There was no external funding for this study. Hung reports employment as a pharmacist for CVS Health, an AHRQ F32 grant, and meeting/accommodation/travel support from AACP, DIA, and ISPOR, all outside the submitted work. Vu and Mostovoy have nothing to disclose. Study concept and design were contributed by Hung and Mostovoy, along with Vu. Hung and Vu collected the data, and data interpretation was performed primarily by Hung, along with Mostovoy. The manuscript was written by Hung and Vu and revised by all the authors. Some of the study results were previously presented as a poster at the ISPOR 22nd Annual International Meeting; May 20-24, 2017; in Boston, Massachusetts.

Results. From 708 identified articles, 25 articles provided data on the relative effectiveness and safety of chemotherapy among elderly versus nonelderly patients. Four of 14 studies showed lower overall survival treatment effects, whereas one of five and one of four studies indicated more favorable treatment effects for time to progression and overall response rate. Grade 3 or 4 adverse events were higher among elderly patients for cardiac disorder (2/5 studies), leukopenia (1/5), neutropenia (4/16), thrombocytopenia (2/13), febrile neutropenia (1/4), infection (2/10), dehydration (2/6), diarrhea (6/20), and fatigue (6/13). Grade 3 or 4 adverse events were lower for neutropenia (2/16 studies), nausea/vomiting (1/16), and neuropathy (1/9). Conclusion.The majority of the evidence suggests that chemotherapy has similar relative effectiveness and safety for patients >65 years of age versus younger patients with stage III colon cancer. When differences are reported, treatment effects are more often worse among the elderly. This review suggests that without other reasons for withholding treatment, elderly patients should receive chemotherapy as often as nonelderly patients. The Oncologist 2013;18:54 -63 Implications for Practice: The underrepresentation of elderly patients from clinical trials has led to uncertainty regarding the efficacy of chemotherapy agents among the elderly. This uncertainty has contributed to underuse in the elderly population. The evidence from this systematic review suggests that colon cancer chemotherapy effectiveness and safety generally are similar in elderly and nonelderly patients; however, there is some evidence of a higher incidence of adverse events in elderly versus nonelderly patients. This systematic review concludes that chemotherapy prescribing decisions for colon cancer should not be based upon age, but rather on other factors such as performance status. Overall, the evidence does not suggest lower chemotherapy effectiveness among elderly patients. Thus, this review does not support observed lower chemotherapy utilization in the elderly population. In the absence of other reasons for withholding treatment, elderly patients should be given chemotherapy as often as nonelderly patients.

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