Colorectal cancer Colorectal cancer Chemotherapy for the Chemotherapy for the pypy

elderlyelderlyyy

Dr Christophe TOURNIGANDDr Christophe TOURNIGANDDr Christophe TOURNIGAND Dr Christophe TOURNIGAND Hôpital Saint Antoine Hôpital Saint Antoine –– FranceFrance

Hôpital Charles LemoyneHôpital Charles Lemoyne -- QuebecQuebecHôpital Charles Lemoyne Hôpital Charles Lemoyne QuebecQuebecGERCOR GERCOR –– EPOG EPOG -- UPMCUPMC

Colorectal cancer ( CRC) : an Elderly Colorectal cancer ( CRC) : an Elderly Disease Disease

3rd leading cause of cancer death worldwide, 3rd leading cause of cancer death worldwide,

More than 800 000 new cases are diagnosedMore than 800 000 new cases are diagnosedMore than 800,000 new cases are diagnosed More than 800,000 new cases are diagnosed annually,annually,

40% of cases occur in patients >75 years of age40% of cases occur in patients >75 years of age40% of cases occur in patients 75 years of age 40% of cases occur in patients 75 years of age

Colorectal cancer ( CRC) : Colorectal cancer ( CRC) : an Improving Survivalan Improving Survival

55--years survival increases in years survival increases in ≥≥75yrs pts75yrs pts

19761976––1987 to 19881987 to 1988––1999 (47.1% versus 53.6%, 1999 (47.1% versus 53.6%, respectively;respectively; pp < 001)< 001)respectively; respectively; pp < .001) < .001)

ResectionResectionPostPost--operative mortalityoperative mortalityp yp y

CRC in Elderly : Undertreated !CRC in Elderly : Undertreated !% of patients treated % of patients treated with chemotherapywith chemotherapywith chemotherapywith chemotherapy

> 75 years> 75 years < 65 years< 65 yearsCôte d’Or department (1997Côte d’Or department (1997--1998) 1998) (1)(1) ::

--Stade II CCRStade II CCR 4,9%4,9% 47,3%47,3%

--Stade III CCRStade III CCR 24,4%24,4% 86,1%86,1%

--Metastatic diseaseMetastatic disease19881988--89 89 (2)(2) 8%8% 44,1% 44,1%

(1)Faivre-Finn C, Bouvier AM, Mitry E et al. Chemotherapy for colon cancer in a well-defined French population: is it under- or over-prescribed? Aliment Pharmacol Ther 2002;16(3):353-359.

DiseaseDisease--free Survival in free Survival in Stage III Patients: N1 & N2Stage III Patients: N1 & N2

1.0

0.9

0.8

0.7

0.6bilit

y

7.2%

0.5

0.4FOLFOX4 443 N1S

prob

ab 11.5%

0.3

0.2

FOLFOX4 – 443 N1LV5FU2 – 443 N1FOLFOX4 – 229 N2

DFS HR: 0.76

HR: 0.720.2

0.1

0 0

LV5FU2 – 232 N2HR: 0.72

0.00

Months666 12 18 24 30 36 42 48 54 60

Data cut-off: January 16, 2005

Time from Relapse to Death: ITTTime from Relapse to Death: ITTTime from Relapse to Death: ITTTime from Relapse to Death: ITT

1.0

0.8

0.9

ity 0.6

0.7FOLFOX4 n= 258 median 21 months

Prob

abil

0.4

0.5 LV5FU2 n=334 median 24 months

P

0.2

0.3Patients alive with relapse (%)

FOLFOX4 69 (6 1)

0

0.1FOLFOX4 69 (6.1)

LV5FU2 88 (7.8)

Time from relapse to death (months)0 6 12 18 24 6030 36 42 48 54 66 8472 78

Exploratory analysis

CRC in Elderly : Undertreated !CRC in Elderly : Undertreated !Relapse in colon cancer : 2-3 yearsLife expectancy :

Lif E t

70-75 80-85 85AGE

Life Expectancy+12-15 years +7-8 years +5-6 years

Adjuvant Metastatic

"To treat or not to treat ?…that is the question: Whether 'tis nobler in the mind to suffer q

The slings and arrows of outrageous fortune Or to take arms against a sea of troubles "

CRC in Elderly : Underrepresentation !CRC in Elderly : Underrepresentation !

