Quality of Life And Adjuvant Treatment of Elderly Colorectal Cancer Patients: Good News
Abstract & Commentary
By William B. Ershler, MD, Editor
Synopsis: In an effort to determine the influence of chemotherapy on elderly patients with colorectal cancer, Bouvier and colleagues measured quality of life at 3 month intervals in a community-based population of registry-identified cancer patients. Quality of life did not decline over the one year after surgery in this cohort as a whole, or in those who received adjuvant chemotherapy or radiation.
Source: Bouvier AM, et al. Adjuvant treatments do not alter the quality of life in elderly patients with colorectal cancer. A population-based study. Cancer. 2008;113:879-886.
Cancers of the colon and rectum occur most commonly in those over the age of 60 years and despite substantial evidence that chemotherapy is effective in both adjuvant and palliative settings, it is also quite well established that older patients are less likely to be treated.1 Upon questioning in this regard, older patients have indicated that the primary determinant of their decision regarding chemotherapy was their physician's advice.2 For their part, physicians may be reluctant to treat, particularly in the adjuvant setting, because of a concern that treatment will disproportionately impair quality of life in older patients. To address this, Bouvier and colleagues from France performed a longitudinal analysis to assess the impact of adjuvant treatments on the quality of life (QoL) of elderly colorectal cancer patients.
For this, the investigators capitalized on the established Burgundy Digestive Cancer Registry. All patients 75 years of age or older who were diagnosed with colorectal cancer between 2003 and 2005 were identified. Of these, a total of 209 patients were asked to complete questionnaires on four occasions at 3 month intervals during the first year after diagnosis. They utilized the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. A total of 125 patients (60%) responded. Mixed model analyses of variance for repeated measurement were used to compare QoL scores according to therapeutic schemes. Interactions between time of follow-up and treatment were tested.
Patient sex, age, location of the tumor (colon or rectum), and TNM stage of disease did not differ significantly between respondents and non-respondents. Global Health and Emotional Functioning improved for both colon and rectal cancer patients during the year after diagnosis. Patients who received chemotherapy for stage III colon cancer or radiotherapy for rectal cancer according to current recommendations reported no significant changes in Global Health compared with those patients not receiving adjuvant therapies. Patients treated with chemotherapy reported better Physical Functioning than patients who did not receive chemotherapy.
Commentary
Thus, it appears that quality of life was not negatively influenced by adjuvant chemotherapy in this cohort of elderly patients. In fact, the component that might have seemed to be most affected (Physical Functioning) was even shown to be better, not worse in those who were receiving chemotherapy. The authors suggest that this might reflect a clinical selection bias, in which chemotherapy tends to be offered to the more healthy patients, or by the presence of a "response shift" phenomenon, which leads patients faced with cancer and its strong treatment to adopt a more pragmatic attitude regarding their everyday life experiences and therefore to reduce their initial expectations regarding QoL and health, resulting in improvements in perceived QoL.
Under either circumstance, the findings are remarkable in that quality of life did not decline while under treatment. The impact of this observation is enhanced by certain methodological considerations. First, by choosing the age of 75 years and older, the focus is truly on geriatric management. Patients in the young-old group (65-74 years) are often included in these type of analyses and many in this age group function more like younger cancer patients. Secondly, these were community-based patients, not those referred to major cancer centers or universities. Accordingly, any selection bias (ie, inclusion of only the most fit elderly) was obviated. Nonetheless, the usual caveats about population-based research need to be considered, particularly the lack of randomization. In this series, for example, it is likely that those who received adjuvant treatment were not quite comparable to those who did not. Perhaps those who were most fearful, or even most likely to develop treatment-related toxicities opted not to be treated, and those who were heartiest and/or most psychologically inclined to receive treatment made that choice. Furthermore, the relatively small number of patients warrants additional caution in interpretation. Yet, it has to be considered good news that quality of life was not impaired during the year after diagnosis when comparing those who were treated with those who were not. This might be the first sequential assessment of QoL in truly old patients treated with adjuvant chemotherapy or radiation, it is an extremely important research domain. If confirmed by additional study, investigators will need to identify existing treatment barriers accounting for the age discrepancy in chemotherapy utilization.
References
1. Sargent DJ, et al. A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients. NEJM. 2001;345(15):1091-1097.
2. Newcomb PA, Carbone PP. Cancer treatment and age: patient perspectives. J Natl Cancer Inst. 1993;85(19):1580-1584.
In an effort to determine the influence of chemotherapy on elderly patients with colorectal cancer, Bouvier and colleagues measured quality of life at 3 month intervals in a community-based population of registry-identified cancer patients.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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