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Journal of Clinical Oncology, Vol 25, No 28 (October 1), 2007: pp. 4502-4503 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.13.1805
In ReplyUniversity of North Carolina at Chapel Hill, Department of Medicine, Division of Hematology-Oncology and Lineberger Comprehensive Cancer Center, Chapel Hill, NC
Institut Jules Bordet, Brussels, Belgium
University of North Carolina at Chapel Hill, Department of Medicine, Division of Hematology-Oncology and Lineberger Comprehensive Cancer Center, Chapel Hill, NC Dr Boncz and colleagues present an interesting overview of the age-related differential distribution of health care costs, a surrogate for health care resource utilization, among Hungarian patients with breast and colorectal cancer. In a society that necessarily caps spending on health care, how does one allocate that precious resource? The preponderance of money spent on patients younger than 65 in Hungary is certainly striking, particularly for young women with breast cancer who account for only 42% of Hungarian breast cancer deaths yet receive 72% of the breast cancer health care expenditures. This vastly unequal cost distribution suggests that older Hungarian patients may be undertreated for their cancers and do not get their proportionate share of resources based on disease burden. These findings are in line with American studies, where health care resources are assumed to be more plentiful, showing a marked decline in colorectal cancer treatment with age.1 We thoroughly agree with Boncz et al's assertion that individualized care is the gold standard for treatment of elderly patients with cancer.2 That is, in order to avoid undertreatment of the fit elderly or overtreatment of the frail, treatment decisions in older patients must be individualized based on physician and patient preference, function, and individual health rather than chronological age. This is particularly true considering that there are clear data that colorectal cancer patients 70 or older who were enrolled on clinical trials had equal benefit with similar toxicity when treated with oxaliplatin-containing3 and irinotecan-containing regimens4 as did younger patients. Both younger and older fit patients with stage IV colorectal cancer are likely to have a similar median survival of 20 months with oxaliplatin, folinic acid, and fluorouracil (FOLFOX) compared with 12 to 14 months with fluorouracil plus leucovorin or 6 months with best supportive care. Devaluing this benefit for the older person by preferentially directing resources to relatively youthful patients is problematic. With individualized care as a gold standard, future attempts to assess the progress of cancer care in the elderly will need to incorporate novel quality measures beyond cost and use of recommended care—both reasonable surrogates for aggressiveness of care, but poor measures of appropriate individualized care. Innovative quality measures that encompass some aspects of care essential to individualized decision making have already been used5,6 to assess the quality of colorectal cancer care. Hopefully using similar measures adapted to the needs of elderly cancer patients, we will be better equipped to study the success of our efforts to individualize the care of the elderly with cancer. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: Hanna K. Sanoff, Sanofi-Aventis (C); Harry Bleiberg, Sanofi-Aventis (C), Roche (C), Pfizer Inc (C); Richard M. Goldberg, Sanofi-Aventis (C), Pfizer (C), Roche (C), Amgen (C), Genentech (C) Stock Ownership: None Honoraria: Harry Bleiberg, Sanofi-Aventis, Roche, Pfizer, Genetech, Amgen; Richard M. Goldberg, Sanofi-Aventis, Pfizer, Roche, Amgen, Genentech Research Funding: None Expert Testimony: Richard M. Goldberg, Sanofi-Aventis (C), Pfizer (C) Other Remuneration: None REFERENCES
1. Schrag D, Cramer LD, Bach PB, et al: Age and adjuvant chemotherapy use after surgery for stage III colon cancer. J Natl Cancer Inst 93:850-857, 2001 2. Sanoff HK, Bleiberg H, Goldberg RM: Managing older patients with colorectal cancer. J Clin Oncol 25:1891-1897, 2007 3. Goldberg RM, Tabah-Fisch I, Bleiberg H, et al: A pooled analysis to assess the safety and efficacy of FOLFOX4 in elderly patients with colorectal cancer. J Clin Oncol 24:4085-4091, 2006 4. Folprecht G, Seymour MT, Saltz L, et al: Irinotecan/5-FU/FA first-line therapy in older and younger patients with metastatic colorectal cancer: Combined analysis of 2,691 patients in randomized controlled trials. J Clin Oncol 25:181s, 2007 (abstr 4071) 5. Ayanian JZ, Zaslavsky AM, Guadagnoli E, et al: Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol 23:6576-6586, 2005 6. Malin JL, Schneider EC, Epstein AM, et al: Results of the National Initiative for Cancer Care Quality: How can we improve the quality of cancer care in the United States? J Clin Oncol 24:626-634, 2006
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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