Most patients with colon cancer are older than 65 years. Their treatment poses multiple challenges, because they may have age-related comorbidities, polypharmacy, and physical or physiologic changes associated with older age. These challenges include limited data on the ability to predict tolerance to anticancer therapy and the appropriate use of treatment modalities in the setting of comorbidity and concurrent frailty. The low number of older patients enrolled in large clinical trials results in a paucity of evidence to guide oncologists in the appropriate management of this population. In early-stage disease, clinical dilemmas arise regarding the ability of older patients to undergo successful curative surgical procedures and the risk/benefit ratio of adjuvant chemotherapy. The management of metastatic disease raises questions regarding the clinical benefit of various anticancer therapies and the role of combination therapy with possible increased toxicity in the noncurative setting. Overall, the available evidence shows that fit older patients are able to tolerate treatment and derive similar clinical benefits to younger patients. Limited data are available to guide treatment for less-fit, more-vulnerable older patients. This lack of data leads to variations in treatment patterns in older adults, making them less likely to receive standard therapies. This review provides an overview of the available data regarding the management of older adults with colon cancer in the adjuvant and metastatic settings.
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Efrat Dotan, Ilene Browner, Arti Hurria, and Crystal Denlinger
June M. McKoy, Peggy S. Burhenn, Ilene S. Browner, Kari L. Loeser, Katrina M. Tulas, Megan R. Oden, and Randall W. Rupper
The number of older individuals with cancer is increasing exponentially, mandating that oncologists contemplate more comprehensive and multidisciplinary approaches to treatment of this cohort. Recruitment of assessment instruments validated in older patients can be invaluable for guiding treatment and decision-making by both patients and providers, and can arguably contribute to improving outcomes and health-related quality of life. The Comprehensive Geriatric Assessment is one such validated instrument that can be used by oncologists to assess patient readiness and appropriateness for prescribed cancer therapy. As a multidisciplinary diagnostic and treatment process, it comprises functional status, cognitive status, social support, and advance care preferences, and is an ideal instrument for evaluating complex older individuals. It is well established that many older individuals with cancer travel with multiple comorbid illnesses, including cognitive impairment, and when presented with a cancer diagnosis struggle to choose from multiple treatment options. In addition to the complete medical history, the ability of patients to decide on a course of therapy in concert with their oncologist is critically important. Alternatively, many oncologists are conflicted as to whether true informed consent for treatment can be obtained from many older patients. Having a roadmap to decision-making capacity is therefore an inescapable imperative in geriatric oncology, because careful attention must be directed at identifying older patients with cancer who might benefit from these assessments and the individualized treatment plans that emerge.
Arti Hurria, Ilene S. Browner, Harvey Jay Cohen, Crystal S. Denlinger, Mollie deShazo, Martine Extermann, Apar Kishor P. Ganti, Jimmie C. Holland, Holly M. Holmes, Mohana B. Karlekar, Nancy L. Keating, June McKoy, Bruno C. Medeiros, Ewa Mrozek, Tracey O’Connor, Stephen H. Petersdorf, Hope S. Rugo, Rebecca A. Silliman, William P. Tew, Louise C. Walter, Alva B. Weir III, and Tanya Wildes
Kai-li Liang, Sean A. Tackett, Valerie Peterson, Tricia Patel, Michelle Turner, Sarah Sagorsky, Julie Brahmer, Christine Hann, Patrick Forde, Jarushka Naidoo, Kristen A. Marrone, David Ettinger, Ilene S. Browner, Vincent Lam, Russell K. Hales, Khinh R. Voong, and Josephine L. Feliciano
Arti Hurria, Tanya Wildes, Sarah L. Blair, Ilene S. Browner, Harvey Jay Cohen, Mollie deShazo, Efrat Dotan, Barish H. Edil, Martine Extermann, Apar Kishor P. Ganti, Holly M. Holmes, Reshma Jagsi, Mohana B. Karlekar, Nancy L. Keating, Beatriz Korc-Grodzicki, June M. McKoy, Bruno C. Medeiros, Ewa Mrozek, Tracey O’Connor, Hope S. Rugo, Randall W. Rupper, Rebecca A. Silliman, Derek L. Stirewalt, William P. Tew, Louise C. Walter, Alva B. Weir III, Mary Anne Bergman, and Hema Sundar
Cancer is the leading cause of death in older adults aged 60 to 79 years. The biology of certain cancers and responsiveness to therapy changes with the patient’s age. Advanced age alone should not preclude the use of effective treatment that could improve quality of life or extend meaningful survival. The challenge of managing older patients with cancer is to assess whether the expected benefits of treatment are superior to the risk in a population with decreased life expectancy and decreased tolerance to stress. These guidelines provide an approach to decision-making in older cancer patients based on comprehensive geriatric assessment and also include diseasespecific issues related to age in the management of some cancer types in older adults.
Noam VanderWalde, Reshma Jagsi, Efrat Dotan, Joel Baumgartner, Ilene S. Browner, Peggy Burhenn, Harvey Jay Cohen, Barish H. Edil, Beatrice Edwards, Martine Extermann, Apar Kishor P. Ganti, Cary Gross, Joleen Hubbard, Nancy L. Keating, Beatriz Korc-Grodzicki, June M. McKoy, Bruno C. Medeiros, Ewa Mrozek, Tracey O'Connor, Hope S. Rugo, Randall W. Rupper, Dale Shepard, Rebecca A. Silliman, Derek L. Stirewalt, William P. Tew, Louise C. Walter, Tanya Wildes, Mary Anne Bergman, Hema Sundar, and Arti Hurria
Cancer is the leading cause of death in older adults aged 60 to 79 years. Older patients with good performance status are able to tolerate commonly used treatment modalities as well as younger patients, particularly when adequate supportive care is provided. For older patients who are able to tolerate curative treatment, options include surgery, radiation therapy (RT), chemotherapy, and targeted therapies. RT can be highly effective and well tolerated in carefully selected patients, and advanced age alone should not preclude the use of RT in older patients with cancer. Judicious application of advanced RT techniques that facilitate normal tissue sparing and reduce RT doses to organs at risk are important for all patients, and may help to assuage concerns about the risks of RT in older adults. These NCCN Guidelines Insights focus on the recent updates to the 2016 NCCN Guidelines for Older Adult Oncology specific to the use of RT in the management of older adults with cancer.
NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021
Featured Updates to the NCCN Guidelines
Efrat Dotan, Louise C. Walter, Ilene S. Browner, Katherine Clifton, Harvey Jay Cohen, Martine Extermann, Cary Gross, Sumati Gupta, Genevieve Hollis, Joleen Hubbard, Reshma Jagsi, Nancy L. Keating, Elizabeth Kessler, Thuy Koll, Beatriz Korc-Grodzicki, June M. McKoy, Sumi Misra, Dominic Moon, Tracey O’Connor, Cynthia Owusu, Ashley Rosko, Marcia Russell, Mina Sedrak, Fareeha Siddiqui, Amy Stella, Derek L. Stirewalt, Ishwaria M. Subbiah, William P. Tew, Grant R. Williams, Liz Hollinger, Giby V. George, and Hema Sundar
The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.