Sir,
We read with great interest a recently published article in your journal titled ‘Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer’ (Feliu, 2010).
Initially, I would like to commend the authors of that article, especially for their interest in finding effective treatment regimens for the elderly, which are also associated with acceptable tolerance levels.
However, I would like to highlight certain data.
People aged 65 years and older have a cancer incidence 11 times greater than that of younger individuals, and the risk of mortality from malignancy is 16 times higher (http://seer.cancer.gov/csr/1975_2000/). Demographic shifts are producing a very rapid growth in at-risk populations, so that by 2030, 20% of the population will be over 65 years. Unfortunately, oncologists are not sufficiently prepared for this demographic shift, as their training focuses on selecting the best therapeutic approaches for young and physically healthy patients (Mandelblatt et al, 2000; Hurria et al, 2003). There is, however, significant heterogeneity among elderly patients, even among those with the same chronological ages. Such heterogeneity is associated with different tolerance levels towards cancer treatments.
Oncologists need an assessment tool that will provide information about the ‘functional age’ of older individuals, rather than the ‘chronological age’. An assessment tool named the ‘comprehensive geriatric assessment’ (CGA) may help to identify elderly patients who are most vulnerable to complications from cancer treatments. This interdisciplinary assessment provides information about the patient's functional status, comorbidity, nutritional status, psychological status, social support, cognitive status and other medications (Extermann et al, 1998; Repetto et al, 2002; Extermann and Hurria, 2007).
Several cross-sectional studies have demonstrated an association between the CGA and factors such as toxicity, morbidity and mortality during cancer treatment in older patients (Extermann et al, 2002; Audisio et al, 2005; Freyer et al, 2005; Maione et al, 2005; Ramesh et al, 2005).
In the field of geriatric oncology, the CGA can distinguish three broad groups of elderly patients: (1) ‘fit’ patients, who can be treated with chemotherapy in the same way as younger patients; (2) ‘prefrail’ patients, for whom chemotherapy should be administered with special schemes, reduced doses and haematological support factors; and (3) ‘frail’ patients, for whom the best therapeutic option involves supportive care and nonspecific palliative treatment (Balducci, 2007). However, the authors of the article merely utilised three parameters to decide whether it was possible to administer chemotherapy to the elderly: functional status, as measured by the Lawton–Brody Scale and the Barthel Scale; comorbidity, as measured by the Charlson Index; and the researchers' own subjective opinions. Recently, it has been reported that low scores on the ‘Mini Nutritional Assessment’ (MNA) questionnaire, which is used to assess nutritional status, and on the ‘Mini Mental State Examination’ (MMSE), which is used to determine cognitive status, are associated with an increased likelihood of elderly patients being unable to complete chemotherapy. In addition, a low score on the MNA is associated with an increased risk of mortality if chemotherapy is administered to the elderly (Aaldriks et al, 2010). Such findings indicate that there are sufficient functional status assessment options for elderly patients with cancer.
Based on these data, we strongly advocate that the CGA be used to evaluate elderly patients before the administration of any cancer treatment. Although only a few authors have used specific models of the CGA (Balducci, 2001; Ingram et al, 2002; Repetto et al, 2002; Hurria et al, 2005; Overcash et al, 2006; Molina-Garrido and Guillén-Ponce, 2010), any of these models could have been applied to this study.
We also believe that the subjective data, though important in subject areas with limited previous research, should be relegated to the background, especially because there is an objective way to evaluate elderly cancer patients: the CGA.
Change history
29 March 2012
This paper was modified 12 months after initial publication to switch to Creative Commons licence terms, as noted at publication
References
Aaldriks AA, Maartense E, le Cessie S, Giltay EJ, Verlaan HA, van der Geest LG, Kloosterman-Boele WM, Peters-Dijkshoorn MT, Blansjaar BA, van Schaick HW, Nortier JW (2010) Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol, e-pub ahead of print 14 August 2010; doi:10.1016/j.critrevonc.2010.05.009
Audisio RA, Ramesh H, Longo WE, Zbar AP, Pope D (2005) Preoperative assessment of surgical risk in oncogeriatric patients. Oncologist 10 (4): 262–268
