Neoadjuvant Treatment of Locally Advanced Rectal Cancer in Elderly Patients: Real-World Experience at a Tertiary Institution

Abstract

Introduction: The incidence of rectal cancer increases with age. Neoadjuvant radiotherapy, with or without concurrent chemotherapy, has been shown to improve outcomes. Elderly patients are underrepresented in clinical trials. In Hong Kong, there is a lack of consensus and local data to inform patient selection and formulate optimal treatment strategies for them. We sought to examine the outcomes of elderly patients undergoing neoadjuvant treatment for locally advanced rectal cancer. Methods: Cases of patients with locally advanced rectal cancers who received neoadjuvant treatment in Department of Clinical Oncology, Queen Elizabeth Hospital from 2015 to 2018 were reviewed. ‘Elderly patient’ was defined as those ≥70 years at diagnosis. The key study endpoints were local relapse-free survival (RFS), regional RFS, distant RFS, overall RFS, and overall survival. Other endpoints included rate of downstaging, rate of conversion from threatened/involved margins to clear margins, and treatment-related toxicities. Results: In all, 74 elderly patients and 142 non-elderly patients were identified. The proportion of patients receiving concurrent chemotherapy during radiotherapy was lower in the elderly patients (p < 0.001). Chemoradiation administered to patients of all ages did not result in statistically significant differences in any survival endpoint. Elderly patients deemed unfit for concurrent chemotherapy had a higher incidence of treatment toxicities. Age was not a significant prognostic factor in any categories of survival. Conclusion: Age should not be a deterministic factor in treatment planning in locally advanced rectal cancer. Satisfactory oncological outcomes can be achieved in selected elderly patients. Utilisation of geriatric assessment and consideration of patients’ preference are required to optimise treatment outcomes.