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Daviu Cobián C, Oreskov JO, Blaakaer J, Jespersen E, Jørgensen TL, Ryg J, Herrstedt J, Høgdall C, Lund CM, Seibæk L, Vinther A, Ekmann-Gade AW, Schnack TH. Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC). J Geriatr Oncol 2024; 15:101713. [PMID: 38326125 DOI: 10.1016/j.jgo.2024.101713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT). MATERIALS AND METHODS This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients. DISCUSSION The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.
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Affiliation(s)
- Cristina Daviu Cobián
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark; Department of Gynecology and Obstetrics, Odense University Hospital, Denmark.
| | - Jakob O Oreskov
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jan Blaakaer
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark
| | - Eva Jespersen
- Department of Clinical Research, University of Southern Denmark, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Trine L Jørgensen
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Jesper Ryg
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Geriatric Medicine, Odense University Hospital, Denmark
| | - Jørn Herrstedt
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
| | - Claus Høgdall
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Cecilia M Lund
- Department of Medicine, Herlev and Gentofte hospital, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark
| | - Lene Seibæk
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark; Hospital Secretariat and Communications, Research, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Anne Weng Ekmann-Gade
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, Denmark
| | - Tine H Schnack
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
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AlAshqar A, Ghazarian M, Webster EM, Upadhyay A, Azodi M, Schwartz PE, Ratner E, Altwerger G. Surgical and oncologic outcomes in surgically treated women 80 years and older with endometrioid endometrial cancer as a function of their comorbidities. Gynecol Oncol Rep 2023; 49:101240. [PMID: 37636496 PMCID: PMC10450407 DOI: 10.1016/j.gore.2023.101240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To describe the surgical and oncologic outcomes in surgically treated oldest old women (≥80 years) with endometrioid endometrial cancer as a function of their comorbidities. Methods In this retrospective cohort study, patients aged 80-99 years who underwent surgical management of stage I endometrioid endometrial cancer between 2006 and 2018 were included. Low- and high-intermediate risk disease was defined using the Gynecologic Oncology Group-99 criteria. The validated, Combined Age-Charlson Comorbidity Index (CA-CCI) was used to quantify comorbidity burden. Logistic regression was used to identify the independent predictors of various surgical and oncologic outcomes. Kaplan-Meier survival analysis was performed to compare survival distributions based on mortality cause and comorbidity status. Results We identified 64 women who met the eligibility criteria. Median age was 84 years (IQR 80, 94 years). Among oldest old women undergoing a hysterectomy with or without lymph node dissection, women with a CA-CCI score of ≥7 had an 8 times higher risk of postoperative infections compared with oldest old women with a <7 score (95% CI 1.53-48.91, P = 0.015). Women with a CA-CCI score of ≥8 were 45% less likely to survive at 3 years (aRR 0.55, 95% CI 0.004-0.87; P = 0.039) than those with a lower CA-CCI score (three-year overall survival 73% vs 96%). Conclusion Surgical and oncologic outcomes in oldest old women with early stage endometrioid endometrial cancer are largely determined by comorbidity status. Less comorbid women (CA-CCI score < 8) had a significantly higher five-year survival at 87% than their more comorbid counterparts. Use of age-comorbidity risk scoring such as CA-CCI, preoperative optimization, and careful selection for and counseling of patients about surgical treatment are paramount in providing optimal recovery and survival advantages in the oldest old.
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Affiliation(s)
- Abdelrahman AlAshqar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Maddie Ghazarian
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Emily M. Webster
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Animesh Upadhyay
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Masoud Azodi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Elena Ratner
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Gary Altwerger
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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3
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Rousseau F, Ranchon F, Bardin C, Bakrin N, Lavoué V, Bengrine-Lefevre L, Falandry C. Ovarian cancer in the older patient: where are we now? What to do next? Ther Adv Med Oncol 2023; 15:17588359231192397. [PMID: 37724138 PMCID: PMC10505350 DOI: 10.1177/17588359231192397] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/19/2023] [Indexed: 09/20/2023] Open
Abstract
In recent years, major advances have been made toward the individualization of epithelial ovarian cancer care, leading to an overall improvement of patient outcomes. However, real-life data indicate that the oldest populations do not benefit from this, due to aspects related to cancer (more aggressive histopathological features), treatment (i.e. frequently suboptimal), and the host (increased toxicities in patients with lower physiological reserve). A specific risk-benefit perspective should therefore be taken when considering surgery, chemotherapy, and maintenance treatments: the decision for cytoreductive surgery should include geriatric vulnerability and surgical complexity, neo-adjuvant chemotherapy being an option when primary surgery appears at high risk; carboplatin paclitaxel association remains the standard even in vulnerable older patients; and bevacizumab and poly(ADP-ribose) polymerase inhibitors maintenance are interesting options provided they are prescribed according to their indications with a close monitoring of their toxicities. Future studies should aim to individualize care without limiting access of older patients to innovation. A specific focus is needed on age-specific translational analyses (focusing on tumor mutational burden and impaired biological pathways), a better patient stratification according to geriatric parameters, an adaptation of both oncological treatment and geriatric interventions, and treatment adaptations not a priori but according to formal pharmacokinetic data.
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Affiliation(s)
- Frédérique Rousseau
- Institut Paoli Calmettes Institute, Marseille, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Florence Ranchon
- Groupement Hospitalier Sud, Unité de Pharmacie Clinique Oncologique, Hospices Civils de Lyon, Pierre-Bénite, France
- CICLY Centre pour l’Innovation en Cancérologie de Lyon, Oullins, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Christophe Bardin
- Service de Pharmacie Clinique, Hôpital Cochin AP-HP Centre Université Paris Cité, Paris, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Naoual Bakrin
- Hospices Civils de Lyon, Service de Chirurgie Digestive, CHU Hôpital Lyon-Sud, Pierre-Bénite Cedex, France
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Vincent Lavoué
- Service de Gynécologie, CHU de Rennes, Hôpital Sud, Rennes, France
- UMR S1085, IRSET-INSERM, Université de Rennes, Rennes, France
- Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN)
| | - Leila Bengrine-Lefevre
- Département d’Oncologie Médicale, Centre Georges-Francois Leclerc, Dijon, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Claire Falandry
- Hospices Civils de Lyon, Unité de Gériatrie, Centre Hospitalier de la Croix Rousse, 103, Grande Rue de la Croix-Rousse, Lyon 69004, France
- Université de Lyon, CarMeN Laboratory, INSERM U.1060/Université Lyon 1/INRA U1397/INSA Lyon/Hospices Civils Lyon Bâtiment CENS-ELI 2D; Hôpital Lyon Sud Secteur 2; Pierre-Bénite 69310, France
- Université Claude Bernard Lyon 1, Pierre-Bénite 69310, France Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
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Multi-Disciplinary Care Planning of Ovarian Cancer in Older Patients: General Statement-A Position Paper from SOFOG-GINECO-FRANCOGYN-SFPO. Cancers (Basel) 2022; 14:cancers14051295. [PMID: 35267603 PMCID: PMC8909025 DOI: 10.3390/cancers14051295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary This position paper aims to provide practitioners a proposal for multidisciplinary care planning for older patients with ovarian cancer from the time of suspected diagnosis. The first-line treatment of advanced ovarian cancer involves several interdependent sequences: cytoreductive surgery, (neo)adjuvant chemotherapy and maintenance targeted treatments. In older patients, care planning must be adapted to their geriatric parameters and consider the geriatric impact of each treatment sequence to allow treatment completion. Care planning should be centered on patient motivation and imply multidisciplinarity. Each step of treatment plan should be reconsidered in light of a geriatric assessment and follow-up. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes. Abstract In this position paper the Société Francophone d’OncoGériatrie (SOFOG; French-speaking oncogeriatric society), the Société Française de Pharmacie Oncologique (SFPO, French society for oncology pharmacy), the Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO, National Investigators’ Group for Studies in Ovarian and Breast Cancer) and the Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN) propose a multi-disciplinary care planning of ovarian cancer in older patients. The treatment pathway is based on four successive decisional nodes (diagnosis, resectability assessment, operability assessment, adjuvant, and maintenance treatment decision) implying multidisciplinarity and adaptation of the treatment plan according to the patient’s geriatric covariates and her motivation towards treatment. Specific attention must be paid to geriatric intervention, supportive care and pharmaceutical conciliation. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes.
