Age does not influence taxol dose intensity in recurrent carcinoma of the ovary

Age and the Risk of Paclitaxel-Induced Neuropathy in Women with Early-Stage Breast Cancer (Alliance A151411): Results from 1,881 Patients from Cancer and Leukemia Group B (CALGB) 40101

PURPOSE

A few previous studies report a direct relationship between older age and chemotherapy-induced neuropathy. This study further evaluated this adverse event's age-based risk.

METHODS

CALGB 40101 investigated adjuvant paclitaxel (80 mg/m² once per week or 175 mg/m² every 2 weeks) in patients with breast cancer and served as a platform for the current study that investigated age-based differences in neuropathy. Grade 2 or worse neuropathy, as per Common Terminology Criteria for Adverse Events version 4, was the primary endpoint; patients were assessed at baseline, every 6 months for 2 years, and then annually for 15 years.

RESULTS

Among these 1,881 patients, 230 were 65 years of age or older, 556 were 55-64 years, and 1,095 were younger than 55; 1,226 neuropathy events (commonly grade 1 or 2) were reported in 65% of the cohort. The number of grade 2 or worse events was 63 (27%), 155 (28%), and 266 (24%) within respective age groups (p = .14). In univariate analysis, only motor neuropathy had a higher age-based incidence: 19 (8%), 43 (8%), and 60 (5%), respectively (p = .04); in multivariate analyses, this association was no longer statistically significant. Other endpoints, such as time to onset of neuropathy (time from trial enrollment to neuropathy development) and time to improvement (time from maximal grade sensory neuropathy to a one-category improvement), showed no statistically significant age-based differences. In contrast, obesity was associated with neuropathy, and every 2-week paclitaxel was associated with trends toward neuropathy.

CONCLUSION

Although paclitaxel-induced neuropathy is common, older age is not an independent risk factor. Clinical trial identification number. NCT00041119 (CALGB 40101).

IMPLICATIONS FOR PRACTICE

Age alone is not an independent risk factor for paclitaxel-induced neuropathy.

Under-treatment of elderly patients with ovarian cancer: a population based study

BACKGROUND

Ovarian cancer is the fourth most common cancer among women in France, and mainly affects the elderly. The primary objective of this study was to compare treatment of ovarian cancer according to age.

METHODS

All patients with invasive cancer (n=1151) diagnosed between 1997 and 2011 in the Herault Department of southern France were included. Demographic data (age, area of residence), cancer characteristics (stage, histology, grade) and treatment modality (type, period and location of treatment) were analysed. Univariate and multivariate logistic regression was used to compare treatment by age.

RESULTS

Ovarian cancer was less treated in elderly compared to younger patients, regardless of the type of treatment. This difference was more pronounced for chemotherapy, and was maximal for surgery followed by chemotherapy (odds ratio (OR) for surgery for patients aged >70 vs those aged <70 years=0.47 [0.24-0.91], OR for chemotherapy, age>70 vs <70=0.30 [0.16-0.55] and OR for surgery plus chemotherapy, age>70 vs <70=0.14 [0.08-0.28]). This effect of age was independent of other variables, including stage and grade. The probability of receiving standard treatment, in accordance with recommendations, was reduced by 50% in elderly patients compared to their younger counterparts. Overall and net survival of elderly patients with standard treatment was similar to those of younger patients treated outside standard treatment.

CONCLUSIONS

Elderly women with ovarian cancer were therapeutically disadvantaged compared to younger women. Further studies including co morbidities are necessary to refine these results and to improve therapeutic management of elderly patients with ovarian cancer.

Doublet chemotherapy in the elderly patient with ovarian cancer

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

Inhibition of human gastric carcinoma cell growth in vitro and in vivo by cladosporol isolated from the paclitaxel-producing strain Alternaria alternata var. monosporus

Cladosporol was isolated from the fermentation broth of Alternaria alternata var. monosporus obtained from the inner bark of the yew tree and mutated for many generations. We investigated the antitumor effects of cladosporol in vitro and in vivo. The growth-inhibitory effects of cladosporol in vitro against six human cancer cell lines were examined using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) method. The results showed that cladosporol selectively killed cancer cells and had a significant inhibitory effect on the human gastric carcinoma cell line MGC-803 in a concentration- and time-dependent manner. In vivo, cladosporol also showed antitumor activity in nude mice bearing MGC-803 gastric cancer xenografts. These findings suggest that cladosporol has potentially useful growth inhibitory effects on human gastric carcinoma cell lines.

