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Locally Advanced Rectal Cancer: Treatment Approach in Elderly Patients

  • Lower Gastrointestinal Cancers (AB Benson, Section Editor)
  • Published:
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Abstract

Independently of age, evidence-based guidelines recommend a multidisciplinary treatment approach in patients with locally advanced rectal cancer (LARC). But actually, elderly patients are grossly underrepresented in clinical trials, accounting < 10% of enrolled cases. Therefore, LARC management in elderly patients remains a crucial issue in daily practice, especially due to their frailty. Multiple clinical factors, including general health status, cognitive status, co-morbidity, disability, and life expectancy should be considered to understand the complexities of geriatric assessment and then define therapy. We use a patient-centered approach in order to tailor the optimal treatment strategy. We treat fit elderly patients as younger patients, including neoadjuvant chemoradiotherapy (CRT), surgery, and adjuvant chemotherapy. Whereas, in vulnerable and frail patients, we propose standard CRT (vulnerable patients) or radiotherapy alone (frail patients).

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A, et al. GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;2018.

  2. Rutten HJ, den Dulk M, Lemmens VE, van de Velde CJ, Marijnen CA. Controversies of total mesorectal excision for rectal cancer in elderly patients. Lancet Oncol. 2008;9(5):494–501.

    Article  Google Scholar 

  3. • National Comprehensive Cancer Network Guidelines, Rectal Cancer, Version 1.2019. www.nccn.org. Guidelines in rectal cancer patients.

  4. Hurria A, Dale W, Mooney M, Rowland JH, Ballman KV, Cohen HJ, et al. Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations. J Clin Oncol. 2014;32(24):2587–94.

    Article  Google Scholar 

  5. Papamichael D, Audisio R, Horiot JC, Glimelius B, Sastre J, Mitry E, et al. Treatment of the elderly colorectal cancer patient: SIOG expert recommendations. Ann Oncol. 2009;20(1):5–16.

    Article  CAS  Google Scholar 

  6. •• Papamichael D, Audisio RA, Glimelius B, de Gramont A, Glynne-Jones R, Haller D, et al. Treatment of colorectal cancer in elderly patients: international society of geriatric oncology (SIOG) consensus recommendations 2013. Ann Oncol. 2015;26(3):463–76 Clinical guidelines in elderly patients with colorectal cancer.

    Article  CAS  Google Scholar 

  7. Decoster L, Van Puyvelde K, Mohile S, Wedding U, Basso U, Colloca G, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in elderly cancer patients: an update on SIOG recommendations. Ann Oncol. 2015;26(2):288–300.

    Article  CAS  Google Scholar 

  8. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The mini nutritional assessment. Clin Geriatr Med. 2002;18(4):737–57.

    Article  Google Scholar 

  9. Kenis C, Decoster L, Van Puyvelde K, De Grève J, Conings G, Milisen K, et al. Performance of two geriatric screening tools in elderly patients with cancer. J Clin Oncol. 2014;32(1):19–26.

    Article  Google Scholar 

  10. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–4.

    Article  Google Scholar 

  11. Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL Jr. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291(20):2441–7.

    Article  CAS  Google Scholar 

  12. Kallogjeri D, Gaynor SM, Piccirillo ML, Jean RA, Spitznagel EL Jr, Piccirillo JF. Comparison of comorbidity collection methods. J Am Coll Surg. 2014;219(2):245–55.

    Article  Google Scholar 

  13. Hathout L, Maloney-Patel N, Malhotra U, Wang SJ, Chokhavatia S, Dalal I, et al. Management of locally advanced rectal cancer in the elderly: a critical review and algorithm. J Gastrointest Oncol. 2018;9(2):363–76.

    Article  Google Scholar 

  14. •• Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, et al. Personalized management of elderly patients with rectal cancer: expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol. 2018;44(11):1685–702 Clinical guidelines in elderly patients with rectal cancer.

    Article  Google Scholar 

  15. Musio D, De Felice F, Bulzonetti N, Guarnaccia R, Caiazzo R, Bangrazi C, et al. Neoadjuvant-intensified treatment for rectal cancer: time to change? World J Gastroenterol. 2013;19(20):3052–61.

    Article  CAS  Google Scholar 

  16. De Felice F, Musio D, Magnante AL, Bulzonetti N, Benevento I, Caiazzo R, et al. Disease control, survival, and toxicity outcome after intensified neoadjuvant chemoradiotherapy for locally advanced rectal cancer: a single-institution experience. Clin Colorectal Cancer. 2016;15(2):e17–22.

