Chapter 92: Gastrointestinal Malignancies

Learning Objectives

• Identify effective methods of colorectal cancer (CRC) screening.

• Integrate appropriate CRC screening recommendations into health maintenance models of care for older adults, including potential discontinuation of screening when expected lifespan is fewer than 5 to 10 years.

• Recognize the overwhelming need to enroll older adults with gastrointestinal (GI) cancers in clinical trials.

Key Clinical Points

1. Older adults remain underrepresented in clinical trials from which treatment standards are defined. The Food and Drug Administration stipulates inclusion of Geriatric Use prescribing information pertinent for older adults because limited guidance can be drawn from product labeling.

2. CRC accounts for approximately 9% of all cancer-related deaths in the United States; it causes more deaths than prostate cancer in men 60 to 79 years and falls just short of breast cancer in women 80 years or older. Noncancer deaths account for a sizeable percentage of deaths in older adults with CRC; congestive heart failure, chronic obstructive pulmonary disease, and diabetes account for 9.4%, 5.3%, and 3.9% of deaths, respectively, in older adults with localized disease.

3. Medicare covers surveillance fecal occult blood testing (FOBT) plus sigmoidoscopy or barium enema or colonoscopy for all beneficiaries; it may be reasonable to discontinue screening when life expectancy is shorter than the time a polyp progresses to a cancer, that is, 5 to 10 years.

4. Early genomic testing of advanced cancers can identify opportunities for use of novel targeted therapies or immunotherapy and identify adults eligible for clinical trial.

5. Perioperative mortality is lower for CRC surgery in high-volume centers versus low-volume centers. Further, less aggressive surgical intervention is more likely in low-volume centers and in older adults, and increases the risk of recurrence and cancer-related death. Finally, laparoscopic procedures have lower mortality and equivalent outcomes in older adults.

6. Morbidity and mortality for surgery to treat resectable pancreatic or gastric cancer are similar in young and older adults.

7. A large number of expanded options in chemotherapy (eg, targeted antibodies, kinase inhibitors, immunotherapy) that are generally tolerated by older adults are now available and should prompt clinicians caring for older adults to seek medical oncology consultation even in those with advanced GI cancer.

8. In those with esophageal cancer, African-American adults 65 years and older were noted to have a lower rate of surgical consultation and half the rate of curative surgery as their older adult Caucasian counterparts—very likely contributing to worse outcomes in minorities with esophageal cancer.

9. African-American adults age 65 or older are approximately 44% more likely to die from colon cancer despite better reduction in mortality among those receiving oxaliplatin-based therapy compared to Caucasian counterparts.