Ovarian cancer in the octogenarian: Does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply?☆
Introduction
In 2007 it is estimated that 22,430 women will be diagnosed with epithelial ovarian cancer (EOC) and 15,280 women will die [1]. Over 25% of patients are diagnosed and 40% of deaths occur over age 75 [2]. As advanced age has been previously identified as the most important risk factor for development of EOC and the proportion of women living into their 8th and 9th decade is increasing, the number of women presenting with advanced EOC who are also elderly can be expected to increase as well.
The current paradigm for primary treatment in advanced EOC includes primary surgical cytoreduction followed by combination platinum/taxane chemotherapy. Multiple studies have demonstrated the survival benefit obtained by achieving cytoreduction to no residual disease. This goal may require certain “radical procedures” such as splenectomy, and resection of the diaphragm, bowel or liver [3], [4], [5], [6], [7], [8], [9]. Complication rates for the addition of these radical procedures vary in the literature and depending on the population studied. The reported morbidities range from 32 to 50% with the majority being minor complications. The reported 30-day mortality rate ranges from 1.5 to 6% with deaths occurring in patients with significant pre-operative or disease related morbidity or age greater than 75. [4], [6], [9] The survival advantage in cytoreduction to no gross residual disease presumes that the primary surgical effort does not result in such morbidity that it significantly delays or prevents administration of combination platinum/taxane based chemotherapy.
The standard of care for adjuvant chemotherapy in advanced EOC is also in flux. The recent collaborative group study evaluating intravenous and intraperitoneal chemotherapy demonstrated a significantly prolonged survival among those patients who received even some of their chemotherapy via an intraperitoneal route [10]. This survival advantage was accompanied by significantly more neuropathy among the intraperitoneal group which persisted to one year post completion of therapy. As the incidence of neuropathy among chemotherapy patients increases with age, will we be able to use a regimen with known high prevalence of significant neuropathy among a more aged population? Will they need a separate standard of care?
Little data exists to guide physicians on whether elderly patients should receive the same management as younger patients who present with advanced EOC. Multiple studies have demonstrated poorer overall survival among patients greater than 65. This poorer survival persisted even when corrected for stage, residual disease and performance status [11], [12]. One explanation for this outcome is that patients considered to be elderly often do not receive the same standard of care as their younger counterparts [13], [14], [15], [16], [17], [18], [19]. This may be a result of bias that they will not tolerate the extensive cytoreductive procedures and combination chemotherapy required to treat advanced EOC. Evaluating patients over 65, studies have reported an increased length of hospital stay, peri-operative mortality, chemotherapy toxicity and decreased survival as compared to younger patients [20], [21].
The counter point to the above is that multiple studies have reported that if elderly patients receive the same therapy, their outcomes are equivalent to younger patients [22], [23], [24], [25].
In general, our institutional practice is to offer primary cytoreductive surgery followed by adjuvant platinum/taxane based chemotherapy to all patients without an age triage. In cases of significant medical co-morbidities or patient choice, treatment plans are individualized. We sought to evaluate our experience with patients who presented with EOC at age 80 or greater in terms of primary therapy offered, operative complications, ability to receive chemotherapy and disease specific survival. It is important to know if this subset of elderly patients should be managed in a conventional manner.
Section snippets
Methods
Study approval was obtained from the University of Oklahoma Institutional Review Board. Records for patients who presented with EOC between 1991 and 2006 were identified and information abstracted. All patients who were treated with primary surgery underwent their procedure by one of the faculty gynecologic oncologists at the University of Oklahoma. Abstracted data included age at diagnosis, Karnofsky's performance status, primary treatment modality, residual tumor after cytoreductive effort,
Results
From a database of over 600 consecutive patients treated at a single institution between 1991 and 2006, 85 patients diagnosed with EOC at age 80 or greater were identified. The median age of diagnosis for this group was 83 years with a range of 80 to 95. Ninety-five percent of patients were Caucasian. At least one co-existing medical co-morbidity was recorded for 70% of this cohort and 30% carried a diagnosis of two or more medical conditions. The most common medical co-morbidity identified was
Discussion
In this retrospective evaluation of patients with advanced ovarian cancer presenting over the age of 80, we demonstrate, at least among those who underwent primary cytoreductive surgery, a high rate of achieving minimal residual disease. This surgical success, however, comes at a price with complicated post-operative courses and, of most concern, death prior to hospital discharge and within 60 days of surgery in 13% and 20% respectively. Further, among patients who underwent CRS, 13% were
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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Chemotherapy alone for patients 75 years and older with epithelial ovarian cancer—is interval cytoreductive surgery still needed?
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2019, Gynecologie Obstetrique Fertilite et SenologieOvarian cancer in the older woman
2016, Journal of Geriatric Oncology
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Presented as Oral Main Plenary Presentation: Society of Gynecologic Oncologists Annual Meeting, 2007.