Intraperitoneal chemotherapy in older women with epithelial ovarian cancer

Cited rationale for variance in the use of primary intraperitoneal chemotherapy following optimal cytoreduction for stage III ovarian carcinoma at a high intraperitoneal chemotherapy utilization center

OBJECTIVE

Studies have demonstrated improved ovarian cancer survival with the administration of a combination of intravenous (IV) and intraperitoneal (IP) chemotherapy following optimal cytoreduction. Despite this, IV/IP chemotherapy is not uniformly used. In this retrospective cohort study, we assessed the documented reasons for giving IV-only chemotherapy.

METHODS

All patients who had optimal primary cytoreductive surgery for stage III ovarian, fallopian tube, or primary peritoneal carcinoma, met eligibility criteria for GOG-172, and received primary chemotherapy at our institution between 2006 and 2013 were identified. Patients who received at least one cycle of adjuvant IV/IP therapy were included in the IP group. Patient characteristics, treatment information, and reason cited for not administering IP therapy were collected.

RESULTS

Of the patients evaluated, 330 met inclusion criteria. The majority (n=261, 79%) received at least one IV/IP cycle (median, 6; range, 1-6), and 62% completed 6cycles. The most common reason for giving IV-only therapy was postoperative status (i.e., delayed wound healing, performance status), accounting for 18 (26%) of the 69 IV-only patients (5% of the entire cohort). Other cited reasons were baseline comorbidities (15%) and IP port complications (12%). Receipt of ≥1cycle of IP chemotherapy (HR 0.51; 95% CI, 0.32-0.80) and no gross residual disease (HR 0.47; 95% CI, 0.31-0.71) were associated with improved overall survival.

CONCLUSION

Potentially modifiable factors identified as leading to the use of IV-only chemotherapy were postoperative status and IP port complications, which if altered, could potentially lead to increased IP chemotherapy use.

Breast and ovarian cancer in the older woman

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.

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

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

Treatment and trials: ovarian cancer in older women

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