Underrepresentation in clinical trials : NCI Underrepresentation in clinical trials : NCI ppdata, 495 trials, 59300 pts, only 32% > 65yrs data, 495 trials, 59300 pts, only 32% > 65yrs were it should be 61%were it should be 61%were it should be 61%were it should be 61%

Lewis, JCO 2003

Metastatic colorectal cancerMetastatic colorectal cancerIrinotecanIrinotecanIrinotecanIrinotecan

Kohne, C.-H. et al. Oncologist 2008;13:390-402

Median survival rates reported among elderly patients with colorectal cancer treated with irinotecan-based regimens

FOLFOX4 in Elderly Patients with Colon FOLFOX4 in Elderly Patients with Colon C n r A P l d An l sisC n r A P l d An l sisCancer : A Pooled AnalysisCancer : A Pooled Analysis

St d C t S tti NStudy Comparatorregimen

Setting N

1MOSAIC1 5-FU/LV Adjuvant 2246

N97412 IFL 1st Line 546

de Gramont3 5-FU/LV 1st Line 420

Rothenberg4 5-FU/LV 2nd Line 530

Total 3742Total 3742

11André et al, NEJM 2004; André et al, NEJM 2004; 22Goldberg et al, JCO 2004; Goldberg et al, JCO 2004; 33de Gramont et al JCO 2000;de Gramont et al JCO 2000; 44Rothenberg et al JCO 2003Rothenberg et al JCO 2003

de Gramont et al, JCO 2000; de Gramont et al, JCO 2000; Rothenberg et al, JCO 2003Rothenberg et al, JCO 2003

OxaliplatinOxaliplatin--based chemotherapy: DFS based chemotherapy: DFS -- PFSPFS

<70 years

≥70 years

Goldberg, R. M. et al. J Clin Oncol; 24:4085-4091 2006

Adverse Events (Gr > 3)

45

50

Age < 70

p = 0.04

14

16

Age < 70p = 0.37

30

35

40

de 3

+

Age > 70

10

12

de 3

+

Age < 70Age > 70

p = 0.38

p = 0.38

15

20

25

Rat

e, G

rad

4

6

8

Rat

e, G

rad

0

5

10 p = 0.08p = 0.04

0

2

4p = 0.20

Neutropenia Thrombocytopenia Fatigue Neurotoxicity Diarrhea Nausea/Vomiting 60 Day Mortailty

ConclusionsConclusionsConclusionsConclusions

Elderly patients benefit from FOLFOX4 treatment Elderly patients benefit from FOLFOX4 treatment to a similar degree to younger patientsto a similar degree to younger patientsElderly patients experience slightly more but Elderly patients experience slightly more but

bl t i itbl t i itmanageable toxicitymanageable toxicityAge alone should not be a criteria to exclude Age alone should not be a criteria to exclude elderly patients from FOLFOX4 chemotherapyelderly patients from FOLFOX4 chemotherapyelderly patients from FOLFOX4 chemotherapyelderly patients from FOLFOX4 chemotherapy

CautionCautionSelected elderly patients for clinical trialsSelected elderly patients for clinical trialsS y pS y p2 of 4 trials limited eligibility to patients 2 of 4 trials limited eligibility to patients << 75 75 yearsyearsyy

OPTIMOXOPTIMOX 11 Study designStudy designy gy g

RRAANN FOLFOX4 until progression OS 20 mNNDDOOMMMMIISSAAAATTIIOO

FOLFOX7 x 6 cysLV5FU2 x 12 cy OS 21.6 m

OONN FOLFOX7 x6 cy

Optimox 1 Optimox 1 -- Overall Survival Overall Survival

1.0

Patients >75 yearsPatients >75 years vsvs Patients Patients ≤≤ 75 years 75 years

0 8

1.0

0 6

0.8

> 75 years

≤ 75 yearsrtio

n 20.7 months

20 2 months

0 4

0.6 ≤ 75 years

Prop

o 20.2 months

p = 0,15

0 2

0.4

0 0

0.2

0 25 50 75 100 125 1500.0

weeks

Targeted agentsTargeted agentsTargeted agentsTargeted agents

AvastinAvastinAvastinAvastin

CetuximabCetuximab

PanitumumabPanitumumab

Tolerance of Avastin in patientTolerance of Avastin in patient11age groupsage groups11

All All (n=1,953) (n=1,953)

<65 years <65 years (n=1,057) (n=1,057) 6565––74 years 74 years ≥75 years ≥75 years ≥80 years* ≥80 years* ( , )( , )

%%( , )( , )