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Ebrahimi V, Khalafi‐Nezhad A, Ahmadpour F, Jowkar Z. Conditional disease-free survival rates and their associated determinants in patients with epithelial ovarian cancer: A 15-year retrospective cohort study. Cancer Rep (Hoboken) 2021; 4:e1416. [PMID: 33949809 PMCID: PMC8714540 DOI: 10.1002/cnr2.1416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/02/2021] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The most common type of ovarian cancer (OC) is epithelial ovarian cancer (EOC) which is the most lethal gynecologic malignancy in adult women. AIM This study aimed to determine the conditional disease-free survival (CDFS) rates and their associated determinants in patients with EOC. METHODS AND RESULTS The clinical and demographic data of 335 patients with confirmed EOC at Motahari Clinic (Shiraz, Iran) were retrospectively reviewed and analyzed. Traditional DFS (TDFS) and CDFS were calculated using the Kaplan-Meier method and cumulative DFS estimates, respectively. To evaluate the effects of the prognostic determinants on the DFS of the patients, a multiple covariate Cox analysis using the landmarking method was applied. The 1- and 3-year TDFSs were 81.1% and 47.0%, respectively, and decreased over time. At baseline, a higher stage tumor and endometrioid histology were associated with a higher risk of recurrence when compared to stage I and other histological subtypes, respectively. The hazard of recurrence for older women (age ≥55 years) was approximately twice and three times more than that of women aged <45 years at 1- and 3-year landmark time points, respectively. CONCLUSION The age at diagnosis, defined by a cut-off of 55 years, was a prognostic factor for the CDFS of EOC women. Moreover, patients with advanced-stage EOC (ASEOC) (stages III and IV) and endometrioid histology had poorer CDFSs compared to those with early-stage EOC (ESEOC) (stages I and II) and other histological types. In ESEOC patients with age at diagnosis of >55 years, CDFS gradually decreased in 3 years after remission which should be considered for follow-up care decision-making.
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Affiliation(s)
- Vahid Ebrahimi
- Department of Biostatistics, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Abolfazl Khalafi‐Nezhad
- Department of Hematology, Medical Oncology and Stem Cell TransplantationSchool of Medicine, Shiraz University of Medical SciencesShirazIran
| | - Fatemeh Ahmadpour
- Department of Obstetrics and Gynecology, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Zahra Jowkar
- Oral and Dental Disease Research Center, Department of Operative Dentistry, School of DentistryShiraz University of Medical SciencesShirazIran
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Zheng S, Fu Y. Age-related copy number variations and expression levels of F-box protein FBXL20 predict ovarian cancer prognosis. Transl Oncol 2020; 13:100863. [PMID: 32898767 PMCID: PMC7486480 DOI: 10.1016/j.tranon.2020.100863] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 12/04/2022] Open
Abstract
About 70% of ovarian cancer (OvCa) cases are diagnosed at advanced stages (stage III/IV) with only 20–40% of them survive over 5 years after diagnosis. A reliably screening marker could enable a paradigm shift in OvCa early diagnosis and risk stratification. Age is one of the most significant risk factors for OvCa. Older women have much higher rates of OvCa diagnosis and poorer clinical outcomes. In this article, we studied the correlation between aging and genetic alterations in The Cancer Genome Atlas Ovarian Cancer dataset. We demonstrated that copy number variations (CNVs) and expression levels of the F-Box and Leucine-Rich Repeat Protein 20 (FBXL20), a substrate recognizing protein in the SKP1-Cullin1-F-box-protein E3 ligase, can predict OvCa overall survival, disease-free survival and progression-free survival. More importantly, FBXL20 copy number loss predicts the diagnosis of OvCa at a younger age, with over 60% of patients in that subgroup have OvCa diagnosed at age less than 60 years. Clinicopathological studies further demonstrated malignant histological and radiographical features associated with elevated FBXL20 expression levels. This study has thus identified a potential biomarker for OvCa prognosis.
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Affiliation(s)
- Shuhua Zheng
- Nova Southeastern University, College of Osteopathic Medicine, Florida 33314, USA.
| | - Yuejun Fu
- Key Laboratory of Chemical Biology and Molecular Engineering of Ministry of Education, Institute of Biotechnology, Shanxi University, Taiyuan 030006, People's Republic of China
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[Epithelial ovarian cancer and elderly patients. Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:238-249. [PMID: 30712964 DOI: 10.1016/j.gofs.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Indexed: 11/24/2022]
Abstract
In ovarian, tubal and primary peritoneal cancers, older adults have an over-mortality due to more aggressive disease (NP4), surgical and chemotherapy under treatment (NP4) and co-morbidities (NP4). Older age is at higher risk for postoperative morbidity and mortality (NP4). Surgery is more often incomplete in this elderly population (NP4). Older age is a risk factor for lower dose intensity in adjuvant chemotherapy (NP4) and incomplete chemotherapy (NP4). Nevertheless, the benefit of a complete surgery remains identical to that of the younger population (NP2). Preoperative functional assessment identifies patients at risk for postoperative complications (NP4). The perioperative risk depends on three variables, the ASA score, the age and the complexity score of the surgery (NP4). It is recommended to perform cytoreduction surgery in an expert centre (grade C) and on the basis of geriatric expertise analysing functional and physical performance (grade C). The benefit/risk balance of surgery should be assessed on a case-by-case basis for the most at-risk (NP4) populations defined by: (i) age≥80 years, especially if albuminemia≤37g/L; (ii) age≥75 years and FIGO stage IV; (iii) age≥75 years, stage FIGO III and≥1 comorbidity. A comprehensive geriatric assessment is recommended prior to the management of an elderly person with primary ovarian, tubal or peritoneal cancer (grade C). The GVS (Geriatric Vulnerability Score) is used to identify vulnerable elderly patients (NP2). In fit elderly patients, it is recommended to perform intravenous chemotherapy identical to that of younger patients (ie platinum-based dual therapy) (grade B). In vulnerable elderly patients, various adapted chemotherapy regimens have been prospectively evaluated in non-comparative trials, and seem feasible considering specific and nonspecific toxicities: carboplatin monotherapy (NP2), carboplatin AUC2+paclitaxel 60mg/m2 3 weeks/4 (NP2), carboplatin AUC 4-5+paclitaxel 135mg/m2/3 weeks (NP2), carboplatin AUC5/3 weeks+paclitaxel 60mg/m2/week (NP3). In the absence of comparative data, no recommendation can be made in this population. Primary chemotherapy decreases the complexity of the surgical procedure and perioperative morbidity and mortality during interval surgery (NP1). It should be considered after 70 years in cases of comorbidities and/or peritoneal carcinomatosis sufficient for complex initial surgery (NP4).
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Tortorella L, Vizzielli G, Fusco D, Cho WC, Bernabei R, Scambia G, Colloca G. Ovarian Cancer Management in the Oldest Old: Improving Outcomes and Tailoring Treatments. Aging Dis 2017; 8:677-684. [PMID: 28966809 PMCID: PMC5614329 DOI: 10.14336/ad.2017.0607] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 06/07/2017] [Indexed: 12/27/2022] Open
Abstract
Ovarian cancer is the most common cause of death from gynecological cancers in developed countries. It is a common disease of older women at or above 63 years upon diagnosis. Thanks to advance in new treatments, mortality from ovarian cancer has declined in developed countries in the last decade. This decline in mortality rate is unevenly distributed across the age-spectrum. While mortality in younger women has decreased 21.7%, for elderly women it has declined only 2.2%. Even if ovarian cancer is clearly a disease of the elderly, older women are underrepresented in clinical trials, and scant evidence exists for the treatment of women older than 80 years. Moreover, older women are frequently undertreated, receive less chemotherapy and less combination of surgery and chemotherapy, despite the fact that this is considered the optimal treatment modality. This may be mainly due to the lack of evidence and physician’s confidence in the management of elderly women with ovarian cancer. In this review, we focus on the management of older women with ovarian cancer, considering geriatric features tied to this population.
