Choice of chemotherapy in metastatic colorectal cancer (mCRC): Age alone should not matter!
Consideration for chemotherapy in patients who are older has been limited to less intensive regimens. A recent study by Davis et al assessing the association of cumulative social risk and social support with receipt of chemotherapy among patients with mCRC confirmed that close to 40% of patients may not receive chemotherapy. Older age (≥65 years) was associated with a lower likelihood of chemotherapy receipt with an odds ratio (OR) of 0.28. Additional social risk (such as gender and/or race) further decreased the risk for not receiving chemotherapy. Identifying patients at risk and targeting them with patient support programs may help them with undergoing recommended treatment as per guidelines. The data from this study suggest that support from family and friends is beneficial and may allow patients to complete their chemotherapy treatment and consequently improve their long-term outcomes. In the absence of such support, any other source of support can mitigate the risk of nontreatment and should be strongly considered.
The study by Nakayama et al not only confirms the benefits of treating older patients but also shows evidence that those older than 80 years appear to derive a very similar benefit as younger patients with more intense chemotherapy. In this group of patients, intensive chemotherapy was defined as at least 2 courses of doublet chemotherapy with oxaliplatin- or irinotecan-based treatment. The results suggest a very similar survival outcomes for the aged and the younger patient groups with a hazard ratio (HR) of 1.29. Overall, this study suggests that older patients, including those older than 80 years, who may be eligible for intensive chemotherapy should not be excluded from this consideration based on their age alone. The option for intensive chemotherapy allows for eligible older patients to be exposed to a continuum of life extending therapies similar to younger patients. Indeed, a recent prospective phase II study by Takahashi et al confirmed that trifluridine/tipiracil (FTD/TPI) was effective and well tolerated in elderly patients with mCRC and is in line with similar benefits historically observed in younger patients.
In conclusion, the cumulative knowledge from these studies confirms that identifying proper social support to older patients with mCRC will ensure that they are able to receive chemotherapy as indicated. It is also important to emphasize that age itself should not be a discriminator against the use of intensive chemotherapy and the opportunity to be exposed to the continuum of treatment options as indicated. It is understandable that for those older patients who may not be eligible for intensive chemotherapy, consideration for less intense therapy has been well validated in the past. At any point of the treatment continuum, as with any part of our oncologic care, discussion with patients and shared decision making is key to preserving the sacrosanct principles of patient autonomy and do no harm.