Review Article| Volume 48, ISSUE 10, P1112-1118, October 2016

Download started.


Colorectal cancer care in elderly patients: Unsolved issues


      Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Digestive and Liver Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Frerot M.
        • Jooste V.
        • Binquet C.
        • et al.
        Factors influencing inclusion in digestive cancer clinical trials: a population-based study.
        Digestive and Liver Disease. 2015; 47: 891-896
        • Sorbye H.
        • Pfeiffer P.
        • Cavalli-Bjorkman N.
        • et al.
        Clinical trial enrollment, patient characteristics, and survival differences in prospectively registered metastatic colorectal cancer patients.
        Cancer. 2009; 115: 4679-4687
        • Yee K.W.
        • Pater J.L.
        • Pho L.
        • et al.
        Enrollment of older patients in cancer treatment trials in Canada: why is age a barrier?.
        Journal of Clinical Oncology. 2003; 21: 1618-1623
        • Papamichael D.
        • Audisio R.A.
        • Glimelius B.
        • et al.
        Treatment of colorectal cancer in older patients: International Society of Geriatric Oncology (SIOG) consensus recommendations 2013.
        Annals of Oncology. 2015; 26: 463-476
        • Vercelli M.
        • Capocaccia R.
        • Quaglia A.
        • et al.
        Relative survival in elderly European cancer patients: evidence for health care inequalities. The EUROCARE Working Group.
        Critical Reviews in Oncology/Hematology. 2000; 35: 161-179
      1. Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group.
        Lancet. 2000; 356: 968-974
        • Ferrat E.
        • Paillaud E.
        • Laurent M.
        • et al.
        Predictors of 1-year mortality in a prospective cohort of elderly patients with cancer.
        Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2015; 70: 1148-1155
        • Hurria A.
        • Togawa K.
        • Mohile S.G.
        • et al.
        Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study.
        Journal of Clinical Oncology. 2011; 29: 3457-3465
        • Soubeyran P.
        • Fonck M.
        • Blanc-Bisson C.
        • et al.
        Predictors of early death risk in older patients treated with first-line chemotherapy for cancer.
        Journal of Clinical Oncology. 2012; 30: 1829-1834
        • Balducci L.
        • Extermann M.
        Management of cancer in the older person: a practical approach.
        Oncologist. 2000; 5: 224-237
        • Aparicio T.
        • Navazesh A.
        • Boutron I.
        • et al.
        Half of elderly patients routinely treated for colorectal cancer receive a sub-standard treatment.
        Critical Reviews in Oncology/Hematology. 2009; 71: 249-257
        • Doat S.
        • Thiebaut A.
        • Samson S.
        • et al.
        Elderly patients with colorectal cancer: treatment modalities and survival in France. National data from the ThInDiT cohort study.
        European Journal of Cancer. 2014; 50: 1276-1283
        • Aparicio T.
        • Bouarioua N.
        • Lobry C.
        Evolution de la prescription d’une chimiothérapie adjuvante pour cancer du côlon après 75ans sur la période 1995–2005.
        Journal Oncogériatrie. 2015; 6: 13-16
        • Mahoney T.
        • Kuo Y.H.
        • Topilow A.
        • et al.
        Stage III colon cancers: why adjuvant chemotherapy is not offered to elderly patients.
        Archives of Surgery. 2000; 135: 182-185
        • Extermann M.
        • Albrand G.
        • Chen H.
        • et al.
        Are older French patients as willing as older American patients to undertake chemotherapy?.
        Journal of Clinical Oncology. 2003; 21: 3214-3219
        • Puts M.T.
        • Hardt J.
        • Monette J.
        • et al.
        Use of geriatric assessment for older adults in the oncology setting: a systematic review.
        Journal of the National Cancer Institute. 2012; 104: 1133-1163
        • Kenis C.
        • Bron D.
        • Libert Y.
        • et al.
        Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study.
        Annals of Oncology. 2013; 24: 1306-1312
        • Caillet P.
        • Canoui-Poitrine F.
        • Vouriot J.
        • et al.
        Comprehensive geriatric assessment in the decision-making process in elderly patients with cancer: ELCAPA study.
        Journal of Clinical Oncology. 2011; 29: 3636-3642
        • Brugel L.
