Performance status rather than age is the key prognostic factor in second-line treatment of elderly patients with epithelial ovarian carcinoma

Assessing the Role of Operative Intervention in Elderly Patients With Nonfunctional Pancreatic Neuroendocrine Neoplasms

OBJECTIVES

Resection of locoregional pancreatic neuroendocrine neoplasms (PanNENs) is typically recommended, but there is a paucity of data on the management of elderly patients.

METHODS

The National Cancer Database (2004-2016) was queried for patients 80 years or older with localized PanNENs. Patients were grouped as nonoperative or operative management. Postoperative outcomes and survival were compared.

RESULTS

In total, 591 patients were included: 202 underwent resection, and 389 did not. Increasing age and pancreatic head tumors were associated with lower likelihood of resection. The overall 90-day mortality rate was 6.4%, which was higher for pancreatoduodenectomy than distal pancreatectomy (13.6% vs 5.1%, respectively). Operatively managed patients had longer median survival (80.8 vs 45.0 months, P < 0.001), and this association was independent of tumor location. On multivariable Cox regression, resection remained associated with longer survival (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95). Among operatively managed patients, age and tumor location were not associated with survival; however, greater comorbidity and high-risk tumor-specific features were associated with worse survival.

CONCLUSIONS

Resection of nonfunctional PanNENs in elderly patients is associated with improved survival compared with nonoperative management. Resection could be considered in appropriate operative candidates, regardless of tumor location, but the perioperative mortality rate must be considered.

Current treatment of older patients with recurrent gynecologic cancer

PURPOSE OF REVIEW

Gynecologic cancer patients of elderly has been increasing rapidly. Useful information on older patients, especially, with recurrent gynecological cancer is extremely limited.

RECENT FINDINGS

A unified concept for assessing treatment risk was proposed when providing cancer treatment to older patients. Fit: patients capable of withstanding the same standard treatment as healthy younger patients; Vulnerable: patients incapable of withstanding the same standard treatment as healthy younger patients, but capable of undergoing some sort of treatment; and Frail: patients incapable of withstanding the same standard treatment as healthy younger patients, and also unsuitable to undergo any kind of active treatment.It is important to identify vulnerability by using geriatric assessment as a patient background factor, to intervene if treatment is required, and to modify the intensity of treatment in an attempt to extend overall survival, decrease adverse events, improve health-related quality of life, and reduce medical costs.

SUMMARY

It is important to carry out a pretreatment functional assessment of older cancer patients using the geriatric assessment, and to choose the method of treatment for older patients in light of its results with recurrent gynecological cancer in addition to chronological age.

Management of endometrial, ovarian and cervical cancer in the elderly: current approach to a challenging condition

PURPOSE

Gynaecological cancer management in older people represents a current challenge. Therefore, in the present paper, we aimed to gather all the evidence reported in the literature concerning gynecological cancers in the elderly, illustrating the state of art and the future perspectives.

METHODS

We searched MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, IBECS, BIOSIS, Web of Science, SCOPUS and Grey literature (Google Scholar; British Library) from January 1952 to May 2017, using the terms "ovarian cancer", "endometrial cancer", "cervical cancer", "gynecological cancers" combined with 'elderly', 'cancer', 'clinical trial' and 'geriatric assessment'.

RESULTS

The search identified 81 citations, of which 65 were potentially relevant after initial evaluation and met the criteria for inclusion and were analyzed. We divided all included studies into three different issue: "Endometrial cancer", "Ovarian cancer" and "Cervical cancer".

CONCLUSIONS

The present literature review shows that, in spite of the higher burden of comorbidities, elderly patients can also benefit from standard treatment to manage their gynecological cancers. It is important to overcome the common habit of undertreating the elderly patients because they are more fragile and with a lower life expectancy than their younger counterpart. Further trials with elderly women are warranted.

Do patients with reduced or excellent performance status derive the same clinical benefit from novel systemic cancer therapies? A systematic review and meta-analysis

Background

Whether patients with excellent and reduced performance status (PS) derive different net clinical benefit from novel anticancer systemic therapies on clinical trials is unclear.

Materials and methods

A systematic review was conducted of randomised controlled trials (RCTs) cited for drug approvals between 2006 and August 2015 by the Food and Drug Administration, the European Medicines Agency and Health Canada. Included studies had overall survival (OS) and/or progression-free survival (PFS) primary endpoints. Meta-analyses of OS/PFS based on PS dichotomised into excellent and reduced subgroups were performed using random effects.

Results

The systematic review identified 110 RCTs, with none reporting PS subgroup analyses for toxicity and 66 (60%) for efficacy. For these 66 RCTs involving 44 511 patients, pooled HRs for excellent and reduced groups were 0.65 (95% CI 0.61 to 0.70) and 0.67 (95% CI 0.62 to 0.72), respectively, with no difference between the two groups (p=0.68). Sensitivity analyses based on drug or cancer type and type of endpoints (OS or PFS) demonstrated similar results.

Conclusions

No decrease in relative efficacy from novel systemic therapy was found for patients with reduced PS when compared with patients with excellent PS for the range which were included in modern RCTs. Reporting of PS subgroup analyses of toxicities and more inclusion of patients with borderline low PS in RCTs should be considered for a more comprehensive understanding of the net clinical benefits of contemporary systemic therapies in patients across the spectrum of different PS.