    Article  Google Scholar 

  17. Gérard JP, Azria D, Gourgou-Bourgade S, Martel-Laffay I, Hennequin C, Etienne PL, et al. Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2. J Clin Oncol. 2010;28:1638–44.

    Article  Google Scholar 

  18. Rödel C, Liersch T, Becker H, Fietkau R, Hohenberger W, Hothorn T, et al. Preoperative chemoradiotherapy and postoperative chemotherapy with fluorouracil and oxaliplatin versus fluorouracil alone in locally advanced rectal cancer: initial results of the German CAO/ARO/AIO-04 randomised phase 3 trial. Lancet Oncol. 2012;13:679–87.

    Article  Google Scholar 

  19. O’Connell MJ, Colangelo LH, Beart RW, Petrelli NJ, Allegra CJ, Sharif S, et al. Capecitabine and oxaliplatin in the preoperative multimodality treatment of rectal cancer: surgical end points from National Surgical Adjuvant Breast and Bowel Project trial R-04. J Clin Oncol. 2014;32(18):1927–34.

    Article  Google Scholar 

  20. Aschele C, Cionini L, Lonardi S, Pinto C, Cordio S, Rosati G, et al. Primary tumor response to preoperative chemoradiation with or without oxaliplatin in locally advanced rectal cancer: pathologic results of the STAR- 01 randomized phase III trial. J Clin Oncol. 2011;29:2773–80.

    Article  CAS  Google Scholar 

  21. Jiao D, Zhang R, Gong Z, Liu F, Chen Y, Yu Q, et al. Fluorouracil-based preoperative chemoradiotherapy with or without oxaliplatin for stage II/III rectal cancer: a 3-year follow-up study. Chin J Cancer Res. 2015;27(6):588–96.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. De Felice F, Benevento I, Magnante AL, Musio D, Bulzonetti N, Caiazzo R, et al. Clinical benefit of adding oxaliplatin to standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer: a meta-analysis: oxaliplatin in neoadjuvant treatment for rectal cancer. BMC Cancer. 2017;17(1):325.

    Article  Google Scholar 

  23. An X, Lin X, Wang FH, Goodman K, Cai PQ, Kong LH, et al. Short term results of neoadjuvant chemoradiotherapy with fluoropyrimidine alone or in combination with oxaliplatin in locally advanced rectal cancer: a meta analysis. Eur J Cancer. 2013;49(4):843–51.

    Article  CAS  Google Scholar 

  24. Maas M, Nelemans PJ, Valentini V, Das P, Rödel C, Kuo LJ, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 2010;11:835–44.

    Article  Google Scholar 

  25. De Felice F, Izzo L, Musio D, Magnante AL, Bulzonetti N, Pugliese F, et al. Clinical predictive factors of pathologic complete response in locally advanced rectal cancer. Oncotarget. 2016;7(22):33374–80.

    Article  Google Scholar 

  26. Tougeron D, Roullet B, Paillot B, Hamidou H, Tourani JM, Bensadoun RJ, et al. Safety and outcome of chemoradiotherapy in elderly patients with rectal cancer: results from two French tertiary centres. Dig Liver Dis. 2012;44(4):350–4.

    Article  Google Scholar 

  27. Ausili Cèfaro G, Genovesi D, Vinciguerra A, Augurio A, Di Tommaso M, Marchese R, et al. Effects of preoperative radiochemotherapy with capecitabine for resectable locally advanced rectal cancer in elderly patients. Tumori. 2012;98(5):622–9.

    Article  Google Scholar 

  28. De Felice F, Musio D, Izzo L, Pugliese F, Izzo P, Bolognese A, et al. Preoperative chemoradiotherapy in elderly patients with locally advanced rectal cancer. Biomed Res Int. 2013;2013:610786.

    Article  Google Scholar 

  29. Margalit DN, Mamon HJ, Ancukiewicz M, Kobayashi W, Ryan DP, Blaszkowsky LS, et al. Tolerability of combined modality therapy for rectal cancer in elderly patients aged 75 years and older. Int J Radiat Oncol Biol Phys. 2011;81(5):e735–41.

    Article  Google Scholar 

  30. Cai X, Wu H, Peng J, Zhu J, Cai S, Cai G, et al. Tolerability and outcomes of radiotherapy or chemoradiotherapy for rectal cancer in elderly patients aged 70 years and older. Radiat Oncol. 2013;8:86.