        • Laurent M.
        • Caillet P.
        • et al.
        Impact of comprehensive geriatric assessment on survival, function, and nutritional status in elderly patients with head and neck cancer: protocol for a multicentre randomized controlled trial (EGeSOR).
        BMC Cancer. 2014; 14: 427
        • Kalsi T.
        • Babic-Illman G.
        • Ross P.J.
        • et al.
        The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people.
        British Journal of Cancer. 2015; 112: 1435-1444
        • Hamaker M.E.
        • Jonker J.M.
        • de Rooij S.E.
        • et al.
        Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review.
        Lancet Oncology. 2012; 13: e437-e444
        • Handforth C.
        • Clegg A.
        • Young C.
        • et al.
        The prevalence and outcomes of frailty in older cancer patients: a systematic review.
        Annals of Oncology. 2015; 26: 1091-1101
        • Bellera C.A.
        • Rainfray M.
        • Mathoulin-Pelissier S.
        • et al.
        Screening older cancer patients: first evaluation of the G-8 geriatric screening tool.
        Annals of Oncology. 2012; 23: 2166-2172
        • Liuu E.
        • Canoui-Poitrine F.
        • Tournigand C.
        • et al.
        Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: the ELCAPA-02 study.
        Journal of Geriatric Oncology. 2014; 5: 11-19
        • Paillaud E.
        • Liuu E.
        • Laurent M.
        • et al.
        Geriatric syndromes increased the nutritional risk in elderly cancer patients independently from tumour site and metastatic status. The ELCAPA-05 cohort study.
        Clinical Nutrition. 2014; 33: 330-335
        • Faivre J.
        • Dancourt V.
        • Lejeune C.
        • et al.
        Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study.
        Gastroenterology. 2004; 126: 1674-1680
        • Quarini C.
        • Gosney M.
        Review of the evidence for a colorectal cancer screening programme in elderly people.
        Age and Ageing. 2009; 38: 503-508
        • Arora A.
        • Singh P.
        Colonoscopy in patients 80 years of age and older is safe, with high success rate and diagnostic yield.
        Gastrointestinal Endoscopy. 2004; 60: 408-413
        • Day L.W.
        • Walter L.C.
        • Velayos F.
        Colorectal cancer screening and surveillance in the elderly patient.
        American Journal of Gastroenterology. 2011; 106: 1197-1206
        • Gross C.P.
        • McAvay G.J.
        • Krumholz H.M.
        • et al.
        The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening.
        Annals of Internal Medicine. 2006; 145: 646-653
        • van Hees F.
        • Saini S.D.
        • Lansdorp-Vogelaar I.
        • et al.
        Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness.
        Gastroenterology. 2015;
        • Lin O.S.
        • Kozarek R.A.
        • Schembre D.B.
        • et al.
        Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy.
        JAMA. 2006; 295: 2357-2365
        • Faivre-Finn C.
        • Bouvier-Benhamiche A.M.
        • Phelip J.M.
        • et al.
        Colon cancer in France: evidence for improvement in management and survival.
        Gut. 2002; 51: 60-64
        • Mitry E.
        • Bouvier A.M.
        • Esteve J.
        • et al.
        Benefit of operative mortality reduction on colorectal cancer survival.
        British Journal of Surgery. 2002; 89: 1557-1562
        • Modini C.
        • Romagnoli F.
        • De Milito R.
        • et al.
        Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly.
        Colorectal Disease. 2012; 14: e312-e318
        • Lemmens V.E.
        • Janssen-Heijnen M.L.
        • Verheij C.D.
        • et al.
        Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer.
        British Journal of Surgery. 2005; 92: 615-623
        • Allardyce R.A.
        • Bagshaw P.F.
        • Frampton C.M.
        • et al.
        Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection.
        British Journal of Surgery. 2010; 97: 86-91
        • Kvasnovsky C.L.
        • Adams K.
        • Sideris M.
        • et al.
        Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery.
        Colorectal Disease. 2016; 18: 94-100
        • Finlayson E.
        • Zhao S.
        • Boscardin W.J.
        • et al.
        Functional status after colon cancer surgery in elderly nursing home residents.
        Journal of the American Geriatrics Society. 2012; 60: 967-973
        • Mazzoni G.