Tolerance to Chemotherapy in Elderly Patients with Cancer

Background

Due to demographic changes, the number of elderly people with cancer will increase in the next decades. In the past, elderly patients with cancer were often excluded from clinical trials. Chronological age has been considered a risk factor for increased toxicity and reduced tolerance to chemotherapy.

Methods

We present a review on toxicity of chemotherapy and factors associated with toxicity in elderly patients with cancer, and we discuss chemotherapeutic agents and treatment options in treating this patient population.

Results

Age is a risk factor for increased toxicity to chemotherapy and decreased tolerance. However, few trials have been reported with adjustment for age-associated changes such as impairment of functional status and increased comorbidity, which also show an independent association with increased toxicity. Published data may include several biases, such as referral and publication bias.

Conclusions

Decision making in elderly cancer patients should be based on the results of a geriatric assessment. Patients with few or no limitations should be treated as younger patients are treated. Data with a high level of evidence are unavailable for patients showing moderate or severe limitations in a geriatric assessment.

Clinical features and outcomes of germline mutation BRCA1-linked versus sporadic ovarian cancer patients

Background

The role of germline mutations in BRCA1 and BRCA2 genes in the risk of the development of ovarian cancer is clinically well established. BRCA1/2 testing seems to have increasing role in clinical management in patients with advanced ovarian cancer who require treatment with poly(ADP-ribose) polymerase inhibitors.

Methods

Between 2002 – 2008, 125 consecutive patients with ovarian cancer were categorized as having three founder mutations in the BRCA1 gene in Poland as: 5382insC [exon 20], 4153delA [exon 11.17], and 300 T > G [exon 5]. PFS (progression free survival) and OS (overall survival) were determined by Kaplan-Meier analysis with log rank test, univariate comparisons, and multivariate regression analysis using Cox proportional hazards model.

Results

Of the 125 patients, the founder mutations of BRCA1 were reported in 17 patients (13.6 %). The median OS was longer for BRCA mutated patients (not reached vs 35.6 months, p = 0.041). PFS was similar for both kinds of ovarian cancer. In multivariate analysis, age ≥70 years, suboptimal surgery, and BRCA1 wild type were poor prognostic factors. The BRCA1 mutation reduced the likelihood of death in ovarian cancer by 86 % (HR 0.14; CI: 0.032-0.650, p = 0.012).

Conclusion

In conclusion, we found better overall survival for ovarian cancer patients with BRCA1 germline mutations in comparison with patients without these mutations (sporadic) ovarian cancer. Thus, BRCA1 germline mutations appear to be an independent prognostic factor for ovarian cancer.

A Simple Risk Model to Predict Survival in Patients With Carcinoma of Unknown Primary Origin

Carcinoma of unknown primary origin (CUP) is characterized by diverse histological subtypes and clinical presentations, ranging from clinically indolent to frankly aggressive behaviors. This study aimed to identify prognostic factors of CUP and to develop a simple risk model to predict survival in a cohort of Asian patients.We retrospectively reviewed 190 patients diagnosed with CUP between 2007 and 2012 at a single medical center in Taiwan. The clinicopathological parameters and outcomes of our cohort were analyzed. A risk model was developed using multivariate logistic regression and a prognostic score was generated.The prognostic score was calculated based on 3 independent prognostic variables: the Eastern Cooperative Oncology Group (ECOG) scale (0 points if the score was 1, 2 points if it was 2-4), visceral organ involvement (0 points if no involvement, 1 point if involved), and the neutrophil-to-lymphocyte ratio (0 points if ≤3, 1 point if >3). Patients were stratified into good (score 0), intermediate (score 1-2), and poor (score 3-4) prognostic groups based on the risk model. The median survival (95% confidence interval) was 1086 days (500-1617, n = 42), 305 days (237-372, n = 75), and 64 days (44-84, n = 73) for the good, intermediate, and poor prognostic groups, respectively. The c-statistics using the risk model and ECOG scale for the outcome of 1-year mortality were 0.80 and 0.70 (P = 0.038), respectively.In this study, we developed a simple risk model that accurately predicted survival in patients with CUP. This scoring system may be used to help patients and clinicians determine appropriate treatments.

Epithelial ovarian cancer in older women: defining the best management approach

Epithelial ovarian cancer is a cancer of older women. In fact, almost half of women diagnosed with ovarian cancer will be older than age 64, and 25% will be older than age 74. Therefore, it is crucial to examine the available data in older populations to optimize the therapeutic approach without negatively affecting the quality of life permanently. Unfortunately, little prospective data are available in this under-represented population of women. Although ovarian cancer traditionally has been approached with aggressive cytoreductive surgery, older patients may benefit from a less aggressive surgical approach and, in some cases, may be candidates for neoadjuvant chemotherapy followed by an interval cytoreduction. Modalities do exist for assessing an older woman's ability to tolerate surgery and chemotherapy, and these tools should be familiar to clinicians who are caring for this population of women in making treatment decisions. Ongoing planned trials to evaluate pretreatment assessment for older patients will provide objective, feasible, clinical tools for applying our treatment-based knowledge. Future trials of both surgery and chemotherapy, including a focus on the sequence of these two treatment modalities, are crucial to guide decision making in this vulnerable population and to improve outcomes for all.