    Article  Google Scholar 

  31. Guimas V, Boustani J, Schipman B, Lescut N, Puyraveau M, Bosset JF, et al. Preoperative chemoradiotherapy for rectal cancer in patients aged 75 years and older: acute toxicity, compliance with treatment, and early results. Drugs Aging. 2016;33(6):419–25.

    Article  CAS  Google Scholar 

  32. De Felice F, Llange K, Rubini F, Bulzonetti N, Caiazzo R, Musio D, et al. Intensified neoadjuvant chemoradiotherapy for locally advanced rectal cancer in elderly patients: toxicity, disease control, and survival outcomes. Clin Colorectal Cancer. 2018;17(1):e77–81.

    Article  Google Scholar 

  33. Benson AB 3rd, Venook AP, Al-Hawary MM, Cederquist L, Chen YJ, Ciombor KK, et al. NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw, 2018. 16(7):874–901.

  34. De Felice F, D’Ambrosio G, Musio D, Iafrate F, Benevento I, Marzo M, et al. Induction chemotherapy followed by neoadjuvant chemoradiotherapy and surgery in locally advanced rectal cancer: preliminary results of a phase II study. Oncotarget. 2018;9(72):33702–33,709.

    Article  Google Scholar 

  35. •• Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, et al. Personalized management of elderly patients with rectal cancer: expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol. 2018;44(11):1685–702 International clinical guidelines in elderly patients with rectal cancer.

    Article  Google Scholar 

  36. Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, et al. ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making. Ann Oncol. 2012;23(10):2479–516.

    Article  CAS  Google Scholar 

  37. Wang SJ, Hathout L, Malhotra U, Maloney-Patel N, Kilic S, Poplin E, et al. Decision-making strategy for rectal cancer management using radiation therapy for elderly or comorbid patients. Int J Radiat Oncol Biol Phys. 2018;100(4):926–44.

    Article  Google Scholar 

  38. Hallam S, Messenger DE, Thomas MG. A systematic review of local excision after neoadjuvant therapy for rectal cancer: are ypT0 tumors the limit? Dis Colon Rectum. 2016;59(10):984–97.

    Article  Google Scholar 

  39. Appelt AL, Pløen J, Vogelius IR, Bentzen SM, Jakobsen A. Radiation dose-response model for locally advanced rectal cancer after preoperative chemoradiation therapy. Int J Radiat Oncol Biol Phys. 2013;85(1):74–80.

    Article  Google Scholar 

  40. Gerard JP, Chapet O, Ramaioli A, Romestaing P. Long-term control of T2-T3 rectal adenocarcinoma with radiotherapy alone. Int J Radiat Oncol Biol Phys. 2002;54(1):142–9.

    Article  Google Scholar 

  41. Corner C, Bryant L, Chapman C, Glynne-Jones R, Hoskin PJ. High-dose-rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma. Brachytherapy. 2010;9(1):66–70.

    Article  Google Scholar 

  42. Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, et al. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys. 2014;88(4):822–8.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Radiotherapy, Policlinico Umberto I, “Sapienza” University of Rome, Viale Regina Elena 326, 00161, Rome, Italy

    Francesca De Felice PhD, Veronica Maiuri MD, Martina Parisi MD, Francesco Marampon PhD, Daniela Musio MD & Vincenzo Tombolini FP

  2. Department of Surgery “Pietro Valdoni”, Policlinico Umberto I, “Sapienza” University of Rome, Rome, Italy

    Daniele Crocetti PhD, Luciano Izzo FP & Giorgio De Toma FP

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  1. Francesca De Felice PhD
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  2. Daniele Crocetti PhD
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Correspondence to Francesca De Felice PhD.

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Francesca De Felice declares that she has no conflict of interest. Daniele Crocetti declares that she has no conflict of interest. Veronica Maiuri declares that she has no conflict of interest. Martina Parisi declares that she has no conflict of interest. Francesco Marampon declares that he has no conflict of interest. Luciano Izzo declares that he has no conflict of interest. Giorgio De Toma declares that he has no conflict of interest. Daniela Musio declares that she has no conflict of interest. Vincenzo Tombolini declares that he has no conflict of interest.

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De Felice, F., Crocetti, D., Maiuri, V. et al. Locally Advanced Rectal Cancer: Treatment Approach in Elderly Patients. Curr. Treat. Options in Oncol. 21, 1 (2020). https://doi.org/10.1007/s11864-019-0692-8

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  • DOI: https://doi.org/10.1007/s11864-019-0692-8

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