Elderly patients and chemotherapy.

Median age at diagnosis for patients with colorectal cancer (CRC) is around 70 years in Western Europe and over 20% of patients are at least 80 years old. Management of CRC has been extensively investigated for younger patients and until a few years ago elderly patients were under-treated [1]. For example, only 30% of patients over 75 years of age with metastases were considered for chemotherapy. For patients over 80 years old, often a decision not to give chemotherapy was taken by the family without discussing with the patient the full details of their cancer and without considering the palliative effect of chemotherapy. The situation has now changed [2] and one can identify at least three reasons for these changes: (1) with time the population is getting older, but many elderly patients are still active and have a good life-expectancy with no severe comorbidity; (2) side effects of chemotherapy are now better controlled by supportive treatments, careful follow-up and dose adaptations; (3) when asked about their willingness to receive chemotherapy, 70.5-77.8% of elderly patients volunteered to be treated with heavy chemotherapy and 88.5-100% with moderately aggressive chemotherapy if there is a chance of survival benefit, and in France it was shown that there was a significant difference between the willingness of elderly cancer patients (77.8-100% in favour of chemotherapy) and people without cancer (only 34-67.5% in favour of chemotherapy) [3].

For all these reason we frequently have to consider chemotherapy, as adjuvant or palliative treatment, for elderly patients. It has been argued that these patients are candidates for active treatments because there is evidence that they may benefit as much as younger patients from 5-FU-based chemotherapy [4]. It has also been suggested that chemotherapy agents may be administered without dose reduction if there is no renal, haematological or hepatic dysfunction [5, 6].

In this issue, the efficacy and tolerance of irinotecan in elderly patients is reported by Gunnar Folprecht and of cetuximab by Jean Baptiste Bachet and colleagues. Their experiences confirm that elderly patients may be treated with active polychemotherapies.

As the number of elderly cancer patients has increased, the need for useful geriatric assessment has become increasingly more important. Balducci and Extermann have proposed a decision tree, in order to facilitate the management of elderly patients, using three categories: (1) functionally independent people without comorbidity who are candidates for any form of standard cancer treatment; (2) frail people (dependent in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are candidates for palliative treatment only; and (3) people 'in between' who may benefit from chemotherapy with some adaptation such as dose reduction for the initial dose and subsequent dose escalation [7]. At the same time, the need has emerged for the development of oncogeriatric management, based on better social, medical and psychological knowledge of these patients. Such management has been developed [8], as described by Tristan Cudennec and colleagues in this issue.

There is now effective collaboration between geriatricians and oncologists in many centres, which results in better knowledge of this population of patients and a better estimation of their ability to support chemotherapy and to benefit from it. The question of considering geriatric oncology as a speciality has now been raised in many countries and should be accepted as long as it is integrated into the departments of oncology. The creation of an 'isolated' specialised department of geriatric oncology is probably not suitable for the following reasons: (1) fit elderly patients do not need to receive different treatments from younger patients as long as they have no impairment of their haematological, renal, hepatic, cardiological, respiratory or neurological functions; (2) the elderly like to be with younger patients and appreciate not being 'concentrated' with other elderly people who often have cognitive disorders; (3) it is impossible for a geriatrician to be able to take care of all solid tumours and haematological malignancies. In addition, it is unrealistic to ask representatives of any specialties to attempt to take care of patients who require specific nursing and care for specific carcinomas. If a department of geriatric oncology is established, it must be carefully evaluated to determine whether the quality of care is improved and whether patients do better than those treated in specialised departments (medical oncology but also for example digestive or thoracic oncology, or head and neck department); and (4) in some hospitals, mobile geriatric teams are in charge of the geriatric evaluation of elderly patients in surgical or medical departments. They are very competent and can give advice within a few hours or days and may rapidly help to adapt the treatment strategy according to the patient's status. They are also invited to give their advice and if necessary to participate at multidisciplinary staff meetings when treatment decisions depend on the geriatric assessment. This solution has been adopted in our hospital, Ambroise-Pare, and is discussed in this issue by Tristan Cudennec and colleagues.

If we have made progress in the management of elderly patients, many questions still remain. (1) Because of the large number of cases of cancer in elderly patients, which patients should be assessed by a geriatrician? (2) What is the real benefit of geriatric evaluation in terms of quality of life, in particular the ability to spare undue toxicity of treatment? (3) Which simplified scales can be used to rapidly screen elderly patients?

References

[1.] Mitry E, Bouvier AM, Esteve J and Faivre J. Improvement in colorectal cancer survival: a population-based study. Eur J Cancer, 2005, 41, 2297-2303.

[2.] Lichtman SM, Balducci L and Aapro M. Geriatric oncology: a field coming of age. J Clin Oncol, 2007, 25, 1821-1823.

[3.] Extermann M, Albrand G, Chen H et al. Are older French patients as willing as older American patients to undertake chemotherapy? J Clin Oncol, 2003, 21, 3214-3219.

[4.] Folprecht G, Cunningham D, Ross P et al. Efficacy of 5-fluorouracil-based chemotherapy in elderly patients with metastatic colorectal cancer: a pooled analysis of clinical trials. Ann Oncol, 2004, 15, 1330-1338.

[5.] Kohne CH, Grothey A, Bokemeyer C et al. Chemotherapy in elderly patients with colorectal cancer. Ann Oncol, 2001, 4, 435-442.

[6.] Balducci L. Aging, frailty, and chemotherapy. Cancer Control, 2007, 1, 7-12.

[7.] Balducci L and Extermann M. Management of cancer in the older person: a practical approach. Oncologist, 2000, 5, 224-237.

[8.] Monfardini S, Aapro MS, Bennett JM et al. Organization of the clinical activity of geriatric oncology: report of a SIOG (International Society of Geriatric Oncology) task force. Crit Rev Oncol Hematol, 2007, 62, 62-73.

Philippe Rougier (1) Tristan Cudennec (2) and Emmanuel Mitry (1)

Departments of (1) Hepato-Gastroenterology and (2) Geriatric Medicine, Hopital Ambroise-Pare, Boulogne, France