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Affiliation(s)
- Lucia Tortorella
- 1Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Vizzielli
- 1Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Domenico Fusco
- 2Geriartic Department, Fondazione Policlinico A.Gemelli, Rome, Italy
| | - William C Cho
- 3Department of Clinical Oncology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Roberto Bernabei
- 2Geriartic Department, Fondazione Policlinico A.Gemelli, Rome, Italy
| | - Giovanni Scambia
- 1Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Colloca
- 2Geriartic Department, Fondazione Policlinico A.Gemelli, Rome, Italy
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Crim A, Rowland M, Ruskin R, Dvorak J, Greenwade M, Walter A, Gillen J, Ding K, Moore K, Gunderson C. Evaluation of the efficacy and toxicity profile associated with intraperitoneal chemotherapy use in older women. Gynecol Oncol 2017; 146:268-272. [PMID: 28583323 DOI: 10.1016/j.ygyno.2017.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/11/2017] [Accepted: 05/24/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Intraperitoneal (IP) chemotherapy (CT) for treatment of epithelial ovarian cancer (EOC) has been shown to provide a substantial OS advantage. This study aims to compare the toxicity and benefits of IP CT in patients ≥70 with those <70. METHODS We performed a single institution retrospective review of patients diagnosed with Stage IIA-IIIC EOC from 2000 to 2013 who received IP CT. Clinicopathologic characteristics were extracted, and survival was calculated. RESULTS 133 patients were included with 100 pts. <70years old and 33 pts. ≥70years old. Clinical trial enrollment was similar despite age. In trial enrolled patients, older patients received statistically fewer cycles of therapy (6.4 vs 5.8, p=0.002) but had similar dose delays (0.9 vs 0.7, p=0.72), and modifications (0.9 vs 0.36, p=0.11). Median PFS (27 vs 31months) and OS (71 and 62months) were not statistically different. Grade 3/4 neutropenia was significantly worse in the older patients (82% vs 100%, p=0.04). Neuropathy grade ≥2 and other non-hematologic toxicities were not different between age groups. CONCLUSIONS Despite completing fewer cycles of IP CT, older EOC patients had comparable survival to younger patients. The population of older patients receiving IP CT in this study were on clinical trial and likely to be heartier than the general older population. IP CT appears well tolerated and effective among select older patients and is likely under-utilized outside of clinical trials.
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Affiliation(s)
- A Crim
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - M Rowland
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - R Ruskin
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - J Dvorak
- Department of Biostatistics and Epidemiology, University of Oklahoma, Oklahoma City, OK, USA.
| | - M Greenwade
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - A Walter
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - J Gillen
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - K Ding
- Department of Biostatistics and Epidemiology, University of Oklahoma, Oklahoma City, OK, USA.
| | - K Moore
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
| | - C Gunderson
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA.
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Dumas L, Ring A, Butler J, Kalsi T, Harari D, Banerjee S. Improving outcomes for older women with gynaecological malignancies. Cancer Treat Rev 2016; 50:99-108. [PMID: 27664393 PMCID: PMC5821169 DOI: 10.1016/j.ctrv.2016.08.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 12/13/2022]
Abstract
The incidence of most gynaecological malignancies rises significantly with increasing age. With an ageing population, the proportion of women over the age of 65 with cancer is expected to rise substantially over the next decade. Unfortunately, survival outcomes are much poorer in older patients and evidence suggests that older women with gynaecological cancers are less likely to receive current standard of care treatment options. Despite this, older women are under-represented in practice changing clinical studies. The evidence for efficacy and tolerability is therefore extrapolated from a younger; often more fit population and applied to in every day clinical practice to older patients with co-morbidities. There has been significant progress in the development of geriatric assessment in oncology to predict treatment outcomes and tolerability however there is still no clear evidence that undertaking a geriatric assessment improves patient outcomes. Clinical trials focusing on treating older patients are urgently required. In this review, we discuss the evidence for treatment of gynaecological cancers as well as methods of assessing older patients for therapy. Potential biomarkers of ageing are also summarised.
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Affiliation(s)
- Lucy Dumas
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom
| | - Alistair Ring
- Breast Unit, Royal Marsden NHS Foundation Trust, Downs Road, Sutton SM2 5PT, United Kingdom
| | - John Butler
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom
| | - Tania Kalsi
- Department of Ageing and Health, 9th Floor North Wing, St Thomas' Hospital, Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom; Division of Health and Social Care Research, King's College London, Capital House, 42 Weston Street, London SE1 3QD, United Kingdom
| | - Danielle Harari
- Department of Ageing and Health, 9th Floor North Wing, St Thomas' Hospital, Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom; Division of Health and Social Care Research, King's College London, Capital House, 42 Weston Street, London SE1 3QD, United Kingdom
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom.
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Eo W, Kim HB, Lee YJ, Suh DS, Kim KH, Kim H. Preoperative Lymphocyte-Monocyte Ratio Is a Predictor of Suboptimal Cytoreduction in Stage III-IV Epithelial Ovarian Cancer. J Cancer 2016; 7:1772-1779. [PMID: 27698915 PMCID: PMC5039359 DOI: 10.7150/jca.15724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/29/2016] [Indexed: 12/29/2022] Open
Abstract
Objective: To determine whether the preoperative lymphocyte-monocyte ratio (LMR) is a predictor of suboptimal cytoreduction in advanced-stage epithelial ovarian cancer (EOC). Methods: Preoperative clinico-pathologic and hematologic parameters were reviewed in a total of 154 patients with EOC submitted to primary cytoreductive surgery. Patients were categorized into two different groups according to the results of cytoreductive surgery: optimal and suboptimal cytoreduction. Continuous variables were categorized into two groups using the best cutoff points selected on the receiver operating characteristic (ROC) curve for suboptimal cytoreduction. Results: Based on data collected from the 154 patients, 133 (86.4%) and 21 (13.6%) patients presented with stage III and IV disease, respectively. One hundred seventeen (76.0%) patients had serous adenocarcinoma, and 92 (59.7%) had histologic tumor grade 3. The optimal and suboptimal cytoreduction groups included 96 (62.3%) and 58 patients (37.7%), respectively. The best LMR cutoff point for suboptimal cytoreduction was 3.75. On multivariate logistic regression analysis, age, cancer antigen 125, white blood cell count, and LMR were found to be the strongest predictors for suboptimal cytoreduction (P=0.0037, 0.0249, 0.0062, and 0.0015, respectively). Conclusion: Preoperative LMR is an independent predictor of suboptimal cytoreduction. It provides additional prognostic information beyond the biological parameters of the tumor.