Recent Advancements in Prognostic Factors of Epithelial Ovarian Carcinoma

Ovarian cancer remains the most common cause of gynecologic cancer-related death among women in developed countries. Nevertheless, subgroups of ovarian cancer patients experience relatively longer survival. Efforts to identify prognostic factors that characterize such patients are ongoing, with investigational areas including tumor characteristics, surgical management, inheritance patterns, immunologic factors, and genomic patterns. This review discusses various demographic, clinical, and molecular factors implicating longevity and ovarian cancer survival. Continued efforts at identifying these prognosticators may result in invaluable adjuncts to the treatment of ovarian cancer, with the ultimate goal of advancing patient care.

Assessment of solid cancer treatment feasibility in older patients: a prospective cohort study

PURPOSE

To assess solid cancer treatment feasibility in older patients.

METHODS

Between 2007 and 2010, 385 consecutive elderly patients (mean age: 78.9 ± 5.4 years; 47.8% males) with solid malignancies referred to two geriatric oncology clinics were included prospectively. We recorded feasibility of first-line chemotherapy (planned number of cycles in patients without metastases and three to six cycles depending on tumor site in patients with metastases), surgery (patient alive 30 days after successfully performed planned surgical procedure), radiotherapy (planned dose delivered), and hormonal therapy (planned drug dose given), and we recorded overall 1-year survival.

RESULTS

Main tumor sites were colorectal (28.6%), breast (23.1%), and prostate (10.9%), and 47% of patients had metastases. Planned cancer treatment was feasible in 65.7% of patients with metastases; this proportion was 59.0% for chemotherapy, 82.6% for surgery, 100% for radiotherapy, and 85.2% for hormonal therapy. In the group without metastases, feasibility proportions were 86.8% overall, 72.4% for chemotherapy, 95.7% for surgery, 96.4% for radiotherapy, and 97.9% for hormonal therapy. Factors independently associated with chemotherapy feasibility were good functional status defined as Eastern Cooperative Oncology Group performance status <2 (p < .0001) or activities of daily living >5 (p = .01), normal mobility defined as no difficulty walking (p = .01) or no fall risk (p = .007), and higher creatinine clearance (p = .04).

CONCLUSION

Feasibility rates were considerably lower for chemotherapy than for surgery, radiotherapy, and hormonal therapy. Therefore, utilization of limited geriatric oncology resources may be optimized by preferential referral of elderly cancer patients initially considered for chemotherapy to geriatric oncology clinics.

Considerations regarding the administration of systemic therapy for elderly patients with ovarian cancer

To improve the benefit and tolerability of cancer treatment, we must develop new geriatric-specific trials, better assessment tools, and encourage enrollment of older patients in clinical trials. Age is a strong predictor of survival in ovarian cancer and often influences the treatment plan. Elderly patients, broadly defined as older than age 65 years, are commonly not offered participation in clinical research or provided with substandard chemotherapy or surgical options. Because first-line, platinum-based chemotherapy with cytoreductive surgery is a potentially curative modality, all standard treatment options should be explored (intravenous, neoadjuvant, and/or intraperitoneal chemotherapy). However, one must balance the specific needs of the older patient and be aware of the increased risk of side effects. To be mindful and respectful, the oncologist should clearly define the goals (palliative vs. curative) and specific risks of treatment to patients and their families. As the field of geriatric oncology evolves and prospective trials tailored to older women with ovarian cancer are developed, specific guidelines will ultimately assist in these difficult decisions.

Treatment and trials: ovarian cancer in older women

Ovarian cancer (OC) is a disease of elderly women. The disease spreads insidiously and presents at an advanced stage at initial diagnosis for most patients. Several groups reported at least a two-fold increased risk of death in women older than 65. Various theories have been proposed to explain this survival disparity in older women, including: (1) more aggressive cancer with advanced age, (2) inherent resistance to chemotherapy, (3) individual patient factors such as multiple concurrent medical problems, and (4) physician and health-care biases toward the elderly that lead to inadequate surgery, less than optimal chemotherapy, and poor enrollment in clinical trials. As a result of this high clinical variability, oncologists need to be more familiar with the comprehensive geriatric assessment to better identify vulnerable patients at higher risk of complications. Several geriatric tools are available to assess the physiologic and functional capacities of older patients and to better individualize treatment. This paper gives an overview of the management of elderly patients with OC, in particular the integration of chemotherapy, surgery, and geriatric assessment to improve treatment tolerance and survival outcomes.

Doublet chemotherapy in the elderly patient with ovarian cancer

The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.

The impact of hospital type on the efficacy of chemotherapy treatment in ovarian cancer patients

OBJECTIVE

The hospital type affects the surgical outcomes of ovarian cancer patients. In the present study, we wanted to investigate the effect of hospital type on chemotherapy efficacy.