        • Tocchi A.
        • Miccini M.
        • et al.
        Surgical treatment of liver metastases from colorectal cancer in elderly patients.
        International Journal of Colorectal Disease. 2007; 22: 77-83
        • de Liguori C.N.
        • van Leeuwen B.L.
        • Ghaneh P.
        • et al.
        Liver resection for colorectal liver metastases in older patients.
        Critical Reviews in Oncology/Hematology. 2008; 67: 273-278
        • Barrier A.
        • Ferro L.
        • Houry S.
        • et al.
        Rectal cancer surgery in patients more than 80 years of age.
        American Journal of Surgery. 2003; 185: 54-57
        • Rutten H
        • den Dulk M.
        • Lemmens V.
        • et al.
        Survival of elderly rectal cancer patients not improved: analysis of population based data on the impact of TME surgery.
        European Journal of Cancer. 2007; 43: 2295-2300
        • Manceau G.
        • Karoui M.
        • Werner A.
        • et al.
        Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review.
        Lancet Oncology. 2012; 13: e525-e536
        • Tougeron D.
        • Roullet B.
        • Paillot B.
        • et al.
        Safety and outcome of chemoradiotherapy in elderly patients with rectal cancer: results from two French tertiary centres.
        Digestive and Liver Disease. 2012; 44: 350-354
        • Olsson L.I.
        • Granstrom F.
        • Glimelius B.
        Socioeconomic inequalities in the use of radiotherapy for rectal cancer: a nationwide study.
        European Journal of Cancer. 2011; 47: 347-353
        • Jung B.
        • Pahlman L.
        • Johansson R.
        • et al.
        Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish Rectal Cancer Registry 1995–2004.
        BMC Cancer. 2009; 9: 68
        • Martijn H.
        • Vulto J.C.
        Should radiotherapy be avoided or delivered differently in elderly patients with rectal cancer?.
        European Journal of Cancer. 2007; 43: 2301-2306
        • Maas M.
        • Beets-Tan R.G.
        • Lambregts D.M.
        • et al.
        Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer.
        Journal of Clinical Oncology. 2011; 29: 4633-4640
        • Faivre-Finn C.
        • Bouvier A.M.
        • Mitry E.
        • et al.
        Chemotherapy for colon cancer in a well-defined French population: is it under- or over-prescribed?.
        Alimentary Pharmacology and Therapeutics. 2002; 16: 353-359
        • Lievre A.
        • Laurent V.
        • Cudennec T.
        • et al.
        Management of patients over 80 years of age treated with resection for localised colon cancer: results from a French referral centre.
        Digestive and Liver Disease. 2014; 46: 838-845
        • Bouvier A.M.
        • Launoy G.
        • Lepage C.
        • et al.
        Trends in the management and survival of digestive tract cancers among patients aged over 80 years.
        Alimentary Pharmacology and Therapeutics. 2005; 22: 233-241
        • Sargent D.J.
        • Goldberg R.M.
        • Jacobson S.D.
        • et al.
        A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients.
        New England Journal of Medicine. 2001; 345: 1091-1097
        • Andre T.
        • Boni C.
        • Mounedji-Boudiaf L.
        • et al.
        Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer.
        New England Journal of Medicine. 2004; 350: 2343-2351
        • McCleary N.J.
        • Meyerhardt J.A.
        • Green E.
        • et al.
        Impact of age on the efficacy of newer adjuvant therapies in patients with stage II/III colon cancer: findings from the ACCENT database.
        Journal of Clinical Oncology. 2013; 31: 2600-2606
        • Tournigand C.
        • Andre T.
        • Bonnetain F.
        • et al.
        Adjuvant therapy with fluorouracil and oxaliplatin in stage II and elderly patients (between ages 70 and 75 years) with colon cancer: subgroup analyses of the Multicenter International Study of Oxaliplatin, Fluorouracil, and Leucovorin in the Adjuvant Treatment of Colon Cancer trial.
        Journal of Clinical Oncology. 2012; 30: 3353-3360
        • Aparicio T.
        • Francois E.
        • Cristol-Dalstein L.
        • et al.
