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Colon cancer and the elderly: From screening to treatment in management of GI disease in the elderly

https://doi.org/10.1016/j.bpg.2009.10.010Get rights and content

Colorectal cancer is one of the commonest tumours in the Westernized world affecting mainly the elderly. This neoplasm in older individuals occurs more often in the right colon and grows more rapidly than in the young, often shows a mucinous histology and mismatch repair gene changes. Effective screening permits discovery of colorectal cancer at an early highly treatable stage and allows for detection and removal of premalignant colorectal adenomas. Screening methods that focus on cancer detection use fecal assays for the presence of blood or altered DNA, those for detection of adenomas (and early cancer) use endoscopic or computerised radiologic techniques. Broad use of screening methods has lowered colorectal cancer development by about 50%. In addition, prevention of the earliest stage of colon carcinogenesis has been shown to be effective in small prospective studies and epidemiologic surveys but have not been employed in the general population.

Since 1996 the chemotherapeutic armamentarium for metastatic colorectal cancer has grown beyond 5-fluorouracil to include an oral 5-fluorouracil prodrug, capecitabine as well as irinotecan and oxaliplatin. Three targeted monoclonal antibodies (Moabs), bevacizumab (an anti-vascular endothelial growth factor Moab) and cetuximab/panitumumab, both anti-epidermal growth factor receptor inhibitors, have also earned regulatory approval. Most stage IV patients are treated with all of these drugs over 2 or 3 sequential lines of palliative chemotherapy and attain median survivals approaching 24 months. Lastly, adjuvant oxaliplatin plus 5-fluorouracil for high risk resected stage II and stage III colon cancer patient has led to substantial improvement in cure rates. With appropriate care of age associated comorbidities these treatment modalities are feasible and effective in the geriatric population.

Section snippets

Screening and surveillance methods

Preventive methods to reduce the incidence and mortality from colorectal cancer distinguishes screening from surveillance. Screening includes testing of asymptomatic individuals at average risk for colorectal cancer or at higher risk because of a family history to diagnose colorectal cancer or precancerous neoplastic adenomas. Surveillance involves monitoring of individuals with premalignant conditions including inflammatory bowel disease, primary sclerosing cholangitis or with previous

Fecal immunochemical testing

Immunochemical testing (FIT) for human globin or haemoglobin is more specific, particularly for lower gastrointestinal bleeding and requires simpler collection methods than qFOBT tests and has become the preferred fecal test in Europe and Japan. Several FIT are available whose sensitivity for detection of cancer and advanced adenomas depend upon the haemoglobin threshold used. Side to side testing of differing FIT's against standard gFOBT methods have regularly shown superiority for the FIT's

Stool DNA testing

Since colorectal cancer and precancerous adenomas often contain altered DNA which is shed into the gastrointestinal lumen and DNA is stable in the stool, fecal tests seeking altered DNA are being evaluated. Multiple DNA markers need to be tested usually including point mutations in K-ras, APC, P53, BAT26 (a probe for micro-satellite instability), methylated promoter markers and several DNA integrity tests. One disadvantage of DNA testing is that at least 30 gms of stool need to be collected and

Chemoprevention for reducing the risk of colorectal cancer risk

Presently, the sole accepted method of risk reduction (prevention) of colorectal cancer is detection and removal of preneoplastic adenomas. This represents secondary prevention – the elimination of existing lesions that may progress to cancer. Primary prevention focuses upon risk reduction of the carcinogenic process from a normal colorectal mucosa to benign adenomatous neoplasia. Risk reduction methods have included lifestyle changes, including increasing physical activity, dietary factors and

Summary

Colorectal cancer in the elderly is common, shows differing clinical and biologic features and can be detected and prevented using several screening strategies. Because progression of adenomas to cancer takes a decade, invasive screening colonoscopy has risks and comorbidities reduce life span in the elderly, screening should be modified after age 75 and avoided after 85. However, nutritional measures may have a place in prevention.

Treatment algorithms for all stages of colorectal cancer,

Acknowledgements

Supported in part by NCI grant U54CA100926; UL1RR024143 from the NCRR and the NIH Roadmap for Medical Research.

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