt. Our Men’s Health column this month is on “Urinary Incontinence among Aging Men,” and is written by Dr. Ehab A. Elzayat, Dr. Ali Alzahran, and Dr. Jerzy Gajewski, who is a member of our partner association, the Canadian Society for the Study of the Aging Male. Dr. Gayatri Gupta and one of our international advisers, Dr. Wilbert S. Aronow, contribute an important article on "Prevalence of the Use of Advance Directives among Residents of a Long-term Care Facility" this month. Finally, it is imperative that physicians acknowledge the increasing prevalence of herbal medication use, which can lead to adverse drug interactions among their older patients. Dr. Edzard Ernst reviews this this topic in "What Physicians Should Know about Herbal Medicines.

Enjoy this issue.
Barry Goldlist

Update on Prostate Cancer among Older Men

Michel Carmel, MD, FRCSC, Professor, Sherbrooke University; Chair, Division of Urology, CHUS, Sherbrooke, QC.

Prostate cancer is the highest in incidence in Canada, ahead of lung and colon cancers. This is largely due to prostate-specific antigen (PSA) screening. Choosing among management options, including watchful waiting, active surveillance, and surgery, seems more difficult than ever for the patient and his physician as new treatments are emerging, often presented as accepted alternatives, while long-term efficacy and toxicity results are not yet available.
Key words: cancer, prostate, older adults, prostate-specific antigen, screening.