METHODS

Data were collected from 1077 ovarian cancer patients treated from 1996 to 2003 in a random sample of 18 Dutch hospitals. Hospitals were categorized by the number of medical oncologists working in a hospital and additionally by chemotherapy volume (< or =100, 101-200, or >200 patients yearly) and ovarian cancer patient-volume (< or =6, 7-12, >12 yearly). The outcomes were the proportions of patients achieving complete remission, recurrence rates, and disease-free and overall survival. Data were analyzed using multivariable logistic regression (complete remission and recurrence) and Cox regression (survival).

RESULTS

Data of 761 of the 777 patients who received chemotherapy could be analyzed. Hospital type did not affect the complete remission rates, recurrence rates, or the disease-free survival. Overall survival was better in hospitals with 2 or more medical oncologists and in hospitals with a high ovarian cancer patient-volume (hazard ratios both 0.8 (95% confidence interval=0.7-1.0)).

CONCLUSIONS

Thus, hospital type did not influence the outcomes of first-line chemotherapy in ovarian cancer patients. However, overall survival was better in hospitals with 2 or more medical oncologists and in hospitals with a high ovarian cancer patient-volume, suggesting differences in second-line chemotherapy.

Treatment of Elderly Cancer Patients with Chemotherapy

Persons over the age of 65 are the fastest growing segment of the United States population. In the next 30 years, they will comprise over 20 percent of the population. Fifty percent of all cancers occur in this age group and, therefore, there will be an expected rise in the total cancer burden. Data is becoming available that will better guide the use of chemotherapy in the older patient population. Information regarding age-related physiologic changes are presented with their relationship to pharmacology, functional status, and hematopoiesis. Treatments are reviewed in regard to the adjuvant treatment of breast and colon cancer as well as primary therapy of aggressive non-Hodgkin's lymphoma. The treatment of more advanced breast, ovary and non-small cell lung cancer also are discussed.

Do elderly cancer patients achieve an adequate dose intensity in common clinical practice?

BACKGROUND

Elderly patients rarely receive adequate dose intensity (DI) using conventional regimens. Possible causes are improper patient assessment, the chemotherapy (CT) regimen chosen, the number and severity of comorbidities, patient compliance and physician experience. To explore this issue, DI was retrospectively analyzed in elderly patients treated with conventional CT regimens for advanced solid cancer.

PATIENTS AND METHODS

Patients > or =69 years were evaluated. All patients had metastatic solid tumors. Comorbidities, performance status (PS), toxicities, number of CT cycles, dose reduction and discontinuation of treatment were recorded. Relative DI (RDI) was calculated and regressed against these parameters.

RESULTS

108 patients were eligible. The most frequent diagnoses were: lung, head-and-neck and colorectal cancer. In 48 patients (44%), their initially scheduled treatment was modified. Mean RDI was 79% (range 19-100%, SD 20.6). Grade 3/4 non-hematological and hematological toxicity occurred in 27 (35/130) and 8% of patients (11/130), respectively. In regression analysis, RDI was significantly associated with hematological toxicity. RDI affected response rate but not overall survival.

CONCLUSIONS

RDI is significantly affected by toxicity. These data suggest the importance of the treatment schedule and patient selection as predictorsof adequate treatment. Some non-ratable variables, however, might also play a role regarding the dose intensity delivered.

Prognostic factors for stage III epithelial ovarian cancer: a Gynecologic Oncology Group Study

PURPOSE

Conflicting results on prognostic factors for advanced epithelial ovarian cancer (EOC) have been reported because of small sample size and heterogeneity of study population. The purpose of this study was to identify factors predictive of poor prognosis in a similarly treated population of women with advanced EOC.

PATIENTS AND METHODS

A retrospective review of demographic, pathologic, treatment, and outcome data from 1,895 patients with International Federation of Gynecology and Obstetrics stage III EOC who had undergone primary surgery followed by six cycles of intravenous platinum/paclitaxel was conducted. A proportional hazards model was used to assess the association of prognostic factors with progression-free survival (PFS) and overall survival (OS).

RESULTS

Increasing age was associated with increased risks for disease progression (HR = 1.06; 95% CI, 1.02 to 1.11 for an increase every 10 years) and death (HR = 1.12; 95% CI, 1.06 to 1.18). Mucinous or clear-cell histology was associated with a worse PFS and OS compared with serous carcinomas. Patients with performance status (PS) 1 or 2 were at an increased risk for recurrence compared with PS 0 (HR = 1.12; 95% CI, 1.01 to 1.24). Compared with patients with microscopic residual disease, patients with 0.1 to 1.0 cm and > 1.0 cm residual disease had an increased risk of recurrence (HR = 1.96; 95% CI, 1.70 to 2.26; and HR = 2.36; 95% CI, 2.04 to 2.73, respectively) and death (HR = 2.11; 95% CI, 1.78 to 2.49; P < .001; and HR = 2.47; 95% CI, 2.09 to 2.92, respectively).

CONCLUSION

Age, PS, tumor histology, and residual tumor volume were independent predictors of prognosis in patients with stage III EOC. These data can be used to identify patients with poor prognosis and to design future tailored randomized clinical trials.

Response and outcomes in elderly patients with stages IIIC–IV ovarian cancer receiving platinum–taxane chemotherapy

OBJECTIVE

Recent reports have suggested that only half of women age > or =65 with advanced ovarian cancer are treated with platinum-based chemotherapy. The objective of this study was to compare the response to platinum-taxane chemotherapy and subsequent outcomes between patients older and younger than 65 years of age with stages IIIC-IV epithelial ovarian cancer (EOC).