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Affiliation(s)
- Wankyu Eo
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Hong-Bae Kim
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Korea
| | - Yong Joo Lee
- Department of Medicine, Pusan National University Graduate School
| | - Dong Soo Suh
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ki Hyung Kim
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Heungyeol Kim
- Department of Obstetrics and Gynecology, College of Medicine, Kosin University, Busan, Korea
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Duska LR, Tew WP, Moore KN. Epithelial ovarian cancer in older women: defining the best management approach. Am Soc Clin Oncol Educ Book 2015:e311-21. [PMID: 25993191 DOI: 10.14694/edbook_am.2015.35.e311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Linda R Duska
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
| | - William P Tew
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
| | - Kathleen N Moore
- From the University of Virginia, Charlottesville, VA; Memorial Sloan Kettering Cancer Center, New York NY; University of Oklahoma, Oklahoma City, OK
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Baruah U, Barmon D, Kataki AC, Deka P, Hazarika M, Saikia BJ. Neoadjuvant chemotherapy in advanced epithelial ovarian cancer: A survival study. Indian J Med Paediatr Oncol 2015; 36:38-42. [PMID: 25810573 PMCID: PMC4363849 DOI: 10.4103/0971-5851.151781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Context: Patients with advanced ovarian cancer have a poor prognosis in spite of the best possible care. Primary debulking surgery has been the standard of care in advanced ovarian cancer; however, it is associated with high mortality and morbidity rates as shown in various studies. Several studies have discussed the benefit of neoadjuvant chemotherapy in patients with advanced ovarian cancer. Aims: This study aims to evaluate the survival statistics of the patients who have been managed with interval debulking surgery (IDS) from January 2007 to December 2009. Materials and Methods: During the period from January 2007 to December 2009, a retrospective analysis of 104 patients who underwent IDS for stage IIIC or IV advanced epithelial ovarian cancer at our institute were selected for the study. IDS was attempted after three to five courses of chemotherapy with paclitaxal (175 mg/m2 ) and carboplatin (5-6 of area under curve). Overall survival (OS) and progression free survival (PFS) were compared with results of primary debulking study from existing literature. OS and PFS rates were estimated by means of the Kaplan-Meier method. Results were statistically analyzed by IBM SPSS Statistics 19. Results: The median OS was 26 months and the median PFS was 18 months. In multivariate analysis it was found that both OS and PFS was affected by the stage, and extent of debulking. Conclusions: Neoadjuvant chemotherapy, followed by surgical cytoreduction is a promising treatment strategy for the management of advanced epithelial ovarian cancers.
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Affiliation(s)
- Upasana Baruah
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Debabrata Barmon
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Amal Chandra Kataki
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Pankaj Deka
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Munlima Hazarika
- Department of Medical Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Bhargab J Saikia
- Department of Medical Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
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Perioperative and postoperative morbidity after sacrocolpopexy according to age in Korean women. Obstet Gynecol Sci 2015; 58:59-64. [PMID: 25629020 PMCID: PMC4303754 DOI: 10.5468/ogs.2015.58.1.59] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/20/2014] [Accepted: 08/07/2014] [Indexed: 11/13/2022] Open
Abstract
Objective This study aimed to compare perioperative and postoperative morbidity of older and younger women undergoing sacrocolpopexy (SCP). Methods A retrospective study included 271 patients who underwent laparotomic SCP for symptomatic pelvic organ prolapse from November 2008 to June 2013 at our institution. By the review of medical records, perioperative and postoperative data including the length of the surgery, estimated blood loss, blood transfusion, the length of hospital stay, wound complications and febrile morbidity were collected. In addition, cardiovascular, pulmonary, gastrointestinal, genitourinary, or neurological adverse events were retrieved. The need for an indwelling urinary catheter or performance of clean intermittent self-catheterization, mesh erosion rate and the number of days required for each were included in the postoperative outcomes. For the outcome variable analyzed in this study, the patients was dichomotized into women aged 65 and older and those younger than 65. Results One hundred and thirty-five (49.8%) patients were younger than 65 and 136 (50.2%) were aged 65 and older. Older women had higher body mass index, vaginal parity and prior surgery for hysterectomy than younger women (P<0.05). And older women had higher baseline comorbidities, such as hypertension, diabetes, cardiac disease (P<0.05), and their American society of Anesthesiologist class was higher (P<0.001). In the perioperative and postoperative complication, older group showed no differences in most of the operation-related complication rates, but gastrointestinal complication rate. Also, mesh erosion rate was not found to be significantly different between the two groups at the last visit. Conclusion Older women undergoing laparotomic SCP have similar perioperative and postoperative morbidities as younger women, suggesting surgeons can counsel older and younger women similarly in terms of operative risks.
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Tew WP, Fleming GF. Treatment of ovarian cancer in the older woman. Gynecol Oncol 2015; 136:136-42. [DOI: 10.1016/j.ygyno.2014.10.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 10/21/2014] [Accepted: 10/28/2014] [Indexed: 01/05/2023]
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Tew WP, Muss HB, Kimmick GG, Von Gruenigen VE, Lichtman SM. Breast and ovarian cancer in the older woman. J Clin Oncol 2014; 32:2553-61. [PMID: 25071129 DOI: 10.1200/jco.2014.55.3073] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Nearly half of all women diagnosed with breast or ovarian cancer are age 65 years or older with the number of women diagnosed expected to increase as the population ages and life expectancy improves. Older women are less likely to be offered standard cancer treatments, are more likely to develop higher toxicity, and have higher mortality. Chronologic age should not be the only factor used for making treatment decisions. Functional dependence, organ function, comorbidity, polypharmacy, social support, cognitive and/or psychosocial factors, overall life expectancy, and patient's goals of care are equally vital and should be assessed before and during treatment. In this review, current evidence and treatment guidelines for older women with breast or ovarian cancer are outlined.
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Suh DH, Kim JW, Kim HS, Chung HH, Park NH, Song YS. Pre- and intra-operative variables associated with surgical complications in elderly patients with gynecologic cancer: the clinical value of comprehensive geriatric assessment. J Geriatr Oncol 2014; 5:315-22. [PMID: 24751482 DOI: 10.1016/j.jgo.2014.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 02/05/2014] [Accepted: 03/31/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the associations of pre- and intra-operative variables including comprehensive geriatric assessment (CGA) with surgical complications in elderly patients who underwent primary surgery for gynecologic cancer. METHODS Sixty consecutive patients ≥70years of age who were scheduled to undergo elective surgery for the treatment of gynecologic cancer were preoperatively assessed by CGA. Every category of CGA, performance status (PS), and brief fatigue inventory (BFI) as well as surgical complexity were evaluated for 30-day surgical complications. RESULTS The overall postoperative complication rate was 30.0% (18/60) including 9 (15.0%) major and 8 (13.3%) multiple complications. Univariate analysis revealed that dependent instrumental activity of daily living (IADL) was associated with any (p=0.023) and multiple complications (p=0.019). Poor PS was associated with major (p=0.021) and multiple complications (p=0.014). Multivariate logistic regression analysis revealed that high surgical complexity was the most independent predictor of any, major, and multiple complications, whereas poor PS was the independent predictor only for multiple complications (odds ratio 10.7, 95% confidence interval 1.7 to 90.2, p=0.043). There was no CGA component which could independently predict postoperative complications. CONCLUSION Surgical complexity can predict any, major, and multiple postoperative complications, while PS seems to be useful in predicting multiple complications in elderly patients with gynecologic cancer. In this small study, a CGA was not useful in predicting postoperative complications.
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Affiliation(s)
- Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-744, Republic of Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-744, Republic of Korea
| | - Hyun Hoon Chung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-744, Republic of Korea
| | - Noh Hyun Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-744, Republic of Korea
| | - Yong Sang Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-744, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul 110-779, Republic of Korea; WCU Biomodulation Major, Department of Agricultural Biotechnology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 151-921, Republic of Korea
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Worley MJ, Guseh SH, Rauh-Hain JA, Williams KA, Muto MG, Feltmate CM, Berkowitz RS, Horowitz NS. Does neoadjuvant chemotherapy decrease the risk of hospital readmission following debulking surgery? Gynecol Oncol 2013; 129:69-73. [PMID: 23375727 DOI: 10.1016/j.ygyno.2013.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 01/13/2013] [Accepted: 01/16/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare primary debulking surgery (PDS) vs. neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among elderly patients with ovarian/fallopian tube/primary peritoneal carcinoma. METHODS Medical records of patients ≥70 years old with epithelial ovarian/fallopian tube/primary peritoneal carcinoma between January 2000 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures and postoperative and oncologic outcomes were compared. Surgical procedures were given a complexity score based on a previously published method. RESULTS Of 165 patients, 125 (75.8%) underwent PDS and 40 (24.2%) underwent NACT-IDS. Patients undergoing NACT-IDS were more likely to have a pleural effusion (without cytology) and stage 4 disease. Median CA-125 at diagnosis was greater for those undergoing NACT-IDS. The NACT-IDS group was associated with less intraoperative blood loss (250 vs. 400 mL, p=0.001), a greater chance of achieving no residual disease (40% vs. 16%, p=0.005) and a shorter hospital length of stay (LOS) (5 vs. 7 days, p<0.001). PFS (17 vs. 15 months, p=0.708) and OS (29 vs. 33 months, p=0.827) were similar between the two groups. Readmission rates within 30 days of surgery were greater in those undergoing PDS (17.6% vs. 2.5%, p=0.016). After readmission, the median hospital LOS was 6 days (range: 1-41). CONCLUSIONS Elderly patients undergoing PDS have similar oncologic outcomes when compared to patients undergoing NACT-IDS. The risk of readmission within 30 days of surgery is significantly greater among patients undergoing PDS.
