P-0285 Neoadjuvant Chemotherapy Followed by Chemo-Radiotherapy for Locally Advanced Rectal Cancer in the Very Elderly: Efficacy and Tolerability

Abstract

ABSTRACT Introduction Locally advanced rectal cancer (LARC) is a challenging clinical situation where surgery alone risks incomplete resection, with attendant risks of local and metastatic relapse. Neoadjuvant strategies giving chemotherapy followed by long-course chemo-radiotherapy may be effective in reducing this risk, but concerns exist around toxicity. Increasingly elderly populations bring the decision to use such strategies into focus. Study aim: to assess the efficacy and tolerability of neoadjuvant chemotherapy followed by chemo-radiotherapy in patients with LARC over 75 years of age. Methods We undertook a retrospective review of patients with locally advanced rectal cancer who received this treatment within the Sussex Cancer Network (UK) between 2006 and 2011. For patients over 75 with T3 (with threatened circumferential resection margin on pre-operative MRI) or T4, N0-2 M0 rectal cancer we collected data on treatment, toxicities and responses on MRI assessment and surgico-pathological outcomes. Neoadjuvant chemotherapy comprised 12 weeks of capecitabine and oxaliplatin followed immediately by long-course chemo-radiotherapy with 50.4Gy in 28 fractions of radiotherapy and concurrent capecitabine. Results Seventeen patients were identified, with a mean age of 79 years. Patients were WHO performance status (PS) 0 or 1 with no comorbidities. Neoadjuvant chemotherapy was completed in 82% (14/17) of patients with two patients stopping due to infection (CTC grade 3/4) and one due to thrombocytopenia (CTC grade 3). All completed at least six weeks of treatment. Chemo-radiotherapy was given as planned in 76% (13/17) of patients. Of the remaining four patients, three completed radiotherapy without chemotherapy due to the accumulated toxicity of neoadjuvant chemotherapy, and in one patient treatment was stopped due to the unmasking of CTC grade 3 cognitive impairment. The overall response rate was 88% (15/17) with the other two patients demonstrating stable disease. Twelve patients (71%) proceeded to surgery with curative intent. The remaining five patients had no curative surgery as a result of: patient choice (2), discovery of second primary cancer at laparotomy (1) and being surgically unfit (2) (due to cognitive impairment and incidental finding of significant abdominal aortic aneurysm, respectively). Of the patients who had surgery, all had a pathologically complete excision; 81% were down-staged and two had a pathological complete response. Conclusion Neoadjuvant chemotherapy followed by long-course chemo-radiotherapy for LARC is deliverable with manageable toxicity in patients over 75 who have a good performance status and no comorbidities. Response rates are consistent with those seen in younger patients and surgical outcomes are good. We conclude that decisions to use an intensive pre-operative strategy should not be based on age alone. However, better methods are needed to screen for biological fitness and predict for treatment toxicity in this age-group.