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Professor Joseph James McKendrick

1 July 2008


Adjuvant therapy also for older CRC patients

Older patients with colorectal cancer (CRC) should be afforded equal access to adjuvant therapy as their younger counterparts because of the comparable treatment benefits and acceptable toxicity levels, says a leading oncologist.

Associate Professor Dr. Joseph James McKendrick, director of medical oncology, Box Hill Hospital, Victoria, Australia, raised the issue that fewer older patients, particularly those above the age of 70, are being referred to an oncologist upon diagnosis, and fewer still are offered adjuvant therapy, indicative of prevailing prejudices among patients and doctors against chemotherapy in the elderly.

Lower treatment efficacy and increased toxicities, often observed with adjuvant treatments in older patients with other forms of cancer, is not such a major problem in stage II and III CRC, he stressed. [Journal of the National Cancer Institute 2001;93(11):850-7] In terms of outcomes, the relapse-free and overall survival is the same, regardless of age. [N Engl J Med 2001;345(15):1091-7]

Co-morbidities like heart disease, chronic obstructive pulmonary disease and diabetes may not be a significant contraindication to treatment as previously thought, he suggested, adding that evidence shows that CRC patients with co-morbidities who undergo treatment fare better than those who do not receive treatment.

Another concern with older patients is that, at their advanced age, treatment is generally not warranted. But McKendrick clearly showed that with consideration of population-based life expectancies, most patients, with the exception of men over 90 years, could expect to enjoy the five-year survival benefits afforded by adjuvant therapy.

It is theorized that prejudice overrides life philosophies when it comes to accepting treatment, said McKendrick. The anxiety, worry of discomfort, interpretation of personal life-expectancy and perceived feelings of ‘wellness’ often hinder treatment acceptance, particularly as older patients are sometimes unwilling to compromise on quality of life in exchange for longer survival.

Despite a number of these patients not wanting to opt for adjuvant treatment, evidence suggests that physician recommendation is the strongest influencing factor in their decision-making. On this point, McKendrick stressed the importance of physician impartiality and thoroughness when discussing a patient’s case.

Choice of treatment must be influenced by treatment characteristics ie, morbidities, toxicities and mortality rates, staging (highrisk stage II and stage III) and by patient characteristics. On the latter, he said further exploration of these parameters is necessary “before precluding patients from treatment”.

McKendrick concluded by warning the audience that patients who fail to complete adjuvant therapy risk poorer outcomes, facing reduced survival rates.

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Associate Professor Joseph McKendrick is the Director of Medical Oncology, Haematology & Palliative Care, Eastern Health and Director of Medical Oncology, Box Hill Hospital. Associate Professor McKendrick trained in oncology at the Royal Melbourne Hospital in Melbourne and spent time as a research fellow at the Cancer Research Campaign Wessex Medical Oncology Unit in Southampton UK. Here he also completed an MD and gained extensive experience in the management of hematological malignancies, germ cell cancer and colorectal cancer. He is actively involved with the Eastern Hill's busy research unit participating in local, national and international clinical studies. As a researcher, he has published extensively in peer-review publications (51 papers) and other medical publications. He is also an active member of the Clinical Oncology Society of Australia, American Society of Clinical Oncology, Australian New Zealand Lymphoma Group and the Medical Oncology Group.
 


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