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Affiliation(s)
- Michael J Worley
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, MA, USA
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Glasgow MA, Yu H, Rutherford TJ, Azodi M, Silasi DA, Santin AD, Schwartz PE. Neoadjuvant chemotherapy (NACT) is an effective way of managing elderly women with advanced stage ovarian cancer (FIGO Stage IIIC and IV). J Surg Oncol 2012; 107:195-200. [PMID: 22648987 DOI: 10.1002/jso.23171] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Accepted: 05/04/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND To compare outcomes in women ≥ age 70 who receive neoadjuvant chemotherapy (NACT) for advanced epithelial ovarian cancer (EOC) followed by cytoreductive surgery with those undergoing upfront cytoreductive surgery followed by the same chemotherapy. METHODS A retrospective cohort study was performed for women ≥ age 70 with Stage IIIC or Stage IV EOC from 1996 to 2009. RESULTS Sixty-two patients who underwent upfront cytoreductive surgery and 42 patients who received NACT were eligible for analysis. Patients receiving NACT were significantly more likely to have Stage IV disease (P = 0.004). Cytoreduction to no macroscopic disease was achieved in 71.4% of women who received NACT and 28.1% of women undergoing upfront surgery (P < 0.001). NACT patients had significantly less blood loss at surgery (P = 0.01), required fewer small bowel resections (P = 0.009), had shorter ICU stays (P = 0.02) and fewer hospital days (P = 0.04). NACT patients experienced a trend toward an improved progression-free survival (P = 0.078); however, no statistically significant differences were found in either the progression-free or overall survival analyses. CONCLUSION NACT is associated with reduced perioperative morbidity in elderly patients with advanced stage ovarian cancer.
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Affiliation(s)
- Michelle A Glasgow
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT 06510, USA.
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Management of the Elderly Patient With Gynecologic Cancer: Report of the 2011 Workshop in Geriatric Gynecologic Oncology. Int J Gynecol Cancer 2012; 22:161-9. [DOI: 10.1097/igc.0b013e318234f8d5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
AbstractReflecting the worldwide aging trend and close association of aging with cancer, geriatric oncology is now growing beyond its pioneer years. Nevertheless, geriatric oncology in the gynecologic field is in the beginning stage; indeed, there is no geriatric specialist who is trained in this particular field of gynecologic oncology. Therefore, we held the first workshop in geriatric gynecologic oncology. In this review, we summarize what we discussed at the workshop and provide evidence-based recommendations for the diagnosis and treatment of gynecologic cancer in elderly individuals.
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Wright JD, Lewin SN, Deutsch I, Burke WM, Sun X, Neugut AI, Herzog TJ, Hershman DL. Defining the limits of radical cytoreductive surgery for ovarian cancer. Gynecol Oncol 2011; 123:467-73. [PMID: 21958535 DOI: 10.1016/j.ygyno.2011.08.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 08/26/2011] [Accepted: 08/28/2011] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Despite significant morbidity, surgical cytoreduction is the standard of care for ovarian cancer. We examined the outcomes of cytoreductive surgery to determine if there are groups of patients in which the morbidity is so substantial that alternate treatment strategies are warranted. METHODS The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1998 to 2007. The effect of age, number of radical procedures performed, and clinical characteristics on morbidity and mortality were examined. RESULTS A total of 28,651 women were identified. The complication rates increased with age from 17.1% in those <50 years of age to 29.7% in women age 70-79 and to 31.5% in those ≥ 80 (p<0.05). The number of extended procedures performed was also a predictor of morbidity; complications increased from 20.4% for women with 0 procedures to 34.0% for 1 and 44.0% for ≥ 2 procedures (p<0.0001). In multivariable analysis age, comorbidity, and the number of procedures performed were the strongest predictors of outcome. The morbidity associated with additional procedures was greatest in the elderly. Medical complications in women <50 years of age occurred in 10.2% of those who underwent 0 radical procedures vs. 23.7% in those who underwent 2 or more procedures. For women ≥ 80 years, complications were noted in 18.3% for 0 procedures, and 33.3% for 2 or more procedures. CONCLUSION The morbidity of cytoreduction is greatest in elderly women where the effects of age and the number of radical procedures performed have an additive effect on complication rates.
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Affiliation(s)
- Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA.
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Abstract
Elderly patients are more commonly diagnosed with advanced ovarian cancer and represent a growing proportion of all ovarian cancer cases. Despite this, the elderly have historically been underrepresented in clinical trials. Because clinical trials form the basis for most treatment guidelines and the elderly have been, to date, largely excluded from this process, little is known about the appropriate assessment and treatment of elderly ovarian cancer patients. Recognizing this knowledge deficit and the pressing need to correct it, this article aimed to summarize existing data and identify future areas of research focus.
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Lestrade L. Cancer épithélial évolué de l’ovaire de la patiente âgée: quel état des lieux suite à la Conférence internationale de Vancouver? ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-1988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lim MC, Kang S, Song YJ, Park SH, Park SY. Feasibility and safety of extensive upper abdominal surgery in elderly patients with advanced epithelial ovarian cancer. J Korean Med Sci 2010; 25:1034-40. [PMID: 20592895 PMCID: PMC2890880 DOI: 10.3346/jkms.2010.25.7.1034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/30/2009] [Indexed: 11/21/2022] Open
Abstract
We performed a retrospective study to evaluate the feasibility and safety of extensive upper abdominal surgery (EUAS) in elderly (>/=65 yr) patients with advanced ovarian cancer. Records of patients with advanced epithelial ovarian cancer who received surgery at our institution between January 2001 and June 2005 were reviewed. A total of 137 patients including 32 (20.9%) elderly patients were identified. Co-morbidities were present in 37.5% of the elderly patients. Optimal cytoreduction was feasible in 87.5% of the elderly while 95.2% of young patients were optimally debulked (P=0.237). Among 77 patients who received one or more EUAS procedures, 16 (20.8%) were elderly. Within the cohort, the complication profile was not significantly different between the young and the elderly, except for pleural effusion and pneumothorax (P=0.028). Elderly patients who received 2 or more EUAS procedures, when compared to those 1 or less EUAS procedure, had significantly longer operation times (P=0.009), greater blood loss (P=0.002) and more intraoperative transfusions (P=0.030). EUAS procedures are feasible in elderly patients with good general condition. However, cautious peri-operative care should be given to this group because of their vulnerability to pulmonary complications and multiple EUAS procedures.