%%yy

(n=533) %(n=533) %yy

(n=363) %(n=363) %yy

(n=161) %(n=161) %

GI perforationGI perforation 2.02.0 2.62.6 1.51.5 1.11.1 0.60.6

Postoperative Postoperative bleedingbleedingor WHCsor WHCs††

5.15.1 5.05.0 4.54.5 4.54.5 3.83.8

Grade 3/4 bleedingGrade 3/4 bleeding 2.62.6 2.22.2 3.43.4 2.22.2 1.21.2

ATEsATEs 1.91.9 1.61.6 1.31.3 3.93.9 3.73.7

New/worsening New/worsening HTNHTN

20.720.7 20.520.5 20.620.6 21.221.2 21.121.1

6060--day mortality rateday mortality rate 2.12.1 1.41.4 3.43.4 2.22.2 3.13.1y yy y

Multivariate analysis identified risk factors for ATEs,which included ECOG PS and prior history of ATEs2

*≥75 and ≥80 years overlap; therefore the total number for all subgroups does not add up to 1 953

1. Kozloff, et al. ASCO 2008; 2. Sugrue, et al. JCO 2007

*≥75 and ≥80 years overlap; therefore, the total number for all subgroups does not add up to 1,953†The denominators (i.e. number of patients undergoing surgery at post-baseline only) are 622, 399, 156, 67and 26, respectively

DREAM study (Phase III)DREAM study (Phase III)DREAM study (Phase III) DREAM study (Phase III)

mFOLFOX7 +bevacizumab

X6 cycles

mFOLFOX7 +bevacizumab

X6 cycles

bevacizumab bevacizumab + erlotinib+ erlotinib

RANmLV5FU2 or mLV5FU2 or X6 cyclesX6 cycles

mXELOX +mXELOX +

until PDuntil PDNDOM

CR2capecitabine

+bevacizumab

capecitabine+

bevacizumabOr1

mXELOX + bevacizumab

x6 cycles

mXELOX + bevacizumab

x6 cycles

ISA

orPR or

bevacizumab3 months

bevacizumab3 months

bevacizumabbevacizumabuntil PDuntil PD

TIO

or SD

FOLFIRI – bevacizumab 6 monthsFOLFIRI – bevacizumab 6 monthsOr1

N

1 investigator’s choice 2without surgery Age 18-80 years

Validation of a Scale predictive of chemotherapies toxicities in Elderly G

OLD 07 1 ( i )

Cognitive functionsCognitive functions 1.1. Date du jour et nom de la ville de l’HôpitalDate du jour et nom de la ville de l’Hôpital

OLD 07-1 (ongoing)

Cognitive functionsCognitive functions j pj p2.2. Répétition de trois mots (cigare, fleur, porte ou Répétition de trois mots (cigare, fleur, porte ou

citron, clé, ballon) et après quelques minutescitron, clé, ballon) et après quelques minutes

3. 3. Aide pourAide pour ::--téléphoner téléphoner --prendre les médicamentsprendre les médicaments

DependanceDependance--faire les courses faire les courses -- tenir ses comptestenir ses comptes--préparer les repas préparer les repas -- conduire ou utiliser les conduire ou utiliser les --entretenir la maison transportsentretenir la maison transports

4.4. Appui monopodal 5sAppui monopodal 5s

H it li ti d l’ é é éd tH it li ti d l’ é é éd tComorbiditiesComorbidities

1.1. Hospitalisation dans l’année précédenteHospitalisation dans l’année précédente6. Poly médications > 5 6. Poly médications > 5

Renal function andRenal function and 7. Clairance de la créatinine >30ml/mn7. Clairance de la créatinine >30ml/mnRenal function and Renal function and nutritial statusnutritial status

8. Albuminémie >30g/l8. Albuminémie >30g/l

Depression and helperDepression and helper 9. Vous sentez vous souvent triste ou déprimé9. Vous sentez vous souvent triste ou déprimé ??10. Présence de l’Entourage*10. Présence de l’Entourage*

*Aidant ou famille*Aidant ou famille

Metastatic colorectal cancer, breast cancer, ovarian cancer

T d bi iTest drugs, combinations

Young patients

Elderly patients

Need for specific trials for elderly patients (pharmacokinetic, strategy…)

Acknowledgments:g

Dr Elisabeth Carola Dr Elisabeth Carola Hôpital Senlis FranceHôpital Senlis FranceHôpital Senlis, FranceHôpital Senlis, France

Oncology department of Hôpital Oncology department of Hôpital gy p pgy p pCharles LeMoyne, QCCharles LeMoyne, QC