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Journal of Clinical Oncology, Vol 26, No 27 (September 20), 2008: pp. 4516-4517 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2008.18.7443
Patient Age and Comorbidity Are Major Determinants of Adjuvant Chemotherapy Use for Stage III Colon Cancer in Routine Clinical PracticeDepartment of Medical Oncology, Royal Melbourne Hospital, Australia
Department of Medical Oncology, Royal Melbourne Hospital, Melbourne; Department of Medical Oncology, Western Hospital; and BioGrid Australia, Parkville, Australia
BioGrid Australia, Parkville, Australia
Department of Medical Oncology, Royal Melbourne Hospital, Melbourne; and Department of Medical Oncology, Western Hospital, Footscray, Australia
Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia
Department of Surgery, Western Hospital, Australia
Department of Medical Oncology, Royal Melbourne Hospital, Melbourne; Department of Medical Oncology, Western Hospital; BioGrid Australia; and Ludwig Institute for Cancer Research, Parkville, Australia To the Editor: The publication from Keating et al,1 who surveyed cancer physicians and surgeons to explore the impact of age and comorbidity on adjuvant chemotherapy recommendations for stage III colon cancer, merits further discussion. Although of interest, the relationship between what cancer physicians indicate they would advise for hypothetical patients and what they would actually do in the clinic is uncertain. Also, only two specific age choices were included in this questionnaire, specific treatment recommendations were not sought, and the possible impact of patient attitude could not be explored. To compare the results of this survey with what we see happening in routine practice, and to further analyze the impact of patient factors on physician decision making, we reviewed data from our comprehensive, multicenter colorectal cancer database.2 We identified 252 patients with stage III colon cancer (49.3% men and 50.6% women; median age 67.7 years [range, 35 to 92 years]) who had undergone surgery between January 2003 and February 2008 at four hospitals in Melbourne, Australia. Detailed information regarding tumor stage, treatment recommendation, and treatment delivered was prospectively recorded for all patients. Five medical oncologists were routinely involved in treating these patients, and all patients were treated according to standard protocols.
As shown in Table 1, age and comorbidity were the strongest predictors of a medical oncologist not recommending adjuvant chemotherapy. A significant impact of patient preference was also seen, with this becoming more pronounced with advancing age. Fourteen patients overall (5.6%) decided not to pursue adjuvant chemotherapy against physician advice, with this accounting for 24% of the 58 patients who did not receive treatment. This was significantly more common in patients older than 70 years, with 12 (11.0%) of 109 compared with two (1.4%) of 143 patients
We then examined how age may impact the treatment pursued in those patients who did undergo adjuvant therapy (Fig 1). For this analysis, we examined data on the 125 patients treated since adjuvant oxaliplatin became readily available in Australia (September 2005). Although more than 90% of patients younger than 60 years of age received oxaliplatin-based treatment, with increasing age, the use of a fluoropyrimidine alone became more common, with no patient older than 80 years receiving oxaliplatin. Of note, the introduction of oxaliplatin did not significantly influence the number of patients receiving adjuvant therapy, with 72% of patients receiving treatment before and 76% receiving treatment after September 2005.
In summary, our routine care data are consistent with the survey results reported by Keating et al,1 indicating that in theory and in practice, age and comorbidity are dominant influences on the medical oncologist's decision to recommend treatment. In addition, our data provide further insights into treatment selection, suggesting that with advancing age, clinicians may adjust treatment advice. Presumably, the decision to increasingly treat with a fluoropyrimidine alone as the patient age advances relates to greater uncertainty about the survival benefit and tolerability when oxaliplatin is added. The relatively high proportion of older patients declining the offer of any adjuvant therapy in our series is a concern and warrants further study, particularly as data consistently indicate that these patients will benefit as much from treatment with a fluoropyrimidine as younger patients.3,4 Adjuvant therapy for stage III colon cancer is typical of the increasingly complex scenarios faced by medical oncologists, who must make decisions not only regarding whether to treat patients, but also which therapy to recommend. Although clinical trials will continue to define the optimal therapy for younger, fitter patients, we are faced with a growing population of aging patients who require tailored treatment advice. With recent data also indicating much ongoing uncertainty regarding optimal chemotherapy dosing in the older adult and frail populations,5 further study of how age and comorbidity impact on treatment-related toxicity and survival outcomes is urgently required. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
ACKNOWLEDGMENTS Supported by BioGrid Australia, Ludwig Institute for Cancer Research. REFERENCES
1. Keating N, Landrum M, Klabunde C, et al: Adjuvant chemotherapy for stage III colon cancer: Do physicians agree about the importance of patient age and comorbidity? J Clin Oncol 26:2532-2537, 2008 2. Kosmider S, Jones I, Hibbert M, et al: Towards establishing a national colorectal cancer database: Lessons learnt from Bio21-MMIM. ANZ J Surg (in press) 3. Sargent DJ, Goldberg RM, Jacobson SD, et al: A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients. N Engl J Med 345:1091-1097, 2001 4. 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. Ann Oncol 15:1330-1338, 2004 5. Field K, Kosmider S, Jefford M, et al: Chemotherapy dosing strategies in the obese, elderly, and thin patient: results of a nationwide survey. J Oncol Pract 108-113, 2008
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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70 years of age declining treatment (P < .0001). 
