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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Background:  Advances have occurred in the management of digestive tract cancers, but it is not known how much they have benefited the elderly.

Aims:  To determine trends in treatment, stage at diagnosis and prognosis of digestive tract cancers among patients aged ≥80 years in two well-defined French populations.

Design:  Time trends were studied in three age classes and in 5 four-year time intervals. A multivariate relative survival analysis was performed to estimate the independent effect of both age and period on prognosis.

Results:  Five-year relative survival rates were 1.9% for oesophageal cancer, 12% for stomach cancer, 41% for colon cancer and 37% for rectal cancer. The survival rates improved between the first and the fifth period for all cancer sites except for oesophageal cancer. This improvement remained significant after adjustment for age, sex, site and treatment. It was associated with an increase in the proportion of patients who underwent curative resection. Very few patients received adjuvant chemotherapy. The use of adjuvant radiotherapy for rectal and oesophageal cancers did not significantly increase over time.

Conclusions:  Except for oesophageal cancers, substantial advances in the care of digestive tract cancers in the elderly have been achieved. Surgery should not be restricted on the basis of age alone. Further improvements can be made in particular to enhance adjuvant therapy whenever possible.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Digestive oncogeriatry is becoming a crucial public health problem in western countries. The ageing of the population and the increase in life-expectancy as well as the increasing incidence of colorectal cancer lead to an increasing number of affected patients.1 Over the past 25 years, advances have occurred in the management of digestive tract cancers. Surgery remains the primary treatment but dramatic improvements in perioperative care have been made. Adjuvant treatments have been developed with the aim of reducing recurrence and improving survival.2, 3 Nevertheless, surgical indications can be challenging for the sole reason of age and chemotherapy is often experienced as too toxic for the elderly. If radiotherapy is considered to present fewer side effects, the need for transportation between the home and rare radiotherapy centres can limit its use for elderly patients. The likelihood of using treatments of proven benefit on the elderly population is not well known. Cancer registries recording accurate data on treatment and prognosis of digestive tract cancers at a population level represent a valuable resource to assess the management of patients. There is a paucity of reports of this type in published literature; data being mostly provided by specialized hospital units and as such cannot be used as reference because of unavoidable selection bias. The objective of this study was to determine trends over a 20-year period in treatment, stage at diagnosis and prognosis of digestive tract cancers among patients 80 and over in two well-defined French populations.

Population and method

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Patients

Two French population-based registries of digestive tract cancers were included in the study: Calvados (Normandy) and Côte-d'Or (Burgundy). They covered a resident population of 1 109 000 according to the 1999 census. Information is regularly obtained from pathologists, hospital and private physicians (gastroenterologists, surgeons, oncologists, general practitioners) and death certificates. No case was registered through death certificates alone but they were used to identify missing cases. Due to the involvement of the entire medical profession providing several notification sources per case, we assumed that nearly all newly diagnosed cases were recorded. The quality and exhaustivity of these two registries are certified every 4 years by an audit of the National Institute of Health and Medical Research (INSERM) and by the National Sanitary Survey Institute (InVS). These two registries include accurate data related to the clinical features, treatment, stage at diagnosis and follow-up of the patients. During the period 1978–1997, 1696 digestive tract cancers were recorded among Calvados residents and 1869 among Côte-d'Or residents aged 80 and over. They represented 22.3% of all digestive tract cancers.

