Chemoradiotherapy for Gastrointestinal Malignancies

  • Jonathan B. WallachEmail author
  • Michael J. Nissenblatt
Living reference work entry


There is a paucity of data from randomized controlled trials for evidence-based decision-making for older patients. Many gastrointestinal malignancies require trimodality therapy with surgery, chemotherapy, and radiotherapy, but physicians have historically undertreated older patients who may have benefitted from more aggressive approaches, leading to suboptimal outcomes. The comprehensive geriatric assessment (CGA) has been developed to stratify older adults into tiers based upon their level of fitness to receive oncologic therapy and to assess appropriate goals of care. As with all age cohorts, immunotherapy is dramatically changing survival, and stereotactic body radiotherapy (SBRT) performs very powerful, targeted treatments to a variety of sites. Treatment recommendations should be made at an interdisciplinary tumor board represented by all pertinent specialties. Shared decision-making is important to balance the benefits and risks. Prospective studies should enroll more older patients, enabling physicians to best know how to evaluate and treat this expanding cohort of the oncology population.


Gastrointestinal cancer Geriatric Surgery Chemotherapy Radiotherapy 


  1. Al-Batran SE, Hofheinz RD, Pauligk C. Histopathological regression after neoadjuvant docetaxel, oxaliplatin, fluorouracil, and leucovorin versus epirubicin, cisplatin, and fluorouracil or capecitabine in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4-AIO): results from the phase 2 part of a multicentre, open-label, randomised phase 2/3 trial. Lancet Oncol. 2016;17(12):1697–708.PubMedPubMedCentralCrossRefGoogle Scholar
  2. American Cancer Society. Colorectal cancer facts & figures 2017–2019. Atlanta: American Cancer Society; 2017.Google Scholar
  3. Balducci L, Extermann M. Management of cancer in the older person: a practical approach. Oncologist. 2000;5(3):224–37.PubMedCrossRefPubMedCentralGoogle Scholar
  4. Bang YJ, Cutsem EV, Feyereislova A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet. 2010;28(376):687–97.CrossRefGoogle Scholar
  5. Barrier A, Ferro L, Houry S, et al. Rectal cancer surgery in patients more than 80 years of age. Am J Surg. 2003;185:54–7.PubMedCrossRefPubMedCentralGoogle Scholar
  6. Bregni G, Rebuzzi S, Sobrero A, et al. The optimal duration of adjuvant therapy for stage III colon cancer: the European perspective. Curr Treat Options in Oncol. 2019;20(1):8.CrossRefGoogle Scholar
  7. Ciabatti S, Cammelli S, Frakulli R, et al. Radiotherapy of pancreatic cancer in older patients: A systematic review. J Geriatr Oncol, 2019 Jul;10(4):534–539.PubMedCrossRefGoogle Scholar
  8. Conroy T, Hammel P, Hebbar M. FOLRIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. NEJM. 2018;379:2395–406.PubMedCrossRefPubMedCentralGoogle Scholar
  9. Cooper JS, Guo MD, Herskovic A, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. JAMA. 1999;281(17):1623–7.PubMedCrossRefPubMedCentralGoogle Scholar
  10. Cotte E, Passot G, Decullier E, et al. Pathologic response, when increased by longer interval, is a marker but not the cause of good prognosis in rectal cancer: 17-year follow-up of the Lyon R90-01 randomized trial. Int J Radiat Oncol Biol Phys. 2016;94(3):544–53.PubMedCrossRefGoogle Scholar
  11. Davila JA, Chiao EY, Hasche JC, et al. Utilization and determinations of adjuvant therapy among older patients who receive curative surgery for pancreatic cancer. Pancreas. 2009;38(1):e18–25.PubMedCrossRefGoogle Scholar