PATIENTS AND METHODS

A cohort study was performed of all patients with stages IIIC-IV EOC who had their primary surgery at our institution from 1998 to 2004 and subsequently began platinum-taxane chemotherapy. Main outcomes were response to primary chemotherapy, platinum resistance and progression-free (PFS) and overall survival (OS).

RESULTS

A total of 292 patients began primary platinum-taxane therapy after surgery and comprised our study group. Of these, 108 (37%) were > or =65 years old and 184 (63%) were <65. Stage of disease, optimal cytoreduction rate, number of chemotherapy cycles and chemotherapy regimen alterations were similar between groups. Patients > or =65 achieved a clinical complete response with a similar frequency to those <65 (70% vs. 79%) and had similar rates of platinum sensitivity at 6 months (61% vs. 65%). Patients > or =65 had equivalent PFS (P=0.99) and OS (P=0.36) to those <65. Age > or =65 years was not independently associated with impaired survival.

CONCLUSIONS

Patients > or =65 years of age demonstrated similar rates of initial response, platinum resistance, PFS and OS to younger patients. Elderly women who can tolerate primary cytoreductive surgery should receive combination platinum-taxane chemotherapy.

Older female cancer patients: importance, causes, and consequences of undertreatment

Despite increased interest in treatment of senior cancer patients, older patients are much too often undertreated. This review aims to present data on treatment practices of older women with breast and gynecologic cancers and on the consequences of undertreatment on patient outcome. We also discuss the reasons and validity of suboptimal care in older patients. Numerous studies have reported suboptimal treatment in older breast and gynecologic cancer patients. Undertreatment displays multiple aspects: from lowered doses of adjuvant chemotherapy to total therapeutic abstention. Undertreatment also concerns palliative care, treatment of pain, and reconstruction. Only few studies have evaluated the consequences of nonstandard approaches on cancer-specific mortality, taking into account other prognostic factors and comorbidities. These studies clearly showed that undertreatment increased disease-specific mortality for breast and ovarian cancers. For other gynecological cancers, data were insufficient to draw conclusions. Objective reasons at the origin of undertreatment were, notably, higher prevalence of comorbidity, lowered life expectancy, absence of data on treatment efficacy in clinical trials, and increased adverse effects of treatment. More subjective reasons were putative lowered benefits of treatment, less aggressive cancers, social marginalization, and physician's beliefs. Undertreatment in older cancer patients is a well-documented phenomenon responsible for preventable cancer deaths. Treatments are still influenced by unclear standards and have to be adapted to the older patient's general health status, but should also offer the best chance of cure.

Gynecologic Care of Elderly Women

Evaluation and management strategies for addressing abnormal bleeding, discharge, urinary symptoms, and sexuality amongst elderly women are presented.

Racial disparities in treatment and survival of male breast cancer

PURPOSE

Black women with breast cancer have poorer survival than do white women, but little is known about racial disparities in male breast cancer. We analyzed race and other predictors of treatment and survival among men with stage I-III breast cancer.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) Medicare database to identify men 65 years of age or older diagnosed with stage I-III breast cancer from 1991 to 2002. Multivariate regression was used to compare those treated with those not treated with either chemotherapy or radiation therapy, adjusting for known clinical and demographic factors. Cox proportional hazards regression models were used to analyze survival.

RESULTS

Of 510 male breast cancer cases (456 white, 34 black), 94% underwent mastectomy, 28% received adjuvant chemotherapy, and 29% received radiation therapy. Among those with known hormone receptors, 95% had hormone-sensitive tumors. In a multivariate analysis, chemotherapy was associated with younger age, advanced stage, and hormone receptor-negative tumors. Radiation therapy was associated with younger age and advanced stage. Black men were approximately 50% less likely to undergo consultation with an oncologist and subsequently receive chemotherapy; however, the results did not reach statistical significance. The breast cancer-specific mortality hazard ratio was more than tripled for black versus white men (hazard ratio = 3.29; 95% CI, 1.10 to 9.86).

CONCLUSION

After adjustment for known clinical, demographic, and treatment factors, there was an association of black race with increased male breast cancer-specific mortality. Although male breast cancer is rare, the reasons for these disparities need to be better understood.

Carboplatin/cyclophosphamide or carboplatin/paclitaxel in elderly patients with advanced ovarian cancer? Analysis of two consecutive trials from the Groupe d'Investigateurs Nationaux pour l'Etude des Cancers Ovariens

BACKGROUND

To determine the feasibility of two chemotherapy regimens in elderly patients with advanced ovarian carcinoma (AOC).

PATIENTS AND METHODS

Eighty-three patients >or=70 years were previously enrolled in a trial evaluating carboplatin and cyclophosphamide (CC). On the basis of identical eligibility criteria, 75 further patients were enrolled in a trial evaluating carboplatin and paclitaxel (Taxol) (CP). The primary end point of these studies was the feasibility of six courses of chemotherapy. Comprehensive geriatric assessment (CGA) parameters were assessed in terms of prognostic factors.