Data set

Site of cancer was coded according to the International Classification of Diseases (ICD-10).4 The following sites were included in the study: the oesophagus (C15, n = 256), the stomach (C16, n = 900), the colon (C18, n = 1,571) and the rectum (C19 and C20, n = 838). Anal cancer cases were not included. The number and proportion of patients by cancer site for studied variables are given in Table 1. Three categories were assigned for age: 80–84, 85–89 and 90 years and above. Place of residence was coded as university hospital towns (Caen and Dijon), periurban areas (towns of more than 2000 inhabitants) and rural areas. Surgical treatment procedures were divided into curative resection (macroscopic resection of all malignant tissue and no microscopic evidence of surgical margin spread); palliative resection; and other surgical treatments (by-pass, exploratory laparotomy). Operative mortality was defined as death within 30 days of surgery. Period of diagnosis was divided into five groups of 4 years (1978–81, 1982–85, 1986–89, 1990–93 and 1994–97). Cancer extension at the time of diagnosis was classified according to the TNM classification, 1997 revision.5 Those who underwent resection but were not staged were classified as unknown (n = 7 for stomach, n = 25 for colon, n = 23 for rectum). Those in whom the cancer was not resected (by-pass, exploratory laparotomy, no laparotomy) and with no evidence of visceral metastasis (n = 221 for oesophagus, n = 433 for stomach, n = 207 for colon, n = 276 for rectum) were grouped with stage IV and classified as advanced cases. Adjuvant chemotherapy or radiotherapy was defined as chemotherapy or radiotherapy given after resection with curative intent.

Table 1.  Description of the population according to cancer site
 Oesophagus n (%)Stomach n (%)Colon n (%)Rectum n (%)
Male192 (75)411 (46)598 (38)366 (44)
Female64 (25)489 (54)973 (62)472 (56)
80–84 years161 (63)519 (58)817 (52)472 (56)
85–89 years79 (31)276 (31)556 (35)267 (32)
90 and over16 (6)105 (11)198 (13)99 (12)
1978–8131 (12)145 (16)199 (13)127 (15)
1982–8543 (17)170 (19)243 (15)140 (17)
1986–8950 (20)191 (21)299 (19)160 (19)
1990–9370 (27)197 (22)387 (25)190 (23)
1994–9762 (24)197 (22)443 (28)221 (26)
Urban area84 (33)399 (44)748 (48)369 (44)
Periurban area49 (19)147 (17)257 (16)128 (15)
Rural area123 (48)354 (39)566 (36)341 (41)
Stage I0 (0)60 (7)170 (11)134 (16)
Stage II0 (0)102 (11)542 (34)165 (20)
Stage III2 (1)122 (14)355 (23)134 (15)
Stage IV29 (11)181 (20)272 (17)106 (13)
No resection and no metastasis225 (88)428 (47)207 (13)276 (33)
Not known0 (0)7 (1)25 (2)23 (3)
Curative resection2 (1)276 (30)1080 (69)451 (54)
Palliative resection3 (1)70 (8)183 (12)58 (7)
By-pass/ laparotomy32 (13)106 (12)112 (7)99 (12)
No surgery219 (85)448 (50)196 (12)230 (27)
Chemotherapy13 (5)14 (2)28 (2)13 (2)
Radiotherapy134 (52)25 (3)9 (1)142 (17)

Details on patients’ survival were ascertained from death certificates, registrars of the place of birth and place of residence or practitioners. The life status was known for 94.5% patients at least 5 years after diagnosis.

Statistical analysis

Association between categorical data was analysed using chi-squared tests for homogeneity. The variations in proportions between first and last period for treatment and stage at diagnosis were calculated, using a relative variation of proportion [R = (proportion)94−97 − (proportion)78−81/(proportion)78−81]. A non-conditional logistic regression was used to identify the risk factors independently and significantly associated with curative resection.

Relative survival rates were calculated, these being defined as the ratio of the observed survival rate to the expected survival rate in a population of the same gender and age distribution as the cases estimated from population life-tables. Multivariate analysis was performed using a relative survival model with proportional hazard applied to the net mortality by interval. This model makes it possible to calculate relative risks in comparison with the baseline which is the cumulative net hazard calculated from a priori defined intervals. The significance of covariates was tested by the likelihood ratio test. Relative survival was estimated by means of STATA© algorithms (Stata Corporation, College Station, TX, USA).

