Management of locally advanced and metastatic colon cancer in elderly patients

Table 1 Chemotherapy regimen in locally advanced and metastatic colon cancer

No.	Regimen	Dosing	Frequency	Adjuvant	Palliative
1	5-FU/LV	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	Y	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
2	Capecitabine	Capecitabine 1000-1250 mg/m2 by mouth twice daily for 2 wk, then 1 wk off	Every 3 wk	Y	Y
3	FOLFOX	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	Y	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Oxaliplatin 85 mg/m2 IV on day 1
4	CAPOX	Capecitabine 850-1000 mg/m2 by mouth twice daily for 2 wk, then 1 wk off	Every 3 wk	Y	Y
		Oxaliplatin 130 mg/m2 IV on day 1
5	FOLFIRI	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Irinotecan 180 mg/m2 IV over 90 min on day 1
6	FOLFOX + Bevacizumab	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Oxaliplatin 85 mg/m2 IV on day 1
		Bevacizumab 5 mg/kg IV on day 1
7	FOLFIRI + Bevacizumab	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Irinotecan 180 mg/m2 IV over 90 min on day 1
		Bevacizumab 5 mg/kg IV on day 1
8	CAPOX + Bevacizumab	Capecitabine 850-1000 mg/m2 by mouth twice daily for 2 wk, then 1 wk off	Every 3 wk	N	Y
		Oxaliplatin 130 mg/m2 IV on day 1
		Bevacizumab 7.5 mg/kg IV on day 1
9	Capecitabine + Bevacizumab	Capecitabine 850-1000 mg/m2 by mouth twice daily for 2 wk, then 1 wk off	Every 3 wk	N	Y
		Bevacizumab 7.5 mg/kg IV on day 1
10	5-FU/LV + Bevacizumab	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Bevacizumab 5 mg/kg IV on day 1
11	FOLFIRI + Cetuximab	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Irinotecan 180 mg/m2 IV over 90 min on day 1
		Cetuximab 400 mg/m2 IV loading on treatment day 1, then 250 mg/m2 IV every week
12	FOLFIRI + Ablifercept	Leucovorin 400 mg/m2 IV over 2 h before 5-FU on day 1	Every 2 wk	N	Y
		5-FU 400 mg/m2 IV bolus on day 1, followed by 2400 mg/m2 IV over 46 h
		Irinotecan 180 mg/m2 IV over 90 min on day 1
		Aflibercept 4 mg/kg, over 1 h on day 1
13	Panitumumab	Panitumumab 6 mg/kg IV	Every 2 wk	N	Y
14	Regorafenib	Regorafenib 160 mg by mouth once daily for 3 wk, then 1 wk off	Every 4 wk	N	Y

5-FU: Fluorouracil.

Table 2 Eastern Cooperative Oncology Group performance status

Grade	Description
0	Fully active, able to carry on all pre-disease performance without restriction
1	Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work
2	Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
3	Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4	Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
5	Dead

Table 3 Most common side effects of active agents in colon cancer and their management

Agent	Major side effects	Management
Fluoropyrimidine	Stomatitis, diarrhea, hand-foot syndrome	Identification and early symptom management
5-FU	Vomiting	Dose interuption or reduction if progression (grade 2 or worse)
Capecitabine	Pancytopenia	Adjustment of route of administration: bolus vs continuous infusion
		Predetermined treatment parameter
Oxaliplatin	Peripheral neuropathy (dose limiting)	Education about exposure to cold, dose modification, “stop and go” strategy, and use of neuromodulatory agents
	Pancytopenia	Predetermined treatment parameter
	Nausea, vomiting, diarrhea, fatigue	Identification and early symptom management.
		Dose interuption or reduction if progression (grade 2 or worse)
Irinotecan	Diarrhea	Premedication with atropine sulfate
	Pancytopenia	Proper instruction for the use of anti-motility agent to control diarrhea
		Predetermined treatment parameter
Anti EGFR	Skin toxicity (rash, dryness, pruritus)	Identification and early symptom management
Cetuximab	Mucositis	Proper instruction for the use of anti-motility agent to control diarrhea
Panitimumab	Diarrhea	Dose interuption or reduction if progression (grade 2 or worse).
Anti VEGF	Wound healing impairment	Blood pressure monitoring and adding anti-hypertensive agent if needed
Bevacizumab	Thromboembolism	Avoid in high risk patients.
Ziv-aflibercept	Bowel perforation	Close monitoring if used in patients at risk
	Proteinuria	Regular monitoring of urine protein secretion with urine dipstick or 24HR
	Hypertension	urine protein to creatinine ratio
		Holding medication prior to elective surgical procedure (6-8 wk)
		Appropriate healing time before re-starting medication post-op
Receptor TKI inhibitors	Hand-foot skin syndrome, rash	Identification and early symptom management
Regorafenib	Diarrhea, hypertension	Dose modification

5-FU: Fluorouracil; EGFR: Epidermal growth factor receptor; VEGF: Vascular endothelial growth factor; TKI: Tyrosine-kinase inhibitor.