        PRODIGE 34 – FFCD 1402 – ADAGE: adjuvant chemotherapy in elderly patients with resected stage III colon cancer. A randomized phase 3 trial.
        Digestive and Liver Disease. 2016; 48: 206-207
        • Quasar Collaborative Group
        • Gray R.
        • Barnwell J.
        • et al.
        Adjuvant chemotherapy versus observation in patients with colorectal cancer: a randomized study.
        Lancet. 2007; 370: 2020-2029
        • O’Connor E.S.
        • Greenblatt D.Y.
        • LoConte N.K.
        • et al.
        Adjuvant chemotherapy for stage II colon cancer with poor prognostic features.
        Journal of Clinical Oncology. 2011; 29: 3381-3388
        • Ribic C.M.
        • Sargent D.J.
        • Moore M.J.
        • et al.
        Tumor microsatellite-instability status as a predictor of benefit from fluorouracil-based adjuvant chemotherapy for colon cancer.
        New England Journal of Medicine. 2003; 349: 247-257
        • Sargent D.J.
        • Marsoni S.
        • Monges G.
        • et al.
        Defective mismatch repair as a predictive marker for lack of efficacy of fluorouracil-based adjuvant therapy in colon cancer.
        Journal of Clinical Oncology. 2010; 28: 3219-3226
        • Aparicio T.
        • Schischmanoff O.
        • Poupardin C.
        • et al.
        High prevalence of deficient mismatch repair phenotype and the V600E BRAF mutation in elderly patients with colorectal cancer.
        Journal of Geriatric Oncology. 2014; 5: 384-388
        • Aparicio T.
        • Schischmanoff O.
        • Poupardin C.
        • et al.
        Deficient mismatch repair phenotype is a prognostic factor for colorectal cancer in elderly patients.
        Digestive and Liver Disease. 2013; 45: 245-250
        • Folprecht G.
        • Cunningham D.
        • Ross P.
        • et al.
        Efficacy of 5-fluorouracil-based chemotherapy in elderly patients with metastatic colorectal cancer: a pooled analysis of clinical trials.
        Annals of Oncology. 2004; 15: 1330-1338
        • Folprecht G.
        • Seymour M.T.
        • Saltz L.
        • et al.
        Irinotecan/fluorouracil combination in first-line therapy of older and younger patients with metastatic colorectal cancer: combined analysis of 2,691 patients in randomized controlled trials.
        Journal of Clinical Oncology. 2008; 26: 1443-1451
        • Goldberg R.M.
        • Tabah-Fisch I.
        • Bleiberg H.
        • et al.
        Pooled analysis of safety and efficacy of oxaliplatin plus fluorouracil/leucovorin administered bimonthly in elderly patients with colorectal cancer.
        Journal of Clinical Oncology. 2006; 24: 4085-4091
        • Seymour M.T.
        • Thompson L.C.
        • Wasan H.S.
        • et al.
        Chemotherapy options in elderly and frail patients with metastatic colorectal cancer (MRC FOCUS2): an open-label, randomized factorial trial.
        Lancet. 2011; 377: 1749-1759
        • Aparicio T.
        • Lavau-Denes S.
        • Phelip J.M.
        • et al.
        Randomized phase III trial in elderly patients comparing LV5FU2 with or without irinotecan for first-line treatment of metastatic colorectal cancer (FFCD 2001-02).
        Annals of Oncology. 2016; 27: 121-127
        • Landre T.
        • Uzzan B.
        • Nicolas P.
        • et al.
        Doublet chemotherapy vs. single-agent therapy with 5FU in elderly patients with metastatic colorectal cancer. A meta-analysis.
        International Journal of Colorectal Disease. 2015; 30: 1305-1310
        • Aparicio T.
        • Jouve J.L.
        • Teillet L.
        • et al.
        Geriatric factors predict chemotherapy feasibility: ancillary results of FFCD 2001-02 phase III study in first-line chemotherapy for metastatic colorectal cancer in elderly patients.
        Journal of Clinical Oncology. 2013; 31: 1464-1470
        • Kozloff M.
        • Yood M.U.
        • Berlin J.
        • et al.
        Clinical outcomes associated with bevacizumab-containing treatment of metastatic colorectal cancer: the BRiTE observational cohort study.
        Oncologist. 2009; 14: 862-870
        • Cassidy J.