RESULTS

More patients in the CC group presented with performance status of two or more, depression symptoms, use of co-medications, hypoalbuminemia, abnormal Mini-Mental Status score, or sub-optimal surgery. Both regimens appeared feasible: 75.6% in the CC group and 68.1% in the CP group completed six courses. CC and CP groups had similar overall survival (OS). Independent prognostic factors of poorer OS were the following: increasing age (P = 0.013), depression symptoms at baseline (P < 0.001), International Federation of Gynecology and Obstetrics stage IV (P = 0.001), and use of paclitaxel (P = 0.025).

CONCLUSION

As this is a non-randomised retrospective review of two consecutive studies, no firm conclusion can be drawn. It seems, however, that in elderly patients with AOC the use of paclitaxel results in more toxicity. CGA parameters and particularly emotional disorders might help to determine a priori the risk/benefit ratio of chemotherapy in this patient population.

Prognostic value of plasma soluble urokinase plasminogen activator receptor (suPAR) in Danish patients with recurrent epithelial ovarian cancer (REOC)

The level of the soluble urokinase plasminogen activator receptor (suPAR) is elevated in tumour tissue from several types of cancer. This is the first study aiming to predict the prognosis for survival by the use of a pre-chemotherapeutic plasma suPAR value in 71 patients with recurrent epithelial ovarian cancer (REOC). For determination of suPAR, pre-chemotherapeutic blood samples from the patients with REOC were processed into plasma (EDTA) within one working day from venipuncture. The plasma suPAR level is not correlated with performance status (p=0.41), FIGO stage (p=0.09), treatment-free interval (TFI) of 12 months (p=0.26), site of recurrence (peritoneum, p=0.50 or pelvis, p=0.44), age (p=0.43), or serum CA125 (p=0.09). Univariate as well as multivariate analyses cannot demonstrate that high pre-chemotherapeutic levels of plasma suPAR (p=0.22, p=0.80) are associated with shorter survival of REOC patients. Multivariate analysis showed that only TFI of 12 months (p=0.001) and performance score status of 2 (p=0.02) were independent prognostic factors. Our study indicates that pre-chemotherapeutic measurement of plasma suPAR level in REOC patients may not be useful to identify a subgroup of patients with poor prognosis.

Predictors of surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer

OBJECTIVE

To identify perioperative variables that will predict surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer.

METHODS

A retrospective review of 78 women>or=75 years treated for ovarian and primary peritoneal cancer from 1/1/90 to 06/30/04 was performed. Patients were categorized in two groups based on optimal versus suboptimal cytoreductive surgery. Perioperative variables were compared across the two groups by univariate and multivariate logistic regression analysis to evaluate the impact on survival.

RESULTS

The median age at the time of diagnosis was 79.3 years. Overall, 50% of the patients underwent optimal cytoreductive surgery. Patients with low perioperative serum albumin levels were associated with a 2.4-fold increased risk of suboptimal cytoreductive surgery (95% CI 1.02-5.88, p=0.04). Median survival of patients that underwent cytoreductive surgery was 19 months. As expected, survival analysis showed that patients with suboptimal cytoreductive surgery had a lower survival (median=17 months) than patients with optimal surgery (median=62 months, p=0.00). Patients>or=80 years were associated with a nearly 2-fold increase in the risk of mortality (95% CI 1.05-3.54, p=0.03), while albumin levels of >or=3.7 g/dl were associated with a 40% reduction in risk of mortality (95% CI 0.41-0.89, p=0.01).

CONCLUSIONS

Optimal cytoreductive surgery is feasible in many elderly patients. Women>or=80 years and with poor nutritional status are associated with a poor survival outcome. Perioperative variables such as these can be used to identify the elderly patients that are most likely to be suboptimally cytoreduced and thus have a dismal survival outcome.

Young Age Is Associated with Favorable Characteristics but Is Not an Independent Prognostic Factor in Patients with Epithelial Ovarian Cancer: A Single Institution Experience

BACKGROUND

Young age has been reported to be a favorable prognostic factor in ovarian cancer. The aim of the present study was to investigate the characteristics of ovarian cancer presenting in patients aged < or =40 and assess the prognostic significance of young age.

METHODS

Data from 591 consecutive ovarian cancer patients, including 37 subjects (6.3%) aged < or =40, who were treated postoperatively with platinum-based chemotherapy in our institution were retrospectively reviewed.

RESULTS

In our series, age < or =40 did not show an independent association with overall (p = 0.542) or progression-free survival (p = 0.334). Nonetheless, it was correlated with low tumor grade (p = 0.009) and small volume of residual disease after primary surgery (p = 0.020), while there was a nonsignificant trend for correlation with performance status 0 (p = 0.052). Stratified analysis showed that age < or =40 was associated with improved overall survival in the subgroups of serous histology and stage IIC-IV disease; however, multivariate analyses failed to identify age as an independent predictor of survival within either subgroup (p = 0.079 and p = 0.585, respectively).

CONCLUSIONS

Age < or =40 was not an independent prognostic factor in our analysis. The survival advantage of young patients may be attributed to the association with low tumor grade, more complete surgical debulking and better performance status.

