Use of Adjuvant Chemotherapy (AC) and Outcomes in Stage II Colon Cancer (CC) with Versus Without Poor Prognostic Features

Purpose To address whether all medically fit patients with curatively resected stage II colon cancer should be offered adjuvant chemotherapy as part of routine clinical practice, to identify patients with poor prognosis characteristics, and to describe strategies for oncologists to use to discuss adjuvant chemotherapy in practice. Methods An American Society of Clinical Oncology Panel, in collaboration with the Cancer Care Ontario Practice Guideline Initiative, reviewed pertinent information from the literature through May 2003. Results A literature-based meta-analysis found no evidence of a statistically significant survival benefit of adjuvant chemotherapy for stage II patients. Recommendations The routine use of adjuvant chemotherapy for medically fit patients with stage II colon cancer is not recommended. However, there are populations of patients with stage II disease that could be considered for adjuvant therapy, including patients with inadequately sampled nodes, T4 lesions, perforation, or poorly differentiated histology. Conclusion Direct evidence from randomized controlled trials does not support the routine use of adjuvant chemotherapy for patients with stage II colon cancer. Patients and oncologists who accept the relative benefit in stage III disease as adequate indirect evidence of benefit for stage II disease are justified in considering the use of adjuvant chemotherapy, particularly for those patients with high-risk stage II disease. The ultimate clinical decision should be based on discussions with the patient about the nature of the evidence supporting treatment, the anticipated morbidity of treatment, the presence of high-risk prognostic features on individual prognosis, and patient preferences. Patients with stage II disease should be encouraged to participate in randomized trials.

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Faculty Opinions recommendation of Adjuvant chemotherapy for stage II colon cancer with poor prognostic features.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.13088958.14414057 ◽

2011 ◽

Author(s):

Werner Scheithauer

Keyword(s):

Colon Cancer ◽

Adjuvant Chemotherapy ◽

Stage Ii ◽

Prognostic Features ◽

Stage Ii Colon Cancer

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Adjuvant Chemotherapy Use for Medicare Beneficiaries With Stage II Colon Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2002.11.084 ◽

2002 ◽

Vol 20 (19) ◽

pp. 3999-4005 ◽

Cited By ~ 165

Author(s):

Deborah Schrag ◽

Sheryl Rifas-Shiman ◽

Leonard Saltz ◽

Peter B. Bach ◽

Colin B. Begg

Keyword(s):

Colon Cancer ◽

Adjuvant Chemotherapy ◽

Cox Model ◽

Tumor Grade ◽

Stage Ii ◽

Median Income ◽

Medicare Beneficiaries ◽

Prognostic Features ◽

Resected Stage ◽

Stage Ii Colon Cancer

PURPOSE: Clinical trials have not demonstrated that adjuvant chemotherapy improves survival for patients with resected stage II colon cancer. Nevertheless, patients may receive this treatment despite its uncertain benefit. The objective of this study was to determine the extent to which adjuvant chemotherapy is used for patients with stage II colon cancer. PATIENTS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 3,151 patients aged 65 to 75 with resected stage II colon cancer and no adverse prognostic features. The primary outcome was chemotherapy use within 3 months of surgery ascertained from claims submitted to Medicare. Relationships between patient characteristics and adjuvant chemotherapy use were measured and their significance was assessed using multivariable logistic regression. Survival for treated and untreated patients was compared using a Cox model. RESULTS: Twenty-seven percent of patients received chemotherapy during the 3 postoperative months. Younger age at diagnosis, white race, unfavorable tumor grade, and low comorbidity were each associated with a greater likelihood of receiving treatment. Sex, the number of examined lymph nodes in the tumor specimen, the urgency of the surgical admission, and median income was each unrelated to treatment. Five-year survival was 75% for untreated patients and 78% for treated patients. After adjusting for known between-group differences, the hazard ratio for survival associated with adjuvant treatment was 0.91 (95% confidence interval, 0.77 to 1.09). CONCLUSION: A substantial percentage of Medicare beneficiaries with resected stage II colon cancer receive adjuvant chemotherapy despite its uncertain benefit.

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Adjuvant Chemotherapy for Stage II Colon Cancer With Poor Prognostic Features

Journal of Clinical Oncology ◽

10.1200/jco.2010.34.3426 ◽

2011 ◽

Vol 29 (25) ◽

pp. 3381-3388 ◽

Cited By ~ 254

Author(s):

Erin S. O'Connor ◽

David Yu Greenblatt ◽

Noelle K. LoConte ◽

Ronald E. Gangnon ◽

Jinn-Ing Liou ◽

...

Keyword(s):

Colon Cancer ◽

Overall Survival ◽

Adjuvant Chemotherapy ◽

Survival Benefit ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Stage Ii ◽

Stage Iii ◽

Prognostic Features ◽

Stage Ii Colon Cancer

Purpose Adjuvant chemotherapy is typically considered for patients with stage II colon cancer characterized by poor prognostic features, including obstruction, perforation, emergent admission, T4 stage, resection of fewer than 12 lymph nodes, and poor histology. Despite frequent use, the survival advantage conferred on patients with stage II disease by chemotherapy is yet unproven. We sought to determine the overall survival benefit of chemotherapy among patients with stage II colon cancer having poor prognostic features. Patients and Methods A total of 43,032 Medicare beneficiaries who underwent colectomy for stage II and III primary colon adenocarcinoma diagnosed from 1992 to 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) –Medicare database. χ2 and two-way analysis of variance were used to assess differences in patient- and disease-related characteristics. Five-year overall survival was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression with propensity score weighting. Results Of the 24,847 patients with stage II cancer, 75% had one or more poor prognostic features. Adjuvant chemotherapy was received by 20% of patients with stage II disease and 57% of patients with stage III disease. After adjustment, 5-year survival benefit from chemotherapy was observed only for patients with stage III disease (hazard ratio[HR], 0.64; 95% CI, 0.60 to 0.67). No survival benefit was observed for patients with stage II cancer with no poor prognostic features (HR, 1.02; 95% CI, 0.84 to 1.25) or stage II cancer with any poor prognostic features (HR, 1.03; 95% CI, 0.94 to 1.13). Conclusion Among Medicare patients identified with stage II colon cancer, either with or without poor prognostic features, adjuvant chemotherapy did not substantially improve overall survival. This lack of benefit must be considered in treatment decisions for similar older adults with colon cancer.

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