Elsevier

Gynecologic Oncology

Volume 101, Issue 3, June 2006, Pages 470-475
Gynecologic Oncology

The effect of age on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer

https://doi.org/10.1016/j.ygyno.2005.11.009Get rights and content

Abstract

Objective.

To evaluate the effect of age on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer.

Methods.

All women with surgically treated endometrial cancer at the University of Washington in Seattle, Washington between January 1990 and January 2000 were eligible; 396 patients underwent retrospective chart review. Statistical analysis was performed by SPSS. Median follow-up time was 33 months (range, 1 to 120 months).

Results.

Age was <45 years in 15% of patients, between 46 and 64 years in 47% of patients, and >65 years in 38% of patients. Younger patients were statistically more obese than older patients (Body Mass Index of 40.3 kg/m2 vs. 35.3 kg/m2 vs. 31.0 kg/m2, P < 0.001). Intraoperatively, there were no differences between the three groups in the percentage of patients with lymph node sampling, operative time, blood loss, or complications. Postoperatively, older patients had more wound infections (P = 0.002), more cardiac events (P = 0.001), and more episodes of ileus (P = 0.025). Evaluation of pathology revealed that patients <45 years old were statistically more likely to have endometrioid histology, grade I tumors, and stage IA disease. Women over age 65 were significantly more likely to have papillary serous histology, grade 3 tumors, and stage IC as compared to the younger patients. A subset analysis of patients >75 years of age showed an increase in the percentage of patients with papillary serous histology (22% vs. 3%, P = 0.055), grade 3 disease (42% vs. 16%, P < 0.001), and stage IC disease (21% vs. 3%, P = 0.001) when compared to patients <45 years old. Evaluation of endometrioid tumors only revealed a similar pattern of deeper myometrial invasion and higher tumor grade as age increased.

Conclusions.

Younger patients with endometrial cancer are generally more obese, with lower grade, lower stage disease, and with more favorable histologic cell types. Despite this, approximately a quarter have stage II–IV disease and 9% have positive lymph nodes. The older patients represent a dramatically different subset of patients. They are more likely to have aggressive papillary serous histology, higher grade tumors, and advanced stage disease. Age should be a consideration in appropriate referrals to gynecologic oncologists.

Introduction

Endometrial cancer is the most common gynecologic cancer in the United States, and the fourth most common malignancy among women. In 2005, there projects to be approximately 40,880 new cases and 7310 deaths from endometrial cancer in the U.S., and over 95% of these will be of epithelial origins [1]. The median age at diagnosis is 63 years [2] with 75% of women diagnosed in the postmenopausal period. The remaining 25% are diagnosed in the premenopausal period and of those, 5–10% are under the age of 40 years [3]. Recently, there has been a rise in the incidence of endometrial cancer in older women. While the exact reason is unknown, one possibility may be the increasing life expectancy of the elderly population. Previously, it has been reported that the histopathology of endometrial cancer in the elderly differs from the general population [4], [5].

Bokhman proposed two different pathways of endometrial carcinogenesis. The “classic” pathway describes endometrial cancer that arises from a hyperplastic precursor or area of atypical endometrial hyperplasia, which with estrogen stimulation undergoes malignant change to the more common endometrioid adenocarcinomas. These tumors occur more frequently in younger, more obese women, and are associated with lower stage and lower grade disease, also referred to as Type I tumors [6], [7], [8]. In contrast, the “alternative” pathway, describes a tumor (Type II disease) that arises from an atrophic endometrium in the absence of excess estrogen. This lesion is associated with mutations in the p53 tumor suppressor gene and with the development of serous endometrial cancers. These cancers occur more frequently in older women and are associated with non-endometrioid histologies, higher grade, and poorer prognosis [6], [9], [10].

Age is a prognostic factor for endometrial cancer. However, it is unclear if this is due to more aggressive histology or due to differences in the treatment received. The elderly have often been undertreated due to a lack of inclusion in clinical trials, and an assumption of increased surgical risk, secondary to concurrent comorbid conditions. They have also been less likely to receive additional adjuvant therapy in the form of radiation or chemotherapy [11]. With the increasing life expectancy of women and the increasing incidence of malignancy in the elderly, further evaluation of this group is warranted. Our study sought to determine the effects of age on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer.

Section snippets

Material and methods

International Classification of Diseases codes were used to create a list of patients surgically treated at the University of Washington for endometrial cancer from 1 January 1990 to 1 January 2000. Four hundred thirty-nine patients were identified. Forty-three were excluded for incomplete medical records. Three hundred ninety-six patient charts were retrospectively reviewed. Women were stratified into three age groups: 45 and under, those aged 46–64, and those 65 and over. These cutoffs are

Results

Mean age for the entire population was 60 years (range, 23–95 years). Fifty-eight patients (15%) were less than 45 years of age, 187 patients (47%) were between the ages of 46 and 64, and 151 patients (38%) were over the age of 65. Racial distribution appeared similar to that of our hospital population, and the Pacific Northwest in general, with 371 white (93.7%), 12 Asian or Pacific Islander (3.0%), 7 Native American (1.8%), 4 Hispanic (1.0%), and 2 black (0.5%) patients. The mean BMI was 34

Discussion

The issue of age and its effect on endometrial cancer has long been a topic of study; however, it remains a somewhat controversial one. Much of the earlier data have shown that women of younger age have more favorable tumor types as well as earlier stage disease and better outcomes [3]. Recent investigators have reached conflicting results regarding the performance of both young and old subsets of population [12], [13], [14]. Age may be perhaps the most important prognostic variable in outcomes

References (30)

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