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Affiliation(s)
- Myong Cheol Lim
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sokbom Kang
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Yong Jung Song
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sae Hyun Park
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang-Yoon Park
- Branch of Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Liu JF, Hirsch MS, Lee H, Matulonis UA. Prognosis and hormone receptor status in older and younger patients with advanced-stage papillary serous ovarian carcinoma. Gynecol Oncol 2009; 115:401-6. [PMID: 19796795 DOI: 10.1016/j.ygyno.2009.08.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/25/2009] [Accepted: 08/29/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Prior studies have suggested that patients diagnosed with ovarian cancer at an older age have worse outcomes. However, few studies have examined whether differing patterns of protein expression in tumors in older patients correlate with this poorer prognosis. We investigated the correlation of age with prognosis and the significance of hormone receptor status in younger versus older patients through construction of a clinically-annotated high-density tissue microarray (HTMA) composed of stage III and IV papillary serous ovarian cancer cases. METHODS Two cohorts of patients (age > or =65 and < or =55 at diagnosis) were identified retrospectively from ovarian carcinoma pathology cases reviewed at our institution between 1999 and 2005. An HTMA was constructed from 148 eligible cases, and clinical data were abstracted through chart and database review. RESULTS No difference in survival was observed between younger and older patients. Patients > or =70 years had decreased survival on univariate, but not multivariate, analysis. ER was significantly more likely (p=0.01) and PR significantly less likely (p=0.02) to be expressed in older patients. Neither ER nor PR independently correlated with survival in the overall study population. CONCLUSIONS Patients with advanced-stage papillary serous ovarian cancer > or =65 years of age at diagnosis have a similar survival as patients < or =55 years. Hormone receptor status differs significantly between the two age groups, and in the younger patient cohort, there is a trend towards longer overall survival for ER/PR positive tumors. These results suggest that ovarian cancer in younger patients differs biologically from that in older patients.
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Affiliation(s)
- Joyce F Liu
- Department of Medical Oncology, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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Poor outcome of elderly patients with platinum-sensitive recurrent ovarian cancer: Results from the SOCRATES retrospective study. Crit Rev Oncol Hematol 2009; 71:233-41. [DOI: 10.1016/j.critrevonc.2008.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Revised: 12/16/2008] [Accepted: 12/18/2008] [Indexed: 12/27/2022] Open
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Vaknin Z, Ben-Ami I, Schneider D, Pansky M, Halperin R. A Comparison of Perioperative Morbidity, Perioperative Mortality, and Disease-Specific Survival in Elderly Women (≥70 Years) Versus Younger Women (<70 Years) With Endometrioid Endometrial Cancer. Int J Gynecol Cancer 2009; 19:879-83. [DOI: 10.1111/igc.0b013e3181a73a12] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Gerestein CG, Damhuis RAM, Burger CW, Kooi GS. Postoperative mortality after primary cytoreductive surgery for advanced stage epithelial ovarian cancer: a systematic review. Gynecol Oncol 2009; 114:523-7. [PMID: 19344936 DOI: 10.1016/j.ygyno.2009.03.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 03/06/2009] [Accepted: 03/11/2009] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Accurate estimation of the risk of postoperative mortality (POM) is essential for the decision whether or not to perform cytoreductive surgery in a patient with advanced stage ovarian cancer. To ascertain modern reference figures, a systematic review of studies reporting POM after primary cytoreductive surgery for advanced stage epithelial ovarian cancer (EOC) was performed. MATERIALS AND METHODS A Medline search was performed to retrieve papers on primary cytoreductive surgery for advanced stage EOC. Twenty-three papers met the inclusion criteria and were reviewed. RESULTS According to population-based studies, POM after primary cytoreductive surgery for EOC is 3.7% on average. Single centre studies report an average rate of 2.5%. The overall mean POM is 2.8%. POM is more frequent for elderly women and after extensive procedures. Accurate information on age-specific and procedure-specific rates could not be obtained. CONCLUSION POM rates after surgery for EOC are satisfactorily low. There is a clear need for reliable reference figures for mortality after debulking surgery in the elderly.
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Affiliation(s)
- Cornelis G Gerestein
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
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Vergote I, van Gorp T, Amant F, Leunen K, Neven P, Berteloot P. Timing of debulking surgery in advanced ovarian cancer. Int J Gynecol Cancer 2008; 18 Suppl 1:11-9. [PMID: 18336393 DOI: 10.1111/j.1525-1438.2007.01098.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
It is clear that primary debulking remains the standard of care within the treatment of advanced ovarian cancer (FIGO stage III and IV). This debulking surgery should be performed by a gynecological oncologist without any residual tumor load, or so-called "optimal debulking." Over the last decades, interest in the use of neoadjuvant chemotherapy together with an interval debulking has increased. Neoadjuvant therapy can be used for patients who are primarily suboptimally debulked due to an extensive tumor load. In this situation, based on the randomized European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynecological oncologist. Neoadjuvant chemotherapy can also be used as an alternative to primary debulking. In retrospective analyses, neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of future randomized trials to know whether neoadjuvant chemotherapy followed by interval debulking surgery is a good alternative to primary debulking surgery in stage IIIc and IV patients. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery.
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Affiliation(s)
- I Vergote
- Department of Obstetrics and Gynaecology, Division of Gynaecological Oncology, University Hospitals, Katholieke Universiteit Leuven, Leuven, Belgium.
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Falandry C, You B, Morel-Soldner I, Bonnefoy M, Pujade-Lauraine E, Freyer G. Spécificité du cancer de l’ovaire chez la personne âgée. ONCOLOGIE 2008. [DOI: 10.1007/s10269-007-0781-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Pectasides D, Fountzilas G, Aravantinos G, Bamias A, Kalofonos HP, Skarlos D, Briasoulis E, Konstantara A, Economopoulos T, Dimopoulos MA. Epithelial ovarian carcinoma in younger vs older women: is age an independent prognostic factor? The Hellenic Oncology Cooperative Group experience. Int J Gynecol Cancer 2007; 17:1003-10. [PMID: 17367314 DOI: 10.1111/j.1525-1438.2007.00912.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We retrospectively investigated the outcome of epithelial ovarian cancer (EOC) in women less than 45 years and over 70 years treated with cisplatin-based chemotherapy. We also investigated the impact of various factors on patients' survival. The tumor registry of the Hellenic Cooperative Oncology Group was used to identify women less than 45 years and over 70 years with EOC diagnosed between 1979 and 2004. Survival was calculated by the Kaplan–Meier method, and Cox proportional hazard models were used to determine the independent effect of each variable on survival. Of 1748 EOC patients, 200 were 45 or younger and 282 were over 70 years old. In the univariate analysis, younger age (P < 0.001), better performance status (PS) (P < 0.001), early stage (P < 0.001), 0–2 cm residual disease (P < 0.001), and well or moderate differentiation grade (P= 0.004) were significant prognostic factors for improved survival. In the multivariate analysis, older age (hazard ratio [HR]: 1.88, 95% CI: 1.27–2.77, P= 0.002), advanced stage (HR: 2.87, 95% CI: 1.49–5.52, P= 0.002), PS >1 (HR: 1.91, 95% CI: 1.18–3.08, P= 0.008), and residual disease (HR: 1.46, 95% CI: 1.01–2.13, P= 0.046) were independently associated with inferior survival. With a median follow-up of 45 months (range 0.1–197 months), median survival (118.5 months) of younger patients differed significantly compared to that of older patients (33 months) (P < 0.001). In conclusion, younger women with EOC have significantly improved survival compared to older patients. Age, PS, stage of the disease at diagnosis, and residual disease are important independent predictors for survival.
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Affiliation(s)
- D Pectasides
- Second Department of Internal Medicine, Oncology Section, University General Hospital "ATTIKON," Athens, Greece.
