Elderly patients with colorectal cancer: Treatment modalities and survival in France. National data from the ThInDiT cohort study

https://doi.org/10.1016/j.ejca.2013.12.026Get rights and content

Abstract

Background

Few data exist on how elderly patients with colorectal cancer (CRC) are actually treated in real-life practice. Based on a national cohort, we analysed routine treatment modalities of the elderly who were diagnosed with CRC in France in 2009.

Patients and methods

The characteristics of patients and tumours and the cancer treatments received during the first year of all national incident cases of CRC diagnosed between 1st April and 31st December 2009, were compared between a ‘younger group’ (YG), under 75 years of age (N = 18,410 patients), and an ‘older group’ (OG), aged 75 and over (N = 13,255 patients). In the OG with metastases at baseline, we analysed two-year overall survival (OS) according to the treatment received (e.g. chemotherapy, surgery) and well-known prognostic factors.

Results

Among patients with localised CRC (N = 25,353), surgery was equally performed in both groups in more than 80% of the cases (p = 0.52); time to surgery was shorter in the OG (8 versus 23 days) because there was more emergency surgery for occlusion among the OG. Adjuvant chemotherapy was performed in 15% of the OG (versus 29% in the YG) and consisted of 5-fluorouracil (5FU) monotherapy in more than 50% of OG patients.

Among patients with metastatic CRC (N = 6,312), palliative chemotherapy was given to 48% of the OG versus 85% of the YG. Chemotherapy regimens included 30% monotherapy with 5FU, 30% oxaliplatin combination and 20% bevacizumab combination in the OG; compared to 10%, 34% and 35%, respectively, in the YG. The median OS for the OG was 8.4 months (versus 22.3 months in the YG) and 17.1 months among elderly patients who received chemotherapy.

Conclusion

CRC is more frequently complicated at diagnosis among elderly patients. Adjuvant and palliative chemotherapy is less frequently prescribed among elderly patients. This could be explained by the fact that unfit elderly patients do not deserve chemotherapy, but certainly also reflect the fact that some fit elderly patients are undertreated.

Introduction

With over 1.2 million new cases and 608,700 deaths in 2008 worldwide, colorectal cancer (CRC) is a major public health concern [1]. The median ages at diagnosis are 70 years for men and 73 years for women; 40% of the patients with CRC are over 75 years old at diagnosis, and this proportion is growing [2]. Therefore, care of elderly patients with CRC is a challenge, but the optimal management for these patients has never been clearly defined as such patients are under-represented in clinical trials [3], [4]. However, data from subgroup analysis of selected elderly patients extracted from randomised trials or observational cohorts suggested that, compared with younger patients, the elderly could benefit from adapted CRC treatment in metastatic and localised situations [5], [6], [7]. Nevertheless, these analyses have numerous limitations, such as the small number of elderly patients and the fact that they are highly selected and do not represent the ‘real-life’ elderly population. Moreover, the definition of ‘elderly’ often varies from patients over 65 years of age to patients over 75 years of age. There is an increased incidence of age-related physiological changes and comorbidities after the age of 75, which are risk factors for altered pharmacokinetics and pharmacodynamics, potentially leading to increased treatment-related toxicity. International recommendations extracted from these data suggest that treatment principles of CRC are approximately the same in older patients as in younger patients but should be adapted because of comorbidities or physiological changes [5], [8]. To help physicians make a decision, a comprehensive geriatric assessment (CGA) could help categorise elderly patients and offer them optimal treatment [9], [10]. However, the management of CRC in the elderly remains sub-optimal and sometimes inappropriate [11]. Using the French National Health system database, we were able to describe the characteristics and management of CRC in a countrywide cohort of all incident cases in 2009. Among them, we could focus on the actual state of care of elderly patients in real-life practice and could estimate the survival of patients with synchronous metastatic CRC.

Section snippets

Material and methods

ThInDiT (Therapeutic Innovations in Digestive Tumours) is an ambispective national cohort of all incident CRC cases diagnosed in France in 2009 registered in the French health insurance database, which covers the entire French territory (including 64,304,500 people in 2009). The French National Health system provides public insurance for all people across the country. It consists of 15 regimens according to each social group (e.g. the regime for agricultural workers) and the general regimen

Patient characteristics

The number of incident cases of CRC was 41,342 in 2009; 31,665 patients were diagnosed between April and December 2009 (Fig. 1).

The median age was 72 years (71 in men and 74 in women). A total of 13,255 (42%) patients were ⩾75 years old (the median age was 81), and 3872 patients (13%) were ⩾80 years old. In comparison, 18,410 (58%) patients were <75 years old (the median age was 63). The mean Charlson Comorbidity Index (CCI) was 1.2 in the older group versus 0.7 in the group under 75. Among the

Discussion

To our knowledge, our study is the first and largest to date to examine real-life care of the elderly with CRC at a national level. This study considered 13,255 incident cases of elderly patients with CRC and was conducted from the first national cohort of 41,342 new cases of CRC extracted from the French health insurance system database in 2009. In our study, patients aged 75 and over represented more than 40% of the national incident cases, which is similar to published epidemiological data.

Funding

No external funds were used for this study.

Ethics approval

The study protocol was reviewed by a national institutional review board (CCTIRS 11053).

Conflict of interest statement

None declared.

Acknowledgments

The authors would like to acknowledge the members of the ‘Caisse Nationale d’Assurance Maladie des Travailleurs Salariés’.

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