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Treatment

Overall, curative resection was performed in 1% of patients with oesophageal cancer, 30% with stomach cancer, 69% with colon cancer and 54% of patients with rectal cancer (Table 1). Further analyses on treatment according to age and period of diagnosis were limited to stomach, colon and rectal cancers (Table 2). The curative resection rate increased over time for all sites and all age groups. The increase was particularly marked over the first three-study periods. The increase in the proportion of patients having their cancer resected for cure was associated with a corresponding decrease in the proportion of patients not operated. The proportion of palliative resection also increased except for rectal cancers. The proportion of patients resected for cure decreased with age, more rapidly for stomach and rectal cancer than for colon cancer. This proportion was on average two times higher for colon and rectal cancer than for stomach cancer in the 80–84 and 85–89 age groups, and three-to-five times higher in the 90 and over age group.

Table 2.  Trends in treatment modalities according to age and period at diagnosis*
 StomachColonRectum
1978–811994–97% variation1978–811994–97% variation1978–811994–97% variation
  1. * Due to low number of cases the oesophagus was not represented.

80–84 years
 Number of cases87100 120209 77103 
 Curative resection21.8%38.0%+74.353.3%78.5%+47.342.9%76.7%+78.8
 Palliative resection5.8%12.0%+106.912.5%12.9%+3.210.4%5.8%−44.2
 Not resected72.4%50.0%−30.934.2%8.6%−74.946.8%17.5%−62.6
85–89 years
 Number of cases4962 62167 3879 
 Curative resection16.3%25.8%+58.356.5%69.5%+23.023.7%59.5%+151.0
 Palliative resection4.1%6.5%+58.56.5%14.4%+121.52.6%6.3%+142.3
 Not resected79.6%67.7%−14.937.1%16.2%−56.373.7%34.2%−53.6
90 and over
Number of cases935 1767 1239 
Curative resection0%14.3%23.5%67.2%+185.98.3%43.6%+425.3
Palliative resection0%8.6%5.9%11.9%+101.78.3%2.6%−68.7
Not resected100%77.2%−22.870.6%20.9%−70.483.3%53.9%−35.3

In a multivariate analysis: age, period of diagnosis, place of residence and location of cancer were significant factors that were independently associated with the performance of the tumour curative resection (Table 3). Patients 90 and over were less likely than patients aged 80–84 to undergo a curative resection of their cancer. In the last study period, the odds of tumour resection was three times that of the earliest study period. Patients living in urban or periurban areas were more likely than patients living in rural areas to have a curative resection of their cancer.

Table 3.  Factors associated with curative resection
 OR [CI 95%]P*
  1. P-value of the log likelihood.

Sex
 Male1 
 Female1.04 [0.89-1.21]0.618
Age
 80–84 years1 
 85–89 years0.70 [0.59-0.82]<0.001
 90 and over0.39 [0.30-0.49]<0.001
Place of residence
 Urban area1 
 Peri-urban area0.95 [0.77-1.18]0.632
 Rural area0.79 [0.67-0.93]0.004
Period
 1978–811 
 1982–851.78 [1.36-2.32]<0.001
 1986–892.56 [1.98-3.32]<0.001
 1990–932.73 [2.12-3.51]<0.001
 1994–972.95 [2.30-3.78]<0.001
Cancer site
 Colon1 
 Oesophagus0.02 [0.01-0.06]<0.001
 Stomach0.19 [0.16-0.23]<0.001
 Rectum0.52 [0.44-0.63]<0.001
 Interaction localization*period1.09 [1.01-1.17]0.027

Operative mortality

Table 4 gives operative mortality rates for patients resected for cure according to period at diagnosis. Overall operative mortality after curative resection varied with time period for stomach cancer, being 37.0% during the first period and 15.2% during the last period (P = 0.050). Rates did not vary significantly for colon and rectal cancers. They were respectively 9.5 and 5.6% during the last study period.