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Eisenhauer EL, Tew WP, Levine DA, Lichtman SM, Brown CL, Aghajanian C, Huh J, Barakat RR, Chi DS. Response and outcomes in elderly patients with stages IIIC–IV ovarian cancer receiving platinum–taxane chemotherapy. Gynecol Oncol 2007; 106:381-7. [PMID: 17509673 DOI: 10.1016/j.ygyno.2007.04.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/03/2007] [Accepted: 04/06/2007] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Eric L Eisenhauer
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
Surgery plays a critical role in the optimal management of all stages of ovarian carcinoma. In apparent early-stage ovarian cancer, a comprehensive surgical evaluation allows stratification of patients into low- and high-risk categories. Low-risk patients may be candidates for fertility-sparing surgery and can safely avoid chemotherapy and be observed. Treatment of patients with high-risk early- or advanced-stage ovarian cancer usually requires a combined modality approach. Although it is well known that epithelial ovarian cancer is moderately chemosensitive, what distinguishes it most from other metastatic solid tumors is that surgical cytoreduction of tumor volume is highly correlated with prolongation of patient survival. Procedures such as radical pelvic surgery, bowel resection, and aggressive upper abdominal surgery are commonly required to achieve optimal cytoreduction. Women who develop recurrent disease may be eligible for a secondary cytoreductive surgery or may require a surgical intervention to palliate disease-related symptoms. For women at high risk of ovarian cancer, prophylactic bilateral salpingo-oophorectomy significantly reduces the incidence of this disease. The purpose of this article is to provide a comprehensive review of the surgical management of ovarian carcinoma. The roles of primary, interval, and secondary cytoreductive surgeries; second-look procedures; and palliative surgery are reviewed. The indications for fertility-sparing and minimally invasive surgery as well as the current guidelines for prophylactic surgery in high-risk mutation carriers are also discussed.
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Susini T, Amunni G, Busi E, Villanucci A, Carriero C, Taddei G, Marchionni M, Scarselli G. Ovarian cancer in the elderly: feasibility of surgery and chemotherapy in 89 geriatric patients. Int J Gynecol Cancer 2007; 17:581-8. [PMID: 17309560 DOI: 10.1111/j.1525-1438.2007.00836.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Gynecological oncologists are faced with an increasing proportion of geriatric ovarian cancer patients. Comorbidities are frequently a matter of concern in this age group, and what is adequate treatment for such patients is still debated. The aims of this study were to analyze the feasibility of standard surgery and chemotherapy in a series of elderly ovarian cancer patients (>/=70 years) and to investigate the influence of age (70-75 vs >75 years) on survival. We retrospectively evaluated 89 elderly patients treated at our department between 1985 and 2005. Comorbidities, type of surgical procedure, complications, drugs and schedules of chemotherapy, number of cycles, toxicity, and clinical outcome were registered. Comorbidities were present in 71.9%. Only six patients were inoperable. Among the 83 patients who underwent surgery, 76.4% received adequate surgical treatment. Severe postoperative complications occurred in 16.8%, operative mortality was zero. A total of 801 cycles of chemotherapy were administered to 77 patients (median 10; range 1-38). Overall, G3-G4 toxicity was documented in 61.0%. The rates of dose reduction, treatment delay, and discontinuation were 13.0%, 20.7%, and 3.9%, respectively. Patients who received adequate surgery and those with residual disease <1 cm did significantly better than their counterparts (P= 0.04 and P < 0.001, respectively). No difference in survival according to age (70-75 vs >75 years) was found. Standard surgery and chemotherapy were feasible in elderly ovarian cancer patients. The type of surgery and the amount of residual disease, but not the age of the patients, significantly influenced the clinical outcome.
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Affiliation(s)
- T Susini
- Department of Gynecology, Perinatology and Reproductive Medicine, University of Florence, Florence, Italy.
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38
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Eisenkop SM, Spirtos NM, Lin WCM. “Optimal” cytoreduction for advanced epithelial ovarian cancer: A commentary. Gynecol Oncol 2006; 103:329-35. [PMID: 16876853 DOI: 10.1016/j.ygyno.2006.07.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Revised: 07/05/2006] [Accepted: 07/06/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To derive the most appropriate threshold to classify primary cytoreductive operations as "optimal" and address the clinical significance of this issue. METHODS Criteria used to classify primary cytoreductive outcomes are reviewed. Survival outcomes are analyzed to address relative influences of the completeness of cytoreduction and "biological aggressiveness", as manifested by the extent of intra-abdominal metastases. RESULTS Most cohorts analyzing relative influences of metastatic tumor burden and the dimension of residual disease on survival report completeness of cytoreduction to influence the prognosis more significantly than tumor burden, with necessity to perform various procedures having minimal or no influence. Equivalent survival is reported for completely cytoreduced patients with stage III disease whether substages IIIa/b (smaller tumor burden) are excluded or included. However, some stage IIIc series report more favorable median and 5-year survivals for small fractions of completely cytoreduced patients than series with a large visibly disease-free fraction. Increasing fractions of complete cytoreduction are reported in recent cohorts, without increase in morbidity. CONCLUSIONS Complete primary cytoreduction improves the prognosis for survival significantly more than a small dimension of residual disease. Although prospective randomized trials addressing surgical issues have not been undertaken and numerous variables may reflect "biological aggressiveness" by influencing the prognosis, available data justify elimination of macroscopic disease to be the most appropriate objective of primary cytoreductive surgery. Stratification of survival by dimensions of residual disease in an investigational setting should include a visibly disease-free subgroup and if used, the term "optimal" should be applied to patients undergoing complete cytoreduction.
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Affiliation(s)
- Scott M Eisenkop
- Women's Cancer Center, Southern California, 4835 Van Nuys Blvd., Suite 109, Sherman Oaks, CA 91403, USA.
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40
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Alphs HH, Zahurak ML, Bristow RE, Díaz-Montes TP. Predictors of surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer. Gynecol Oncol 2006; 103:1048-53. [PMID: 16876237 DOI: 10.1016/j.ygyno.2006.06.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2006] [Revised: 06/02/2006] [Accepted: 06/15/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Hannah H Alphs
- The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD 21287, USA
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Wimberger P, Lehmann N, Kimmig R, Burges A, Meier W, Hoppenau B, du Bois A. Impact of age on outcome in patients with advanced ovarian cancer treated within a prospectively randomized phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR). Gynecol Oncol 2006; 100:300-7. [PMID: 16199079 DOI: 10.1016/j.ygyno.2005.08.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2005] [Revised: 08/11/2005] [Accepted: 08/22/2005] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Ovarian cancer exhibits the highest mortality rate among gynecologic cancer and survival rates vary considerably by age. Therefore, we investigated impact of age on outcome in advanced ovarian cancer. METHODS We performed a subgroup-analysis concerning influence of age classified according to three categories: younger patients (YP; <50 years) vs. middle-aged patients (MP; 50-65 years) vs. elderly patients (EP; >65 years). 686 patients with FIGO IIB-IV were treated within a prospectively randomized phase III study (AGO-OVAR 3) comparing cisplatin-paclitaxel vs. carboplatin-paclitaxel. This subgroup-analysis consisted of patients with homogeneous histology and complete surgical data. RESULTS YP had statistically more often achieved no residual tumor after primary surgery than MP and EP (P < 0.0001) resulting in improved median overall survival: 60.7, 41.3, and 33.2 months for YP, MP, and EP, respectively. The survival advantage of YP compared to EP remained significant even in completely debulked patients. Multivariable analysis revealed age being an independent prognostic factor. CONCLUSION Reduced surgical radicality, that means both less optimal debulking and also less radical surgery, contributes to poorer outcome in elderly patients with advanced ovarian cancer. However, age-specific surgical approaches did only partially explain age-dependent outcome. Therefore, generalization of study results to all patient age groups might be limited and further studies should focus specifically on treatment in elderly patients.
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Affiliation(s)
- Pauline Wimberger
- Department of Gynecology and Obstetrics, University of Essen, Hufelandstr. 55, D-45122 Essen, Germany.
