How we treat metastatic colon cancer in older adults

The past decade has seen unprecedented advancements in our ability to treat patients with metastatic colorectal cancer. When applying these advances--hepatic resection and multi-agent chemotherapy--to the care of older patients, it is essential to first perform some assessment of function beyond performance status and to elicit feedback from the patient about how he/she values quality versus quantity of life. For robust older patients with potentially surgically resectable oligometastatic cancer, we recommend a standard approach of surgery with perioperative chemotherapy. However, operative risk increases with age, and careful discussion about prognosis is warranted. For patients with unresectable cancer, first-line chemotherapy with either 5-fluoruracil/leucovorin alone, or with a 20% dose reduced FOLFOX or FOLFIRI regimen, is well tolerated by older patients. Either dose escalation or addition of a second drug can typically be undertaken after 1-2 cycles. First-line bevacizumab with chemotherapy is warranted in those with low risk for atherothrombotic complications. EGFR inhibitors with combination chemotherapy for KRAS wild type cancers offer the best response rates, but toxicity can be difficult and may be best reserved for second-line in all but the fittest elderly. In second-line, we routinely offer continued chemotherapy with the agents that the patient has not yet received. The role of aflibercept and regorafenib has not been well studied in the elderly, but they are both reasonable options for patients with good function and no contraindication. With this cautious approach older patients can be expected to maintain a good quality of life during treatment for metastatic colorectal cancer.