Table 4.  Operative mortality among resected for cure patients according to period at diagnosis
 1978–81 (%)1982–85 (%)1986–89 (%)1990–93 (%)1994–97 (%)P*
  1. * Chi-squared test for homogeneity.

Stomach37.024.514.114.315.20.050
Colon8.716.16.910.69.50.056
Rectum16.39.87.78.85.60.270

Stage at diagnosis

The proportion of stage I–II was on average 18% for stomach cancer, 45% for colon cancer and 36% for rectal cancer (Table 1). The corresponding figures for advanced stages were respectively 67, 30 and 46%. No case presented stage I or II in oesophageal cancer. The overall relative increase in proportion of early stages between the first and the last study period was respectively +30.9 and +66.8% for colon and rectal cancer. This increase was less marked for stomach cancer: +8.8%. Conversely, for these three sites, there was a decrease in the proportion of patients presenting at advanced stage. The proportion of stage I–II was very similar in the different age groups and the different periods of time for colon and rectal cancers, except in patients over 90 where it was lower for rectal cancer than for colon cancer (Table 5).

Table 5.  Trend in stage* at diagnosis according to cancer site, period and age at diagnosis
 StomachColonRectum
1978–811994–97% variation1978–811994–97% variation1978–811994–97% variation
  1. * Not known, i.e. resected cases with missing data: stomach = 7 cases, colon = 25 cases, rectum = 23 cases.

  2. † stage IV and no resected cases.

80–84 years
 Number of cases8799 115208 74100 
 Stage I/II16.1%19.2%+19.236.5%55.8%+52.932.4%54.0%+66.6
 Stage III8.1%20.2%+149.418.3%21.6%+18.09.5%21.0%+121.0
 Advanced stage†75.9%60.6%−20.245.2%22.6%−50.058.1%25.0%−56.9
85–89 years
 Number of cases4861 60163 3778 
 Stage I/II10.4%11.5%+10.636.7%43.0%+16.921.6%42.3%+95.8
 Stage III6.3%14.8%+134.920.0%28.2%+41.00.0%18.0%
 Advanced stage†83.3%73.8%−11.443.3%28.8%−33.578.4%39.7%−49.4
90 and over
 Number of cases935 1665 1239 
 Stage I/II0.0%5.7%12.5%49.2%+293.68.3%25.6%+208.4
 Stage III0.0%11.4%6.3%18.5%+193.60.0%18.0%
 Advanced stage†100.0%82.9%−17.181.3%32.3%−60.391.7%56.4%−38.5

Chemotherapy and radiotherapy

Whatever the site of cancer, chemotherapy remained an anecdotal treatment among patients aged 80 and over: the proportion of cases that received chemotherapy varied from 1.6 (rectum) to 5.1% (oesophagus). Only one patient aged 90 and over had chemotherapy. Adjuvant chemotherapy has been recommended in stage III colon cancer since 1990. Overall, 4.8% of the patients were treated with adjuvant chemotherapy over the 1990–1997 period. The proportion of treated patients was 8.7% between 80 and 84 years and 1.3% in older patients. It was 4.5% over the 1990–93 period and 4.8% over the 1994–97 period. Palliative chemotherapy has also been proven effective in colorectal cancer (i.e. chemotherapy in stage IV and non-resected colorectal cancers). A total of 21 patients (2.4%) were treated. The proportion of patients who received palliative chemotherapy did not vary significantly over time.

Age was not associated with the practice of radiotherapy for rectal cancer: 15.7% of the 80–84 age group, 18.3% of the 85–89 age group and 19.2% of the 90 and over age group received radiotherapy (P = 0.726). Over the 20 years of the study, the use of neoadjuvant or adjuvant radiotherapy in rectal cancers increased slightly: 2.3% during the 1978–81 period, 6.7% during the 1982–85 period, 5.5% during the 1986–89 period, 10.6% during the 1990–93 period and 15.6% during the 1994–97 period (P = 0.001). The corresponding figures for palliative radiotherapy alone were respectively: 8.8, 18.5, 8.4, 5.2 and 3.5% (P = 0.026).