Clinical Pharmacology Issues Relevant to the Dosing and Toxicity of Chemotherapy Drugs in the Elderly

Persons over the age of 65 years are the fastest growing segment of the U.S. population. In the next 30 years, they will comprise more than 20% of the population. Fifty percent of all cancers occur in this age group, and therefore, there is an expected rise in the total cancer burden. Data are becoming available that will better guide the use of chemotherapy in the older patient population. In this paper, information regarding age-related physiologic changes and their relationship to pharmacology, functional status, and hematopoiesis is presented. The adjuvant treatment of breast and colon cancer, as well as the primary therapy of aggressive non-Hodgkin lymphoma is reviewed. The treatment of more advanced breast, ovarian, and non-small cell lung cancer is also discussed.

The influence of age and co-morbidity on treatment and prognosis of ovarian cancer: a population-based study

OBJECTIVES

With the rising mean age, more patients will have one or more other serious diseases at the time of diagnosis of ovarian cancer (co-morbidity). In this study, the independent effects of age and co-morbidity on the application of treatment guidelines and prognosis were evaluated.

METHODS

All patients with epithelial ovarian cancer diagnosed between 1995 and 2001 in the southern part of The Netherlands (N = 1116) were included.

RESULTS

The prevalence of co-morbidity increased from 34% of the age group <70 to 63% of the older age group. Eighty-three percent of the patients with FIGO stage II or stage III younger than 70 years underwent the advised treatment (combination of surgery and chemotherapy) compared to only 45% of the patients aged 70 or older. In a multivariable analysis age, FIGO stage, presence of co-morbidity, and year of diagnosis seemed to be independent predictors of receiving the advised treatment. In multivariable analyses age 70 + (HR = 1.3, 95% CI = 1.03-1.7) and the use of both surgery and chemotherapy (HR = 0.4, 95% CI = 0.3-0.6, reference is only surgery) were independent prognostic factors for overall survival.

CONCLUSIONS

Even in the absence of co-morbidity, standard combination therapy was prescribed significantly less often for elderly patients with FIGO II or III ovarian cancer. Age and combined treatment of surgery and platinum-based chemotherapy were independent prognostic factors. Co-morbidity did not seem to have a prognostic effect.

Effectiveness of platinum-based chemotherapy among elderly patients with advanced ovarian cancer

BACKGROUND

Platinum-based chemotherapy is the standard of care for women with advanced ovarian cancer based on the results of randomized trials. We previously showed that only about half of women over the age of 65 years with this disease received platinum-based chemotherapy, and that the likelihood of receiving it decreases with age.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify women diagnosed from 1/1/92 to 12/31/96 with stage III or IV ovarian cancer who survived > or =120 days beyond diagnosis, and were > or =65 years of age. Cox proportional hazards models and propensity scores were used to control for known predictors of receiving treatment and to estimate the relative effectiveness of different platinum-based regimens.

RESULTS

Of the 1759 patients in the sample who met our eligibility criteria, 53% received platinum-based therapy. For this sample, the Cox proportional hazard ratio was 0.72 (95% CI, 0.62-0.91) for mortality associated with the use of any platinum-based therapy, and 0.59 (95% CI, 0.45-0.76) for combination platinum/paclitaxel therapy. Similar results were obtained using propensity score modeling.

CONCLUSIONS

In this population-based study, we found that only about half of women with advanced ovarian cancer over age 65 were treated with platinum-based chemotherapy; however, survival improved by 38% in treated women, similar to the benefits described in randomized controlled trials among younger patients, and were greatest when platinum was combined with paclitaxel. An effort to increase the utilization of platinum combination therapy among older patients with advanced ovarian cancer is justified.

Too Old to Care?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH (http://www.theschwarzcenter.org/rounds.asp). The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Ageism is a pervasive problem throughout society. It is rooted in language, attitudes, beliefs, behaviors, and policies. Aging profoundly influences physiology, challenging the medical community to accommodate but not discriminate. The elderly are at an increased risk of disease and disability. Sixty percent of cancer occurs in people aged 65 and older, and the population is aging. The treatment of cancer in the elderly is complicated by comorbidities and other physiological factors, particularly renal, bone marrow, and metabolic reserve. Caregivers have to treat patients in a manner that optimizes treatment and avoids anticipated harm. However, the caregiver is often faced with situations where they must balance their personal beliefs, professional values, and knowledge of medicine with their patients' preferences and needs. Discussion in the Rounds focused on age bias, drug toxicity, life prolongation, and symptom relief, with the role of the caregiver, and the relationship to the patient, being pivotal.

Do CA125 response criteria overestimate tumour response in second-line treatment of epithelial ovarian carcinoma?

