Pharmacotherapeutic considerations for elderly patients with colorectal cancer

ABSTRACT

Introduction: Oncology care in the elderly presents a dilemma. The majority of cancer cases are diagnosed in the elderly yet they are underrepresented in clinical trials. In addition to limited evidence-based medicine, the elderly is a heterogeneous population filled with pharmacotherapeutic challenges and barriers. Elderly metastatic colorectal cancer (mCRC) treatment decisions encompass these challenges.

Areas covered: Treatment based solely on chronological age is an unacceptable practice. Physiologic factors such as function, cognition, comorbidities, polypharmacy, among others must be considered. Oncology guidelines emphasize using a geriatric assessment (GA) as opposed to traditional oncology performance status measures to best identify risks. Our review shines light on these issues as they pertain to elderly unresectable metastatic colorectal cancer (mCRC).

Expert opinion: The practical use of GA tools in oncology remain to be determined. Current barriers are the lack of a consistent tool to unify decision-making, provider education, and evidence-based use/outcomes in specific cancers. mCRC antineoplastic data surrounding GAs are scarce, and current mCRC national treatment algorithms are not stratified to encompass GA-driven therapy. Therefore, providers lack clear guidance or practicality of use. We hope mCRC trial designs will abandon age cutoffs and instead place more focus on GAs for inclusion and outcomes.

KEYWORDS:

• Aged
• colorectal neoplasms
• antineoplastic agents

Article Highlights

• Approximately 70% of cancers are diagnosed in the elderly yet the elderly historically are underrepresented in clinical trial designs creating a lack of evidence-based medicine to guide practitioners.

• mCRC is an older age malignancy with a median diagnosis age of 67 years old. As life expectancy is predicted to continue to increase worldwide, mCRC elderly cases will as a result increase.

• National guidelines state common oncology performance status measures lack accurate predictability to determine treatment risks in the elderly and recommend a more in-depth assessment.

• Geriatric assessments focus on specific domains involved in function, cognition, polypharmacy, comorbidities, and nutrition. These assessments have slowly begun to incorporate the oncology world.

• Geriatric assessment use in mCRC is sparse. We hope future trial developments in this cancer will abandon chronological age cutoffs and focus on functional age inclusion criteria.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.