Overall, 134 patients (53.4%) with not resected oesophageal cancer received radiotherapy as the sole treatment. Among them 10 patients (4.0%) received simultaneous chemotherapy. There was no difference between age groups in the proportion of patients treated with radiotherapy: it was performed in 56.7% of patients aged 80–84, 47.4% in those aged 85–89 and 50.0% in those aged 90 and over. Over the 20 years of the study, there was no variation in the rate of radiotherapy in oesophageal cancer.

Prognosis

Table 6 shows the overall, 3- and 5-year relative survival rates according to cancer site, sex, age, period of diagnosis, treatment and stage. The overall 3-year relative survival rates were 5.0% for oesophageal cancer, 15.2% for stomach cancer, 45.2% for colon cancer and 46.2% for rectal cancer. The corresponding 5-year relative survival rates were respectively 1.9, 12.2, 40.9 and 37.3%. Three-year relative survival rates were lower in patients aged 90 and over compared with the younger patients except for rectal cancers. The difference between males and females was significant for stomach and rectal cancers. Survival rates improved significantly between the first and the fifth period for all cancer sites except for oesophageal cancer.

Table 6.  Relative overall, 3- and 5-year survival of digestive tract cancers (%)
 OesophagusStomachColonRectum
35P35P35P35P
  1. * Not known. i.e. resected cases with missing data: stomach = 7 cases, colon = 25 cases, rectum = 23 cases.

  2. ** stage IV and not resected cases.

  3. † log rank test comparing survival curves, NC = not calculated.

Overall5.01.9 15.212.2 45.240.9 46.237.3 
Age
 80–84 years5.63.2 14.210.4 47.040.1 44.335.7 
 85–89 years2.30.2 16.215.3 48.644.2 47.639.6 
 90 and over2.50.00.0811.80.00.00130.120.50.00144.734.30.057
Sex
 Male5.22.3 9.87.0 44.036.3 39.725.0 
 Female2.10.00.16116.914.50.01046.841.60.09251.145.80.001
Period
 1978–811.30.0 4.80.0 34.227.0 35.018.1 
 1982–853.50.0 8.56.8 38.333.6 33.424.9 
 1986–895.92.5 18.014.0 52.945.1 46.034.8 
 1990–931.90.0 18.614.4 44.235.9 54.044.8 
 1995–978.70.00.77515.211.90.00351.347.80.00150.341.70.010
Treatment
 Curative resectionNCNC 39.434.2 64.156.4 65.655.6 
 Other4.42.1NC4.42.60.0018.74.50.00123.515.70.001
Stage*
 Stage I/IINCNC 50.346.8 74.466.6 72.764.2 
 Stage IIINCNC 18.610.7 42.134.5 48.836.4 
 Advanced stage**4.42.1NC3.92.3<0.0017.03.9<0.00119.913.5<0.001

A multivariate relative survival model including age, gender, period of diagnosis, site and treatment was applied (Table 7). Age was independently associated with prognosis: as compared with patients aged 80–84, the relative excess risk of death was 1.08 [(1.00–1.17)P = 0.043] for patients aged 85–89 and 1.29 [(1.15–1.45) P < 0.001] for patients aged 90 and over. Sex, period of diagnosis [risk of death: 0.87 ((0.77–0.98) P = 0.019) for the latest period as compared with the first one], cancer site and treatment were significant independent factors of survival.

Table 7.  Multivariate relative survival analysis in the elderly
 All casesCurative resection*
RRIC 95%PRRIC 95%P
  1. * Operative mortality excluded.