  12. Drilon A, Laetsch TW, Kummar S, et al. Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children. NEJM. 2018;378:731–9.PubMedCrossRefGoogle Scholar
  13. Extermann M, Aapro M, Bernabei R, et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol. 2005;55(3):241–52.PubMedCrossRefGoogle Scholar
  14. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer. 2012;118(13):3377–86.CrossRefGoogle Scholar
  15. Gatalica Z, Xiu J, Swensen J, et al. Molecular characterization of cancers with NTRK gene fusions. Mod Pathol. 2019;32:147–53.PubMedCrossRefGoogle Scholar
  16. Girre V, Falcou MC, Gisselbrecht M, et al. Does a geriatric oncology consultation modify the cancer treatment plan for elderly patients? J Gerontol. 2008;63(7):724–30.CrossRefGoogle Scholar
  17. Gollins S, Sun Myint A, Haylock B, et al. Preoperative chemoradiotherapy using concurrent capecitabine and irinotecan in magnetic resonance imaging-defined locally advance rectal cancer: impact on long-term clinical outcomes. J Clin Oncol. 2011;29(8):1042–9.PubMedCrossRefGoogle Scholar
  18. Hamaker ME, Jonker JM, de Rooij SE, et al. Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol. 2012;13(10):e437–44.PubMedCrossRefGoogle Scholar
  19. Horgan A, Knox J, Aneja P, et al. Patterns of care and treatment outcomes in older patients with biliary tract cancer. Oncotarget. 2015;6(42):44995.PubMedPubMedCentralCrossRefGoogle Scholar
  20. Howlader NNA, Krapcho M, Neyman N, et al. SEER cancer statistics review, 1975–2009 (Vintage 2009). Bethesda: National Cancer Institute; 2013.Google Scholar
  21. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol. 2011;29:3457–65.PubMedPubMedCentralCrossRefGoogle Scholar
  22. Kou T, Kanai M, Ikezawa K, et al. Comparative outcomes of elderly and non-elderly patients receiving first-line palliative chemotherapy for advanced biliary tract cancer. J Gastroenterol Hepatol. 2014;29(2):403–8.PubMedCrossRefPubMedCentralGoogle Scholar
  23. Kunz PL, Mojtahed A, Fisher GA, et al. HER2 expression in gastric and gastroesophageal junction adenocarcinoma in a US population: clinicopathologic analysis with proposed approach to HER2 assessment. Appl Immunohistochem Mol Morphol. 2012;20:13–24.PubMedPubMedCentralCrossRefGoogle Scholar
  24. Liu KT, Wan JF, Yu GH, et al. The recommended treatment strategy for locally advanced gastric cancer in elderly patients aged 75 years and older: a Surveillance, Epidemiology, and End Results database analysis. J Cancer Res Clin Oncol. 2017;143:313–20.PubMedCrossRefPubMedCentralGoogle Scholar
  25. Mehrvarz Sarshekeh A, Overman MJ, Kopetz S. Nivolumab in the treatment of microsatellite instability high metastatic colorectal cancer. Future Oncol. 2018;14(18):1869–74.PubMedCrossRefPubMedCentralGoogle Scholar
  26. Mohile SG, Bylow K, Dale W, et al. A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer. 2007;109(4):802–10.PubMedCrossRefPubMedCentralGoogle Scholar
  27. Onoyama H, Ajiki T, Takada M, et al. Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older? World J Surg. 2002;26(11):1315–8.PubMedCrossRefPubMedCentralGoogle Scholar
  28. Penniment MG, DeIeso PB, Harvey JA, et al. Palliative chemoradiotherapy versus radiotherapy alone for dysphagia in advanced oesophageal cancer: a multicenter randomized controlled trial (TROG 03.01). Lancet. 2018;3(2):114–24.PubMedPubMedCentralGoogle Scholar
  29. Pollom EL, Alagappan M, Park LS, et al. Does radiotherapy still have a role in unresected biliary tract cancer? Cancer Med. 2017;6(1):129–41.PubMedCrossRefPubMedCentralGoogle Scholar
