Approach to the older patient with stage II/III colorectal cancer: who should get curative-intent therapy?

The majority of new colorectal cancer diagnoses occur in adults 65 and older a rapidly growing segment of the U.S. population. Older adults are a markedly heterogeneous group, and although recent clinical trials in locally advanced colorectal cancer have incorporated limited numbers of older patients, the data can not be generalized to most older patients. In particular, patients who are not "fit"-those with poor functional reserve, major comorbidities, or who otherwise meet criteria for frailty or "prefrailty"-are poorly represented in published trials. Population-based data demonstrate that older adults are much less likely to be treated in the adjuvant or neoadjuvant settings for stage II/III colorectal cancer, but it is unclear what the basis should be for withholding potentially curative therapy. Age and Eastern Cooperative Oncology Group (ECOG) performance status (PS) are frequently used to determine eligibility for treatment, but data increasingly suggest these are inadequate; the emerging definition of a spectrum of "fit" to "frail" older patients may provide additional guidance. Available data suggest that fit older patients may benefit as much from curative-intent therapy as younger patients. For frail or vulnerable (prefrail) patients, on the other hand, the benefit must be carefully weighed against the risk of toxicity and competing risks from their comorbidities. Life expectancy and patient preferences should always be elucidated. Geriatrician comanagement may be helpful in determining priorities, providing a comprehensive assessment, and modifying competing risk factors. Even many vulnerable or frail patients can successfully complete (and derive benefit from) carefully considered treatment regimens.