        • Saltz L.B.
        • Giantonio B.J.
        • et al.
        Effect of bevacizumab in older patients with metastatic colorectal cancer: pooled analysis of four randomized studies.
        Journal of Cancer Research and Clinical Oncology. 2010; 136: 737-743
        • Price T.J.
        • Zannino D.
        • Wilson K.
        • et al.
        Bevacizumab is equally effective and no more toxic in elderly patients with advanced colorectal cancer: a subgroup analysis from the AGITG MAX trial: an international randomized controlled trial of Capecitabine, Bevacizumab and Mitomycin C.
        Annals of Oncology. 2012; 23: 1531-1536
        • Cunningham D.
        • Lang I.
        • Marcuello E.
        • et al.
        Bevacizumab plus capecitabine versus capecitabine alone in elderly patients with previously untreated metastatic colorectal cancer (AVEX): an open-label, randomized phase 3 trial.
        Lancet Oncology. 2013; 14: 1077-1085
        • Aparicio T.
        • Bouche O.
        • Francois E.
        • et al.
        PRODIGE 20: bevacizumab+chemotherapy (BEV-CT) versus chemotherapy alone (CT) in elderly patients (pts) with untreated metastatic colorectal cancer (mCRC) – a randomized phase II trial.
        Journal of Clinical Oncology. 2015; 33
        • Rosati G.
        • Aprile G.
        • Cardellino G.G.
        • et al.
        A review and assessment of currently available data of the EGFR antibodies in elderly patients with metastatic colorectal cancer.
        Journal of Geriatric Oncology. 2016; 7: 134-141
        • Fornaro L.
        • Baldi G.G.
        • Masi G.
        • et al.
        Cetuximab plus irinotecan after irinotecan failure in elderly metastatic colorectal cancer patients: clinical outcome according to KRAS and BRAF mutational status.
        Critical Reviews in Oncology/Hematology. 2011; 78: 243-251
        • Jehn C.F.
        • Boning L.
        • Kroning H.
        • et al.
        Influence of comorbidity, age and performance status on treatment efficacy and safety of cetuximab plus irinotecan in irinotecan-refractory elderly patients with metastatic colorectal cancer.
        European Journal of Cancer. 2014; 50: 1269-1275
        • Folprecht G.
        • Köhne C.
        • Bokemeyer C.
        • et al.
        Cetuximab and 1st-line chemotherapy in elderly and younger patients with metastatic colorectal cancer: a pooled analysis of the CRISTAL and OPUS studies.
        Annals of Oncology [European Cancer Congress]. 2010; A597
        • Van Cutsem E.
        • Peeters M.
        • Siena S.
        • et al.
        A phase III randomized controlled trial of panitumumab (Pmab) in patients (pts) with metastatic colorectal cancer (mCRC): subset analyses in elderly pts and in pts with poor performance status.
        in: Proceedings of ASCO GI Cancer Symposium, vol. A349. 2007
        • Sastre J.
        • Aranda E.
        • Gravalos C.
        • et al.
        First-line single-agent cetuximab in elderly patients with metastatic colorectal cancer. A phase II clinical and molecular study of the Spanish group for digestive tumor therapy (TTD).
        Critical Reviews in Oncology/Hematology. 2011; 77: 78-84
        • Sastre J.
        • Gravalos C.
        • Rivera F.
        • et al.
        First-line cetuximab plus capecitabine in elderly patients with advanced colorectal cancer: clinical outcome and subgroup analysis according to KRAS status from a Spanish TTD Group Study.
        Oncologist. 2012; 17: 339-345
        • Sastre J.
        • Massuti B.
        • Pulido G.
        • et al.
        First-line single-agent panitumumab in frail elderly patients with wild-type KRAS metastatic colorectal cancer and poor prognostic factors: a phase II study of the Spanish Cooperative Group for the Treatment of Digestive Tumours.
        European Journal of Cancer. 2015; 51: 1371-1380
        • Van Cutsem E.
        • Sobrero A.
        • Siena S.
        • et al.
        Regorafenib in progressive metastatic colorectal cancer: analysis of age subgroups in the phase III CORRECT trial.
        Journal of Clinical Oncology. 2013; 31