  30. Prithviraj GK, Koroukian S, Margevicius S, et al. Patient characteristics associated with polypharmacy and inappropriate prescribing of medications among older adults with cancer. J Geriatr Oncol. 2012;3:228–37.PubMedPubMedCentralCrossRefGoogle Scholar
  31. Puts MT, Santos B, Hardt J, et al. An update on a systematic review of the use of geriatric assessment for older adults in oncology. Ann Oncol. 2014;25:307–15.PubMedCrossRefGoogle Scholar
  32. Sabel MS, Smith JL, Nava HR, et al. Esophageal resection for carcinoma in patients older than 70 years. Ann Surg Oncol. 2002;9(2):210–4.PubMedCrossRefPubMedCentralGoogle Scholar
  33. Saliba D, Orlando M, Wenger NS, Hays RD, Rubenstein LZ. Identifying a short functional disability screen for older persons. J Gerontol A Biol Sci Med Sci. 2000;55:M750–6.PubMedCrossRefPubMedCentralGoogle Scholar
  34. Sauer R, Becker H, Hohenberger W, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. NEJM. 2004;351:1731–40.PubMedCrossRefPubMedCentralGoogle Scholar
  35. Semrau R, Herzog SL, Vallbohmer D, et al. Radiotherapy in elderly patients with inoperable esophageal cancer: is there a benefit? Strahlenther Onkol. 2012;188(3):226–34.PubMedCrossRefPubMedCentralGoogle Scholar
  36. Shaib Y, El-Serag HB. The epidemiology of cholangiocarcinoma. Semin Liver Dis. 2004;24:115–25.PubMedCrossRefGoogle Scholar
  37. Sheridan J, Walsh P, Kevans D, et al. Determinants of short- and long-term survival from colorectal cancer in very elderly patients. J Geriatr Oncol. 2014;5:376–83.PubMedCrossRefGoogle Scholar
  38. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11–30.PubMedCrossRefGoogle Scholar
  39. Sohn TA, Yeo CJ, Cameron JL, et al. Should pancreaticoduodenectomy be performed in octogenarians? J Gastrointest Surg. 1998;2(3):207–16.PubMedCrossRefGoogle Scholar
  40. Strauss J, Hershman DL, Buono D, et al. Use of adjuvant 5-fluorouracil and radiation therapy after gastric cancer resection among the elderly and impact on survival. IJROBP. 2012;76:1404–12.Google Scholar
  41. Sutera PA, Bernard ME, Wang H, Heron DE. Prognostic factors for elderly patients treated with stereotactic body radiation therapy for pancreatic adenocarcinoma. Front Oncol. 2018;8:282.PubMedPubMedCentralCrossRefGoogle Scholar
  42. Talarico L, Chen G, Pazdur R. Enrollment of elderly patients in clinical trials for cancer drug registration: a 7-year experience by the US Food and Drug Administration. J Clin Oncol. 2004;22:4626–31.PubMedCrossRefPubMedCentralGoogle Scholar
  43. West LA, Cole S, Goodkind D, He W. 65+ in the United States: 2010. Current population reports. National Institutes of Health/US Census Bureau. Issued June 2014.Google Scholar
  44. Yamakawa M, Shiojima K, Takahashi M, et al. Radiation therapy for esophageal cancer in patients over 80 years old. IJROBP. 1994;30(5):1225–32.Google Scholar
  45. Yancik R, Ries LA. Cancer in older persons: an international issue in an aging world. Semin Oncol. 2004;31:128–36.PubMedCrossRefPubMedCentralGoogle Scholar
  46. Zhang B, Fattah A, Nakama H. Characteristics and survival rate of elderly patients with colorectal cancer detected by immunochemical occult blood screening. Hepato-Gastroenterology. 2000;47:414–8.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Radiation OncologySaint Peter’s University HospitalNew BrunswickUSA
  2. 2.Regional Cancer Care AssociatesEast BrunswickUSA

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