Adjuvant chemotherapy in the elderly

Abstract

Cancer is predominantly a disease of the elderly: approximately 60% of all tumors and two-thirds of cancer-related deaths occur in those over 65 years of age. This proportion will grow with the expected increase in the size of the older population in the coming decades. For example, if incidence rates remain constant, the number of elderly women diagnosed with breast cancer in the US will increase by 72% by 2025 [1]. Adequate directives for the treatment of this important group of patients are often lacking, because the elderly have generally been excluded from clinical trials. In an analysis of European Organisation for Research and Treatment of Cancer (EORTC) phase II enrollment, only 22% of patients were ≥65 years of age and 8% were ≥70 years of age; a later Eastern Cooperative Oncology Group (ECOG) trial enrollment report stated that from 1998 to 1999, about 35% of trial participants were ≥60 years of age and only about 17% were ≥70 years of age [2, 3]. Possible reasons for poor participation include the following: few trials are specifically designed for elderly patients; physicians, patients and family members may think that older patients are less likely to benefit from and are less able to tolerate appropriately intensive treatment; the elderly may be less aware of medical developments and less likely to seek out clinical trials; older people are more likely to have other health problems (co-morbidities); and there is lack of financial, logistic and social support for participation of older patients in trials. There is substantial evidence to indicate that, with a range of tumor types, elderly patients have a relative survival similar to that of younger patients when given comparable treatments [4–6]. However, a number of studies have shown that elderly patients often have more advanced disease at the time of diagnosis and receive fewer intensive treatments [7–12]. There is therefore concern that elderly patients frequently receive inadequate treatment. It should be noted, however, that other competing causes of mortality assume a large role in determining survival in older patients and that, relative to other causes of death, breast cancer mortality decreases as patients age [13–15]. In sum, the issues of major concern for evaluating an elderly patient with cancer are whether the patient will die with cancer or of cancer, and whether treatment will produce more benefit than harm.