From the Guidelines
Treatment for an 88-year-old patient with sigmoid cancer and liver metastasis should prioritize a comprehensive geriatric assessment to evaluate fitness for therapy, followed by consideration of modified chemotherapy regimens such as reduced-dose FOLFOX or single-agent capecitabine, with a focus on symptom management and quality of life. When considering the management of synchronous metastatic colon cancer, the ESMO consensus guidelines suggest that patients with clearly resectable metastases may undergo intensive upfront chemotherapy, while those with unresectable or borderline resectable metastases may require preoperative chemotherapy with FOLFOX for 3 months 1. However, in the context of an elderly patient with potential comorbidities and reduced tolerance to aggressive treatments, a more conservative approach is often preferred.
Given the patient's age and the presence of liver metastasis, the primary goal of treatment shifts towards palliation and maintaining quality of life, rather than curative intent. This approach is supported by the principle of avoiding unnecessary harm and focusing on symptom control. The use of chemotherapy in this setting should be carefully considered, with an emphasis on regimens that are better tolerated by elderly patients, such as single-agent capecitabine or reduced-dose FOLFOX 1.
Key considerations in the management of this patient include:
- Comprehensive geriatric assessment to evaluate fitness for therapy
- Modified chemotherapy regimens for symptom control and quality of life
- Palliative procedures for symptom management, such as obstruction
- Supportive care, including pain management, nutritional support, and psychosocial care
- Regular reassessment of treatment effectiveness and patient tolerance, with adjustments made as needed to maintain quality of life.
In the context of real-life clinical practice, the decision to pursue a less aggressive treatment approach for an elderly patient with sigmoid cancer and liver metastasis is guided by the need to balance potential benefits against the risk of treatment-related toxicity and the importance of maintaining quality of life 1.
From the FDA Drug Label
The median age was 60 years; 60% were male, 79% were White, 57% had an ECOG performance status of 0, 21% had a rectal primary and 28% received prior adjuvant chemotherapy. The dominant site of disease was extra-abdominal in 56% of patients and was the liver in 38% of patients The addition of bevacizumab improved survival across subgroups defined by age (<65 years, ≥65 years) and sex.
The treatment of sigmoid cancer with liver metastasis in an 88-year-old patient is not directly addressed in the provided drug labels. However, based on the available information, bevacizumab may be considered as a treatment option for metastatic colorectal cancer, including patients with liver metastasis.
- The median age of patients in the study was 60 years, and the addition of bevacizumab improved survival across subgroups defined by age (<65 years, ≥65 years).
- However, the patient in question is 88 years old, which is significantly older than the median age in the study.
- Therefore, a conservative clinical decision would be to exercise caution when considering bevacizumab as a treatment option for this patient, taking into account their advanced age and potential comorbidities 2.
From the Research
Treatment Options for Sigmoid Cancer with Liver Metastasis
- The treatment for sigmoid cancer with liver metastasis can vary depending on the patient's overall health and the extent of the disease 3, 4, 5, 6, 7.
- In some cases, surgery may be an option, such as partial hepatectomy or laparoscopic resection of the sigmoid colon cancer with multiple liver metastases 3, 5, 7.
- Chemotherapy is also a common treatment option, with various regimens available, including 5-fluorouracil (5-FU), leucovorin, oxaliplatin (FOLFOX), and irinotecan with bevacizumab (FOLFIRI+Bev) 4, 5, 6, 7.
- Targeted therapy, such as cetuximab monotherapy, may also be effective in some cases, especially in patients with KRAS mutation-negative tumors 6.
- Multidisciplinary treatment approaches, including surgery, chemotherapy, and radiofrequency ablation (RFA), may be necessary to achieve long-term survival in patients with perforated sigmoid cancer and simultaneous liver metastasis 7.
Considerations for Elderly Patients
- When treating elderly patients, such as an 88-year-old, it is essential to consider their overall health and potential comorbidities 3, 4, 5, 6, 7.
- The patient's performance status, as measured by the Eastern Cooperative Oncology Group (ECOG) score, should also be taken into account when determining the best course of treatment 6.
- In some cases, less intensive treatment options may be more suitable for elderly patients, while in other cases, more aggressive treatment approaches may be necessary to achieve long-term survival 3, 4, 5, 6, 7.
Potential Outcomes
- With proper treatment, some patients with sigmoid cancer and liver metastasis can achieve long-term survival, even in the presence of multiple liver metastases 3, 4, 5, 7.
- However, the prognosis for patients with advanced disease can be poor, and treatment should be individualized based on the patient's unique needs and circumstances 6.