Colorectal Cancer Part 6: Chemotherapy for the Elderly -- Is It Worth It?

According to the editorial in the New England Journal of Medicine (Older age -- not a barrier to cancer treatment. Vol: 345: 1128-1129. October 2001), more than half of all new cancers in the US occur in patients 65 years of age or older. Similarly about two thirds to three fourth of colorectal cancer cases occur in this elderly age group and three fourths of them die of the disease. In another report, published in the same journal (Vol: 345: 1091-1097), entitled: "A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients" Dr. Daniel Sargent and colleagues analysed data from 3,351 patients and compared the performance of patients in four different age groups. They concluded that:

1. "Selected elderly patients with colon cancer can receive the same benefit" from chemotherapy as their younger counterparts.

2. The five-year overall survival was 71% for those who received chemotherapy, and 64% for those who did not receive chemotherapy.

3. The toxic effects of the therapy were nausea or vomiting, diarrhea, stomatitis and leucopenia (i.e., lowering of white blood cells). The toxic effects in those above 75 years old were not increased compared to other age groups.

Question: The difference of benefits between chemotherapy (5-FU + leucovorin or 5-FU
+ levamisole) and no chemotherapy was 7%. This benefit of increased survival comes with toxic side effects. While the younger patients might be able to tolerate the side effects, I wonder if the elderly would want to go through such "sufferings." To the oncologists and researchers, the results were "statistically significant," but from the viewpoint of patients, I wonder if it worth it?

Theodore, J. I. & Lamont, E.B (in: Effectiveness of adjuvant fluorouracil in clinical practice: A population-based cohort study of elderly patients with stage III colon cancer. J. of Clinical Oncology. October 2002. Vol: 20: 3992-3998) wrote:

"At five years, 52.7% of the elderly, stage III colon patients treated with adjuvant 5-FU were alive compared to only 40.7% of those untreated patients."

Questions: If you are old and had a surgery for your Stage 3 colon, but decided not to go for chemotherapy -- would you die soon after that? The answer is NO. The data of this research shows that you can still be alive after five years even if you do not undergo chemotherapy. Think about this carefully: for every 100 elderly patients who are subjected to chemotherapy, only 12 of them will benefit from the treatment. This means that 88 elderly patients have to endure the side effects of chemotherapy and they do not benefit from the treatment.

Yang, T.S. and colleagues (in: Phase II study of a weekly 8-hour 5-fluorouracil and leucovorin infusion for patients with advanced colorectal cancer: dose adjusted according to its toxicity. Japanese Journal of Clinical Oncology. 2001. Vol:31: 610-615) studied 26 patients with unresectable, metastastatic or local recurrence colorectal cancer. Patients were treated with 5-FU + leucovorin. The results of their result were:

1. The study commenced in June 1998, but by December 2000, i.e., one and half years later, only 3 patients were alive, meaning 23 of the 26 patients or 88% were dead. They survived for 1.5 to 28.3 months (median survival = 12.1 months).

2. The overall survival rate was 53.8% after 1 year, and 11.5% after 2 years.

3. The most frequent side effects noted were nausea, vomiting, diarrhea and mucositis.

4. Hand-foot syndrome occurred in 11.5% of patients.

5. Fatigue or asthenia occurred in 57.7% of patients.

6. The study was terminated because the anticipated response rate was not achievable as expected.

Questions: Do the results of this study done in Taipei, Taiwan, not reflect the agonizing experiences of most cancer patients who had undergone chemotherapy? Are we made to believe that chemotherapy is good for colorectal cancer when 88% were dead 1.5 years after undergoing chemotherapy?

I often tell this to cancer patients: How much longer you live is not important. How you live while alive is the crux of the issue. What is the point of being alive when you have to spend most of your time going in and out of the hospital or enduring the side effects of the treatment?

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