Recent studies indicate that cancer antigen 125 (CA125) response criteria tend to overestimate a tumour reduction measured by standard WHO response criteria in recurrent epithelial ovarian carcinoma. The aim of the study was to validate the recently introduced GCIG (The Gynaecological Cancer Intergroup) CA125 response criteria in predicting a tumour response measured by WHO (World Health Organization) criteria. Changes in CA125 levels (GCIG criteria) were retrospectively compared with alterations in the tumour load (WHO criteria) during second-line chemotherapy with topotecan or paclitaxel-platinum in 124 consecutive patients with recurrent or refractory disease. In patients assessable by both response criteria (n=72), the overall response rate using GCIG CA125 criteria was 57% (95% confidence interval (CI): 45-69%) and significantly higher than the response rate of 39% (95% CI: 28-51%) using WHO response criteria (P=0.045). The GCIG CA125 criteria had a sensitivity of 96% (95% CI: 82-100%), a specificity of 68% (95% CI: 52-81%) and an accuracy of 79% (95% CI: 68-88%) in predicting a response measured by WHO criteria. In conclusion, the GCIG CA125 response criteria seem to overestimate a tumour response by WHO criteria when monitoring the efficacy of second-line chemotherapy with topotecan or paclitaxel-platinum in patients with epithelial ovarian carcinoma.

Pharmacological factors influencing anticancer drug selection in the elderly

Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years this segment will represent more than 20% of the population. Fifty percent of all cancers occur in this age group and therefore the total cancer burden is expected to rise. Data are becoming available that will better guide the use of chemotherapy in the older patient population. Studies are presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those that have entered clinical practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. Aging can affect the pharmacokinetics of chemotherapy in a number of ways. Absorption is only modified minimally by age. The greater concern with the use of oral drugs is patient compliance. Volume of distribution is affected by changes in body composition, anaemia and decreased plasma albumin concentration. There are many drugs in which renal excretion plays an important role. Decline in glomerular filtration is a consistent phenomenon with aging. Drug metabolism is primarily affected by changes in the P450 system and coadministration of drugs which also interact with this important enzyme system. The selection of chemotherapy in the elderly is frequently determined by degree of comorbidity and the patients' functional status. These factors are critical and can often determine response and toxicity. This article discusses the changes that occur with antimetabolites, camptothecins, anthracyclines, taxanes, platinum compounds, epipodophyllotoxins and vinca alkaloids. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in selecting chemotherapeutic agents include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes that occur in older patients. Interpatient variability and age-related changes in drug metabolism are discussed. Careful attention to the physiological changes with age and dose adjustments necessary for end-organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy. In this article specific diseases are discussed (breast, colon, ovarian and non-small lung cancers) with recommendations for drug selection in adjuvant chemotherapy and the treatment of metastatic disease. Future studies will need to incorporate these various factors to properly evaluate chemotherapy in older patients. Research and educational initiatives targeted to this population will need to be a priority.

Establishing a nursing research agenda in gero-oncology

Expanding the evidence base of cancer in the elderly is critical to advance the specialty of geriatric oncology nursing. This article will propose topics for nursing investigation relative to prevention and early detection, response to disease and treatment, and psychosocial responses in the elderly at risk for, or having cancer. International considerations for undertaking nursing research with this special population are also described. Current dilemmas requiring investigation and future demographic implications are highlighted.

Hemorrhagic Peritoneal Carcinomatosis Treated with a Weekly Schedule of Carboplatin and Paclitaxel. A Case Report

Ovarian carcinomas are chemosensitive tumors. Chemotherapy plays a pivotal role also in advanced disease, and the response to chemotherapy appears to be predictive of prolonged survival. Only performance status seems to limit therapy administration and affect patient survival.

Here we report on a 66-year-old patient with a clinical status heavily compromised by peritoneal carcinomatosis associated with bloody effusion, which required increasingly frequent paracentesis and transfusions. The clinical conditions worsened under carboplatin monochemotherapy. A further attempt with carboplatin and paclitaxel in a weekly schedule resulted in a clinical response in terms of reduced need for paracentesis and blood support and improved performance status. This case confirms that treatment is the only chance to improve clinical status even in patients with very advanced ovarian cancer and an extensive tumor load. In our opinion, the modified schedule adopted in the case presented here may be worthwhile for future phase II studies in a selected patient population.

Patterns of chemotherapy use for women with ovarian cancer: a population-based study

PURPOSE

To evaluate adherence to published recommendations for chemotherapy for ovarian cancer patients in the general community and to identify factors associated with its use.

PATIENTS AND METHODS

The study population consisted of 2,150 women residing in Northern California with a first diagnosis of primary epithelial ovarian cancer between January 1994 and December 1996. Patients were identified through the California Cancer Registry and their physicians were surveyed to supplement registry treatment information.

RESULTS

Almost 89% of women younger than 75 years with International Federation of Gynecology and Obstetrics stage III or IV tumors received chemotherapy, with levels of treatment highest for women diagnosed at stage III. Patients 75 years of age and older were significantly less likely than younger women to receive chemotherapy (58.2% v 86.1%; P =.001) regardless of stage at diagnosis. Approximately 20% of patients younger than 55 years with early-stage (stage IC and II) cancer received no chemotherapy. Treatment in an American College of Surgeons hospital and treatment by a gynecologic oncologist increased the likelihood of receiving chemotherapy. Hospitalization for comorbid illness, race/ethnicity, census-based measures of socioeconomic status, and size or teaching status of hospital were all unrelated to probability of treatment after adjustment for other factors. Reasons reported most frequently by physicians for no treatment were lack of clinical indication and patient refusal.

CONCLUSION

The results of this study suggest that, despite scientific evidence and published guidelines that advocate chemotherapy for most women with ovarian cancer, some groups of women did not receive optimum treatment.