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Ben-Ami I, Vaknin Z, Schneider D, Halperin R. Perioperative morbidity and mortality of gynecological oncologic surgery in elderly women. Int J Gynecol Cancer 2006; 16:452-7. [PMID: 16445678 DOI: 10.1111/j.1525-1438.2006.00478.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The study compares the perioperative morbidity and mortality rates of elderly (> or =70 years) and younger (< 70 years) patients. The study cohort consisted of 171 women undergoing explorative laparotomy due to uterine or ovarian cancer. Clinical data included patients' age, comorbidities, chronic use of medications, body mass index (kg/m(2)), past and current surgical procedures, surgical FIGO stage, histologic type and number of dissected lymph nodes, optimal versus nonoptimal debulking, occurrence of perioperative complications, and postoperative hospital stay (days). Participants were divided to 108 (63.2%) patients with uterine cancer and 63 (36.8%) patients with ovarian cancer. Women having uterine cancer were further subdivided to those <70 years of age (72 women, 66.7%) and those > or =70 years of age (36 women, 33.3%). Women with ovarian cancer were subdivided to those <70 years of age (48 women, 76.2%) and those > or =70 years of age (15 women, 23.8%). Excluding the occurrence of postoperative ileus and poorly controlled hypertension in the elderly subgroup of women with uterine cancer, the rate of early postoperative complications was similar between the two subgroups. Chronological age by itself should not be a contraindication for the treatment of elderly women with gynecological malignancy since it is a poor predicting factor for perioperative morbidity.
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Affiliation(s)
- I Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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Sharma S, Driscoll D, Odunsi K, Venkatadri A, Lele S. Safety and efficacy of cytoreductive surgery for epithelial ovarian cancer in elderly and high-risk surgical patients. Am J Obstet Gynecol 2005; 193:2077-82. [PMID: 16325619 DOI: 10.1016/j.ajog.2005.06.074] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Revised: 05/10/2005] [Accepted: 06/14/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Surgery is the cornerstone of management in ovarian cancer. However, in high-risk and elderly patients there is a tendency for less aggressive surgery upfront. The aim of this study was to review cytoreductive surgery, with focus on complications and outcomes in patients with multiple surgical risk factors. STUDY DESIGN Charts of patients with ovarian cancer from 1998 to 2002 were retrospectively reviewed. RESULTS One hundred and forty patients were treated for ovarian cancer. Sixty-three patients (45%) were elderly (> or =65 years), and 69 patients (49%) had comorbidities. Optimal debulking (< or =1 cm) was achieved in 123 patients (88%). There was no significant relation between complications and type of procedure, elderly age, comorbidities, or transfusions. Optimally debulked patients had a significantly longer survival than patients with suboptimal debulking (P < .001). CONCLUSION Aggressive optimal cytoreduction can be achieved in the majority of patients with multiple surgical risk factors and is associated with a low complication rate.
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Affiliation(s)
- Sameer Sharma
- Division of Gynecologic Oncology, Department of Surgery, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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Uyar D, Frasure HE, Markman M, von Gruenigen VE. Treatment patterns by decade of life in elderly women (≥70 years of age) with ovarian cancer. Gynecol Oncol 2005; 98:403-8. [PMID: 16000216 DOI: 10.1016/j.ygyno.2005.04.037] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Revised: 04/11/2005] [Accepted: 04/20/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Elderly patients are less likely to receive surgery and platinum-based combination chemotherapy than younger patients. We evaluated multi-institutional management of ovarian cancer in the elderly. METHODS Charts of women with ovarian, primary peritoneal or fallopian tube cancer from 1/1996-6/2004, age > or =70 years were reviewed. Age, stage, medical co-morbidities, surgery, chemotherapy, treatment modification, toxicity and survival were analyzed. Chi-square, logistic regression and survival analysis were used. RESULTS Of 131 patients, 90 were ages 70-79 (group 1 = G1) and 41 were >80 years of age (group 2 = G2). Surgery was performed in 80 patients in G1; 25 patients in G2 (P = 0.001). Among patients who underwent surgery, optimal debulking and post-operative complications did not differ between groups. Ninety-five percent of patients received platinum-based therapy and 83% received combination platinum/paclitaxel in G1, compared to 90% and 41%, respectively, in G2 (P < 0.001). Of those receiving platinum therapy, 36% in G1 and 41% in G2 required dose reductions or termination of therapy. Forty percent of G1 and 50% of G2 required a delay of therapy; the majority occurring in patients receiving combination therapy. Hematological toxicity increased with use of combination therapy, but not with advancing age or Charlson score. Successful debulking surgery significantly impacted survival, and when controlling for this factor, age was not a significant variable. CONCLUSION The extreme elderly had a decreased likelihood of receiving surgery and combination chemotherapy despite equivalent co-morbidities. In this analysis, optimal surgical cytoreduction had the greatest impact on survival.
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Affiliation(s)
- Denise Uyar
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, Medical College of Wisconsin, WI, USA
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Eisenkop SM, Spirtos NM. Division of pedicles by stapling during cytoreductive surgery for ovarian cancer. Gynecol Oncol 2005; 97:852-7. [PMID: 15943989 DOI: 10.1016/j.ygyno.2005.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Revised: 02/25/2005] [Accepted: 03/01/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the potential of dividing vascular pedicles by stapling to reduce operative time, blood loss, and morbidity associated with cytoreductive operations for advanced ovarian cancer. METHODS A case-control study was undertaken to compare operative outcomes for patients undergoing primary cytoreductive operations for ovarian cancer using two different operative strategies. Between 2002 and 2004, both stapling and conventional techniques were used to divide vascular pedicles for 50 consecutive patients requiring modified posterior exenterations (en-bloc resection of internal reproductive organs, pelvic peritoneum, and recto-sigmoid colon) and upper abdominal procedures in the context of primary cytoreduction for stage IIIC and IV ovarian cancer. The operative time, blood loss, transfusion rate, hospitalization, and incidence of complications were compared to outcomes of 50 consecutive patients operated on between 1994 and 1997 for whom stapling was not used to divide pedicles (chi-square test for binomial data, and t-test analysis for continuous data). RESULTS Both groups were equivalent with respect to disease severity, extent of upper abdominal surgery, and cytoreductive outcomes. The group for whom stapling devises were used to divide pedicles had a significantly reduced total operative time 179 min vs. 284 min, P < 0.001), estimated blood loss (1170 ml vs. 1782 ml, P = 0.004), and transfusion rate (3.6 units packed red cells vs. 5.0 units packed red blood cells, P = 0.03). CONCLUSION Stapling of vascular pedicles significantly reduces the operative time and blood loss for patients undergoing extensive primary cytoreductive operations for advanced ovarian cancer.
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Affiliation(s)
- Scott M Eisenkop
- Women's Cancer Center: Encino-Tarzana, 5525 Etiwanda Avenue, Suite 311, Tarzana, CA 91356, USA.
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Petignat P, Fioretta G, Verkooijen HM, Vlastos AT, Rapiti E, Bouchardy C, Vlastos G. Poorer survival of elderly patients with ovarian cancer: a population-based study. Surg Oncol 2004; 13:181-6. [PMID: 15615654 DOI: 10.1016/j.suronc.2004.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare ovarian cancer survival in elderly and young patients. MATERIAL AND METHODS Using the Geneva Cancer Registry, we identify women diagnosed with primary ovarian cancer between 1980 and 1998. We compared tumors characteristics, treatment patterns of young patients (<or=70 years) versus older patients (>70 years) by logistic regression. To evaluate the effect of age on prognosis, we compared disease specific survival by Cox proportional hazard analysis, taking into account other prognostic factors. RESULTS This study included 285 patient aged 70 years and 451<or=70 years. Older women presented more advanced stage and at equal stage were less often treated by optimal surgery and chemotherapy. Five-year of disease specific survival was 18% (95% CI: 13-23%) and 53% (95% CI: 48-58%) among old versus young women. Over ovarian mortality was only partly explained by these differences and after adjustment for tumor characteristics and treatment, older women still had a 1.8-fold increased risk of dying of ovarian cancer compared to younger (HR 1.8, 95% CI: 1.4-2.4). CONCLUSION Age strongly decreases ovarian cancer mortality. This over mortality is only partly explained by later diagnosis and suboptimal treatment.
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Affiliation(s)
- P Petignat
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Senology, Geneva University Hospitals, 30 Boulevard de la Cluse, 1211 Geneva 14, Switzerland
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