Systematic Review of Treatments for Colorectal Metastases in Elderly Patients to Guide Surveillance Cessation Following Hepatic Resection for Colorectal Liver Metastases

Abstract

Background: Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging.Methods: There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases.Results: Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited.Discussion: The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.

The Prospective Observational Cohort and the Nested Randomized Controlled Trial in the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC Study) Question the Reliance on Existing Evidence for the Magnitude of Benefit From Lung Metastasectomy

“…The excellent study by Alabraba and Gomez1 caught our attention. In a systematic review performed to a high standard they draw attention to the burden of treatments in elderly patients with metastatic colorectal cancer (CRC).…”

“…The excellent study by Alabraba and Gomez caught our attention. (1) In a systematic review performed to a high standard they draw attention to the burden of treatments in elderly patients with metastatic colorectal cancer (CRC). They conclude that the "survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly" and they go further to suggest that under certain circumstances which they specify, clinicians "may consider surveillance cessation in patients aged 75 years and above."…”

“…Better survival due to implementation of treatments, proven in RCTs, provides more opportunities for metastasectomy. (5) The Nottingham study (1) creates an impression of a high-quality evidence base but like nearly all analyses of metastasectomy, it lacks control data. In their Table 2 related to lung metastasectomy, there are only retrospective studies.…”

“…The Nottingham study1 creates an impression of a high-quality evidence base but like nearly all analyses of metastasectomy, it lacks control data. In their table 2 related to lung metastasectomy, there are only retrospective studies.…”

Surveillance Following Hepatic Resection for Colorectal Liver Metastases in Elderly Patients

“…We are grateful to Dr Treasure and colleagues for their letter to AJCO supporting our intention to challenge the status quo related to surveillance for colorectal metastases in the elderly patient 1. Our study2 specifically set out to assess publications comparing treatment outcomes for colorectal cancer (CRC) metastases in older and younger patient cohorts. We observed that older patients treated for CRC metastases have less surgery, less chemotherapy and have higher treatment-related complications.…”