Managing Chemotherapy Side Effects in Elderly Patients with Rectal Cancer

Elderly patients are unable to tolerate chemotherapy?

Dear Director,
My father is 84 years old.
After the Lunar New Year, he was diagnosed with stage 2B rectal cancer (the tumor is 4 cm from the anal opening).
The attending physician assessed that the tumor is too large and recommended six cycles of chemotherapy along with five weeks of radiation therapy.
Surgery will be performed once the tumor shrinks.
The physician presented two chemotherapy options: oral (covered by insurance) or injectable (out-of-pocket).
The doctor indicated that the injectable option has better efficacy, so we chose this method: administering the injection every two weeks, with each hospitalization lasting three days.
However, after my father's third chemotherapy session last week, he has been experiencing very strong side effects, including severe nausea, vomiting, and extreme fatigue.
We are very concerned that he may not be able to endure all six cycles.

Could you please advise if it would be appropriate to switch to oral chemotherapy, which has milder side effects, considering the patient's advanced age and the suffering caused by the current side effects?

Xiao Yun, 30~39 year old female. Ask Date: 2016/03/30

Dr. Lai Yicheng reply Oncology

Dear Miss Hsiao-Yun,
Thank you for your letter.
Here is my response: Your father has a stage 2B malignant tumor in the lower rectum, and there is a possibility for "sphincter-preserving treatment." Based on our experience, preoperative radiation combined with chemotherapy has shown a good tumor response.
In my personal experience, injectable chemotherapy tends to be more effective than oral chemotherapy.
Currently, he is undergoing injectable chemotherapy every two weeks with a combination of Oxaliplatin, 5-FU, and Leucovorin, which is expected to have a strong treatment response.

Considering your father's age of 84, it may be worth discussing with his attending physician the possibility of switching to a weekly regimen of 5-FU and Leucovorin, which has a milder response but is also very effective and covered by health insurance.

Thank you for reaching out for consultation.

Sincerely,
Dr.
Lai Yi-Cheng
Department of Radiation Oncology
Changhua Hospital

Reply Date: 2016/03/30

More Info

Managing chemotherapy side effects in elderly patients, particularly those with rectal cancer, is a complex and nuanced issue that requires careful consideration of both the benefits and risks associated with treatment options. In your father's case, being 84 years old and diagnosed with stage 2B rectal cancer, the treatment plan involving chemotherapy and radiation is aimed at shrinking the tumor before surgical intervention. However, the significant side effects he is experiencing, such as severe nausea, vomiting, and fatigue, raise valid concerns about his ability to tolerate the full course of treatment.

Understanding Chemotherapy Options
Chemotherapy can be administered in various forms, including oral medications and injectable treatments. Each method has its own set of advantages and disadvantages, particularly in elderly patients. Injectable chemotherapy, while often more potent, can lead to more pronounced side effects, as you've observed with your father's experience. On the other hand, oral chemotherapy tends to have a different side effect profile, which may be milder and more manageable for some patients.

Side Effects and Their Management
The side effects of chemotherapy can vary widely among individuals. Common side effects include:
1. Nausea and Vomiting: These are among the most distressing side effects and can significantly impact a patient's quality of life. Anti-nausea medications (antiemetics) can be prescribed to help manage these symptoms. It's essential to communicate with the healthcare team about the severity of these symptoms, as adjustments to the treatment regimen or additional supportive care may be necessary.

2. Fatigue: This is a common complaint among cancer patients undergoing chemotherapy. Encouraging rest, proper nutrition, and light physical activity can help mitigate fatigue.
3. Bone Marrow Suppression: This can lead to a decrease in blood cell counts, increasing the risk of infections, anemia, and bleeding. Regular blood tests are crucial to monitor these levels, and adjustments to treatment may be necessary if significant drops are observed.

4. Gastrointestinal Issues: Diarrhea or constipation can occur, and managing these symptoms is essential for maintaining nutritional intake and overall well-being.

Considering a Change to Oral Chemotherapy
Given your father's age and the severity of his side effects, it is reasonable to consider switching to oral chemotherapy if it is deemed appropriate by his oncologist. Oral agents may offer a more tolerable side effect profile, allowing for better adherence to treatment and improved quality of life. However, the decision to switch should be made collaboratively with the healthcare team, taking into account:
- Efficacy: Oral chemotherapy may be less effective than the injectable option, depending on the specific drugs involved and the individual patient's response to treatment.

- Patient Preference: Engaging your father in discussions about his treatment options and preferences is crucial. His comfort and quality of life should be prioritized.

- Monitoring: If a switch is made, close monitoring will still be necessary to assess the effectiveness of the new regimen and manage any side effects that may arise.

Conclusion
In conclusion, managing chemotherapy side effects in elderly patients with rectal cancer requires a tailored approach that considers the patient's overall health, treatment goals, and personal preferences. If your father is struggling significantly with the current injectable regimen, discussing the possibility of switching to oral chemotherapy with his oncologist is a prudent step. The healthcare team can provide guidance on the best course of action, ensuring that your father's treatment is both effective and as comfortable as possible. Open communication with the medical team about side effects and concerns is vital in navigating this challenging journey.

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