Balducci L (2001) The geriatric cancer patient: equal benefit form equal treatment. Cancer Control 8 (Suppl 2): 1–25
Balducci L (2007) Aging, frailty, and chemotherapy. Aging, frailty, and chemotherapy. Cancer Control 14 (1): 7–12
Extermann M, Chen H, Cantor AB, Corcoran MB, Meyer J, Grendys E, Cavanaugh D, Antonek S, Camarata A, Haley WE, Balducci L (2002) Predictors of tolerance to chemotherapy in older cancer patients: a prospective pilot study. Eur J Cancer 38 (11): 1466–1473
Extermann M, Hurria A (2007) Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 25 (14): 1824–1831
Extermann M, Overcash J, Lyman GH, Parr J, Balducci L (1998) Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 16: 1582–1587
Feliu (2010) Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer. Br J Cancer 102 (10): 1468–1473
Freyer G, Geay JF, Touzet S, Provencal J, Weber B, Jacquin JP, Ganem G, Tubiana-Mathieu N, Gisserot O, Pujade-Lauraine E (2005) Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: a GINECO study. Ann Oncol 16 (11): 1795–1800
Hurria A, Gupta S, Zauderer M, Zuckerman EL, Cohen HJ, Muss H, Rodin M, Panageas KS, Holland JC, Saltz L, Kris MG, Noy A, Gomez J, Jakubowski A, Hudis C, Kornblith AB (2005) Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 104 (9): 1998–2005
Hurria A, Leung D, Trainor K, Borgen P, Norton L, Hudis C (2003) Factors influencing treatment patterns of breast cancer patients age 75 and older. Crit Rev Oncol Hematol 46 (2): 121–126
Ingram SS, Seo PH, Martell RE, Clipp EC, Doyle ME, Montana GS, Cohen HJ (2002) Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. J Clin Oncol 20: 770–775
Maione P, Perrone F, Gallo C, Manzione L, Piantedosi F, Barbera S, Cigolari S, Rosetti F, Piazza E, Robbiati SF, Bertetto O, Novello S, Migliorino MR, Favaretto A, Spatafora M, Ferraù F, Frontini L, Bearz A, Repetto L, Gridelli C, Barletta E, Barzelloni ML, Iaffaioli RV, De Maio E, Di Maio M, De Feo G, Sigoriello G, Chiodini P, Cioffi A, Guardasole V, Angelini V, Rossi A, Bilancia D, Germano D, Lamberti A, Pontillo V, Brancaccio L, Renda F, Romano F, Esani G, Gambaro A, Vinante O, Azzarello G, Clerici M, Bollina R, Belloni P, Sannicolò M, Ciuffreda L, Parello G, Cabiddu M, Sacco C, Sibau A, Porcile G, Castiglione F, Ostellino O, Monfardini S, Stefani M, Scagliotti G, Selvaggi G, De Marinis F, Martelli O, Gasparini G, Morabito A, Gattuso D, Colucci G, Galetta D, Giotta F, Gebbia V, Borsellino N, Testa A, Malaponte E, Capuano MA, Angiolillo M, Sollitto F, Tirelli U, Spazzapan S, Adamo V, Altavilla G, Scimone A, Hopps MR, Tartamella F, Ianniello GP, Tinessa V, Failla G, Bordonaro R, Gebbia N, Valerio MR, D'Aprile M, Veltri E, Tonato M, Darwish S, Romito S, Carrozza F, Barni S, Ardizzoia A, Corradini GM, Pavia G, Belli M, Colantuoni G, Galligioni E, Caffo O, Labianca R, Quadri A, Cortesi E, D'Auria G, Fava S, Calcagno A, Luporini G, Locatelli MC, Di Costanzo F, Gasperoni S, Isa L, Candido P, Gaion F, Palazzolo G, Nettis G, Annamaria A, Rinaldi M, Lopez M, Felletti R, Di Negro GB, Rossi N, Calandriello A, Maiorino L, Mattioli R, Celano A, Schiavon S, Illiano A, Raucci CA, Caruso M, Foa P, Tonini G, Curcio C, Cazzaniga M (2005) Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol 23 (28): 6865–6872
Mandelblatt JS, Hadley J, Kerner JF, Schulman KA, Gold K, Dunmore-Griffith J, Edge S, Guadagnoli E, Lynch JJ, Meropol NJ, Weeks JC, Winn R (2000) Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences. Cancer 89 (3): 561–573
Molina-Garrido MJ, Guillén-Ponce C (2010) Development of a cancer-specific Comprehensive Geriatric Assessment in a University Hospital in Spain. Crit Rev Oncol Hematol, e-pub ahead of print 29 March 2010; doi:10.1016/j.critrevonc.2010.02.006
Overcash JA, Beckstead J, Moody L, Extermann M, Cobb S (2006) The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation. Crit Rev Oncol Hematol 59 (3): 205–210
Ramesh HS, Jain S, Audisio RA (2005) Implications of aging in surgical oncology. Cancer J 11 (6): 488–494
Repetto L, Fratino L, Audisio RA, Venturino A, Gianni W, Vercelli M, Parodi S, Dal Lago D, Gioia F, Monfardini S, Aapro MS, Serraino D, Zagonel V (2002) Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol 20: 494–502
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
From twelve months after its original publication, this work is licensed under the Creative Commons Attribution-NonCommercial-Share Alike 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/3.0/
About this article
Cite this article
Molina-Garrido, M., Guillén-Ponce, C. Comment on ‘Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer’. Br J Cancer 104, 224–225 (2011). https://doi.org/10.1038/sj.bjc.6606037
Published:
Issue Date:
DOI: https://doi.org/10.1038/sj.bjc.6606037
This article is cited by
-
Reply: Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer
British Journal of Cancer (2011)