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