Sex
 Male1  1  
 Female0.83[0.77–0.89]<0.0010.51[0.41–0.65]<0.001
Age at diagnosis
 80–84 years1  1  
 85–89 years1.08[1.00–1.17]0.0430.81[0.61–1.06]0.133
 90 and over1.29[1.15–1.45]0.0012.18[1.53–3.10]0.010
Period at diagnosis
 78–811  1  
 82–851.02[0.91–1.16]0.7050.84[0.57–1.24]]0.888
 86–890.88[0.78–0.99]0.0290.61[0.41–0.90]0.025
 90–930.89[0.79–1.00]0.0530.70[0.49–1.01]0.308
 95–970.87[0.77–0.98]0.0190.53[0.36–0.77]0.016
Cancer site
 Colon1  1  
 Stomach1.24[1.06–1.44]<0.0012.09[1.63–2.70]0.005
 Oesophagus1.33[1.22–1.46]0.006   
 Rectum0.82[0.75–0.90]<0.0010.90[0.68–1.20]0.517
Treatment
Curative resection1     
 Other treatment2.84[2.55–3.16]<0.001   
 Symptomatic treatment2.42[2.21–2.65]<0.001   

A second multivariate model restricted to patients resected for cure and alive after the first month of follow-up was applied for stomach, colon and rectal cancers (Table 7). After adjusting for sex, period and cancer site, age between 85 and 89 was no longer a significant factor of survival.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Data concerning patterns of care and their trends over time in the elderly in a non-selected community-based series are rare. The aim was to provide non-biased and detailed statistics on the management of alimentary tract cancers in the elderly over a 20-year period. The multiplicity of information sources allows the assumption that nearly all newly diagnosed cases were recorded. There was no recruitment selection such as can be observed in specialized units. Information on treatment, stage at diagnosis and survival were almost exhaustive. Data were available for two French regions ensuring a study with a large number of cases. This study emphasizes the predominance of colon and rectal cancers among digestive tract cancers in the elderly. Stomach cancers ranked third and oesophageal cancers were rare. Due to the difference in life-expectancy between sexes (in 1996, it was respectively 74.1 years in men and 82.0 years in women), the proportion of digestive tract cancers increased in women compared with men with increasing age.

One of the main results of this study was the dramatic increase over time of survival rates for stomach, colon and rectal cancer. The study provides several explanations for this trend. There was a major increase in the proportion of patients resected for cure over the first three-study periods. Then it levelled out. Besides progress in perioperative management and resuscitation, this shows a change in the habits and opinions of surgeons and anaesthetists over the first 12 years of the study. The absence of recent improvement in the proportion of curative resection suggests that they consider they cannot be any more forceful. Another important trend was the decrease over time in the proportion of patients diagnosed with advanced stages. Several explanations can be put forward: earlier first consultation, more frequent and more rapid referral for investigations by general practitioners and a more forceful attitude of surgeons. However, there was no further improvements in the stage at diagnosis over the more recent study period. There was a substantial variation in the proportion of cases resected for cure varying with the location of the cancer: <1% for oesophageal cancers vs. 70% for colon cancers. Oesophageal surgery is a major surgery, associated with substantial post-operative morbidity and mortality. Many elderly patients are not suitable for such major surgery because of frequent pre-existing co-morbidities often related to alcohol and tobacco intoxication. This finding is consistent with the EUROCARE study, including several European countries and providing results for patients 75 and over.6 Another reason for the improvement of prognosis is the decrease of operative mortality over the study period, even though it remains higher than in younger patients. This is all the more noticeable as the proportion of patients who were offered surgery increased. Major progress has been made in the thorough evaluation and preoperative correction of associated medical conditions and by improvement in post-operative resuscitation. The proportion of patients resected for cure was lower for stomach cancers than for colon and rectal cancers and decreased with age. This can be explained at least partly by later presentation and thus by a poor performance status. An expectation of a poorer outcome or presence of co-morbidities are other possible explanations. The relative survival model, by disentangling the role of life-expectancy and coexisting pathologies from that of cancer itself, showed that age had a modest effect on prognosis. The prognostic effect of the period of diagnosis becomes borderline significant when adjusting for treatment in the multivariate relative survival model. Our data suggest that patients should not be denied resection because of age alone. Similar conclusions have been reached recently by hospital-based reports.7–12 Our data have also demonstrated significant differences in prognosis between sexes in the elderly. At the same age, women probably have less co-morbidity than men. The period of diagnosis was a significant factor associated to the curative resection independently of site, age and place of residence. Patients who were living in rural areas, as compared with urban areas, were less prone to be resected for cure. This is in line with a French study which underlined that individuals living in rural areas were less likely to seek medical advice than individuals living in urban areas.13

