One of the mysteries of my practice was that I could never predict how well or poorly a patient would tolerate chemotherapy. My bias was that the older a patient was, the less well he or she would be able to take the stuff. Not true. Often my oldest patients would float right through their treatment while younger ones suffered major side effects. I couldn’t explain it except perhaps that having lived a long life exposed these older folk to adversity, which made them better able to tolerate their treatment.
But, there was little written information that confirmed my experience. Most studies of chemotherapy excluded older patients, even though over half of all people with cancer are over 65. But now studies of the elderly are being done. Recently two reports have appeared that focused specifically on cancer in older folks.
The first report, published in the May 21 issue of the British journal, The Lancet, looked at chemotherapy for widespread colorectal cancer in patients in their 70’s. The investigators tested different regimens in these people to see if there was much of a difference in their tolerability and benefit. Doses were given at 80 percent of recommended and then the treating oncologist could lower or raise the dose as he or she saw fit. Rarely did the doctor raise the dose and about half the time it was lowered or even stopped. Yet, the treatment proved beneficial. Over half the patients reported that they felt better. This usually means that the cancer has regressed some and that the side effects of the treatment were tolerable. The one negative part of the report was that these patients did not live as long as younger patients given the same treatment. But, this may be just that cancer is more destructive in the elderly.
A second report, also in The Lancet (Sept. 17) examined whether older patients could tolerate and benefit from standard two drug chemotherapy for lung cancer. These patients were really old, ranging from 70 to 88 years. Half the patients received only a single drug, vinorelbine, which has few side effects and can be effective in lung cancer. Yet it is much more effective when combined with the second drug, carboplatin. This was given along with the vinorelbine to the rest of the patients. Both groups tolerated the drugs and were helped. But, the second group of patients, who received both drugs lived longer with hardly any more side effects than the patients who were given only the one drug, vinorelbine.
None of this means that elderly patients can be given highly aggressive and toxic chemotherapy, although we actually don’t know this for sure because there are no studies. But it does mean for certain that they can receive the benefits of some chemotherapy. You just can’t count us old folks out.
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Colorectal cancer, also called colon cancer, includes any cancers of the colon, rectum and Appendix. It is thought that many cases of colorectal cancer arise from a polyp adenomatoso in the colon. These cellular mushroom growths are usually benign, but from time to time become cancerous over time. In most cases, the diagnosis of localized cancer is colonoscopy. Treatment is usually surgical, and in many cases is followed by chemotherapy
Colorectal cancer, also called colon cancer, includes any cancers of the colon, rectum and Appendix. It is thought that many cases of colorectal cancer arise from a polyp adenomatoso in the colon. These cellular mushroom growths are usually benign, but from time to time become cancerous over time. In most cases, the diagnosis of localized cancer is colonoscopy. Treatment is usually surgical, and in many cases is followed by chemotherapy.
brits have among the highest colon ca deaths in the world. They don't do colonoscopies unless stool is positive , The health service does not pay for screening, only if stool is positive. The population has never heard of that procedure ( nor ekg stress tests) When colon ca is found it is almost always metastatic, And it has ravaged my friends. Also they and other europeans are largely meat eaters. regards.. herb jernow md
I don't know? I think your instincts were a better part of your judgement. Most studies of chemotherapy have excluded older patients. In fact, in clinical trials, many patients are excluded because they could not complete the rather arduous treatment. So randomized comparisions are of healthier treated patients against all the controls, rendering a lot of trials invalid.
If patients in the treated category die during the course of treatment (before the course is completed), their cases are rejected from the data since these patients do not then meet the criteria established by definition of the term "treated." A patient dying on day 89 of a prescribed 90-day course of chemotherapy would be dropped from the list of treated patients.
By analyzing non-cancer deaths among cancer patients, it becomes clear that orthodox therapies often do more harm than good. For example, cancer treatment can damage the heart and cause deaths from heart failure. This means fewer deaths from cancer. Analysis of the records of 1.2 million cancer cases in the Surveilance, Evaluation and End Results (SEER) database showed that non-cancer deaths accounted for 21 - 37% of all deaths. The authors attributed this effect to the damage caused by cancer treatment.
The effects of aging on bodily functions and physiology, according to Michael Fisch, M.D., an assistant professor in the Department of Palliative Care and Rehabilitation Medicine at MD Anderson, cannot be ignored when making treatment and referral decisions. Pharmacokinetic processes such as the absorption, metabolism, and excretion of drugs appear to be different in older patients, and in general, a person’s physiologic tolerance or reserve diminishes with increasing age.
The process of aging reduces your organ capacitance. You may have a functioning kidney, functioning lungs, and a functioning brain, but you have less capacitance at 70 years of age than when you were 50. Older people are generally closer to some edge beyond which they would tip into a more clinically important organ dysfunction.
Dr. Fisch added that decisions about the care of older patients with cancer must take into account the stage and type of cancer and the patient’s competing risks. If you are 82 or you have other diseases, and you have cancer, it is not likely to catch up with you, he said. That is not age bias, it is just making appropriate medical decisions in the face of competing risks and the expected course of illness.
Complications of cytotoxic chemotherapy are more common in older patients (65 years of age and older) with cancer than in younger patients, and the occurrence of myelosuppression, mucositis, cardiodepression, peripheral neuropathy, and central neurotoxicity can complicate treatment. Age-related physiologic changes that can increase the toxicity of chemotherapy are decreased stem-cell reserves, decreased ability to repair cell damage, progressive loss of body protein, and accumulation of body fat.
A decline in organ function can alter the pharmacokinetics of many of the commonly used chemotherapeutic agents in some elderly patients, making toxicity less predictable. Comorbidities increase the risk of toxicity through their effects on the body. Furthermore, the drugs used to treat comorbidities may interact with chemotherapeutic drugs, potentially increasing toxicity in elderly patients. Prospective trials in older patients with solid tumors have found that age is a risk factor for chemotherapy-induced neutropenia and its complications (J Support Oncol 2003;1(Suppl 2):18–24).
Ok here's what we've come across in other research papers. Trials that systematically included functional status and
comorbidity as part of a geriatric assessment were rare.
In trials where functional status and comorbidity have
been assessed, age did not show a significant correla-
tion with toxicity. Most trials reporting an age-associat-
ed increase in toxicity have not controlled for age-asso-
ciated changes such as functional impairment, decline
in organ function, and comorbidity. To date, no
prospective trial has been conducted assessing the
need of a geriatric assessment for the care of elderly
cancer patients receiving chemotherapy. However, a
geriatric assessment may help to classify elderly
patients into different groups: those who can be treat-
ed similarly to younger patients, those who are vulner-
able and need modified therapy, and those who are frail
and cannot tolerate cytotoxic therapy. Cutoff levels to
define these three patient groups will most likely
depend on the underlying tumor entity and the kind
and intensity of therapy that will be used.
The problem with this approach may be that there will be too many variables and thus too many subgroups to accrue enough numbers for statistical significance.
Still, a worthwhile goal.
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