Chemotherapy has been demonstrated effective as adjuvant treatment in TNM stage III colon cancer, as palliative treatment for colorectal cancers and radiotherapy as preoperative treatment for rectal cancer.3, 10, 14 This study underlines that very few patients over the age of 80 received chemotherapy for stage III colon cancer after its effectiveness had been demonstrated. Similar results were reported by SEER-Medicare database: 2.4% of patients aged 80 and over received adjuvant chemotherapy for stage III colon cancer between 1992 and 1998.15 Recorded data in our study did not allow us to estimate the proportion of patients unsuitable for chemotherapy due to pre-existing co-morbidity or refusal of treatment. However, considering the increase in life-expectancy and the relatively low toxicity of chemotherapy in colon cancer, it can be concluded that a larger proportion of patients over 80 who were healthy enough to be operated could benefit from this treatment. The misconception that the elderly are more prone to side effects and that advanced age limits the potential benefit of treatment probably largely explains that chemotherapy has not reached its full development in the elderly. A review of five randomized clinical trials including elderly patients receiving systemic adjuvant and palliative treatment and comparing them to their younger counterparts showed that 5-FU-based treatment was equally effective in spite of more minor toxicity like mucite.16 However a US study reported a more intensive use of adjuvant chemotherapy over the 1991–1996 period: 34% of patients aged 80–84 years, 11% of those aged 85–89 years and 2% of those aged 90 and over.17 This data suggest that efforts can be made to provide this potentially curative treatment to more patients. A study has focused on the analysis of determinants of colon cancer treatment decisions and underlined that the major determinant of the patient's decision was their physician's advice.18 The importance that patients place on physician opinion makes it imperative that clinicians fully remind them of the potential benefit of chemotherapy. Similar comments can be made for palliative chemotherapy of advanced colorectal cancers. Radiotherapy is generally well tolerated in the elderly except the problem of iterative journeys between home and the radiotherapy centre. Radiochemotherapy has been demonstrated as more efficacious than radiotherapy alone. It should be used whenever possible. The few available data suggested that elderly colon or rectal cancer patients benefited from chemotherapy just as much as younger patients did, without significant additional side effects.19–21 The proportion of patients with rectal cancer receiving adjuvant radiotherapy slightly increased without reaching 20% during the last time period. As in chemotherapy, it was probably not made clear enough by recommendations that age alone should not exclude a patient from adjuvant or palliative treatment. Again co-morbidity and advanced age are more commonly cited reasons for not administering adjuvant therapies in patients with rectal cancer aged 75 and over than patient refusal.17, 22 Over the study period, radiotherapy alone remained the main treatment for oesophageal cancer, without significant trend over time. Radiochemotherapy, which is more effective than radiotherapy, could become an alternative in oesophageal cancer.

Experts have to spread targeted information to practitioners to ensure that maximum treatment benefit is obtained in elderly patients and further improvements could come from earlier stage at diagnosis or advances of more effective adjuvant and palliative treatments.

Acknowledgement

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

This study was supported by a grant from the French National Health System (CNAMTS).

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Population and method
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  • 1
    Remontet L, Estève J, Bouvier AM, et al. Cancer incidence and mortality in France over the period 1978–2000. Rev Epidemiol Sante Publ 2003; 51: 330.
  • 2
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