TP53, BCL-2 and BAX analysis in 199 ovarian cancer patients treated with taxane-platinum regimens

OBJECTIVE

In cell line studies, BCL-2 and BAX proteins interfere with cancer response to taxanes. This issue has not received much attention with regard to taxane-platinum (TP)-treated ovarian cancer patients.

METHODS

We evaluated prognostic/predictive significance of BCL-2 and BAX with regard to TP53 status. Immunohistochemical analysis was performed on 199 ovarian carcinomas FIGO stage IIB-IV treated with TP; the results were analyzed by the Cox and logistic regression models.

RESULTS

Clinicopathological parameters (residual tumor size, FIGO stage and/or tumor grade, but not patient's age) were the only or the strongest predictors of patient's outcome. Platinum highly sensitive response showed a positive association with TP53 accumulation (p=0.045). As in our previously published analysis on platinum-cyclophosphamide-treated group, complete remission showed a borderline negative (paradoxic) association with high BAX expression in the whole group (p=0.058) and with BCL-2 expression in the TP53(-) group (p=0.058).

CONCLUSION

Our results suggest that TP53, BCL-2 and BAX proteins carry some predictive potential in taxane-platinum-treated ovarian cancer patients, auxiliary to clinicopathological factors. We have confirmed on another patient group that clinical importance of BCL-2 may depend on TP53 status.

Cell growth inhibition, G2M cell cycle arrest, and apoptosis induced by the novel compound Alternol in human gastric carcinoma cell line MGC803

Alternol is a novel compound purified from fermentation products of a microorganism in the bark of the yew tree. Because it has a similar origin as the anticancer agent paclitaxel, we hypothesized that Alternol may also have an anti-tumor effect. In this report, we chose human gastric carcinoma cell line MGC803 as the model to investigate the effects of Alternol. We evaluated cell viability using the CCK8 kit. The cell cycle distribution was analyzed by flow cytometry. AnnexinV combined with PI was performed to evaluate the apoptosis rate. The mitochondria membrane potential (MMP) was measured by a fluorescence-activated cell sorter using Rhodamin123 staining. We observed the morphological changes by immunofluorescence and Hochest33342 staining. RT-PCR and Western blot analysis were used to evaluate the changes of G2M-related regulators. Our data show that Alternol inhibited the growth of MGC803 and induced G2M arrest. Coincident with G2M arrest, phosphorylation of CDC2 on Tyr-15 was significantly elevated, which could be explained by the increase of Wee1 and decrease of CDC25C. The decreased expression of PLK1 may cause the elevation of Wee1 and CyclinB1 protein levels. Moreover, the apoptosis seemed to be secondary to G2M arrest because the elevated Caspase3, decreased MMP, and typical apoptotic morphology changes appeared after G2M arrest. These findings suggested that Alternol could inhibit the growth of MGC803 by inducing G2M arrest and apoptosis. We expected Alternol may be used as a lead compound one day and our experiments might provide some clues for further research.

Feasibility, toxicity and quality of life of first-line chemotherapy with platinum/paclitaxel in elderly patients aged >or=70 years with advanced ovarian cancer--a study by the AGO OVAR Germany

BACKGROUND

The purpose of the study was to evaluate first-line platinum/paclitaxel (Taxol) under phase III trial conditions in ovarian cancer (OC) patients aged >or=70 years.

PATIENTS AND METHODS

Phase III results of 779 patients with OC International Federation of Gynecology and Obstetrics (FIGO) stage IIB/IV treated with cisplatin/paclitaxel versus carboplatin/paclitaxel were retrospectively analyzed according to feasibility, toxicity (National Cancer Institute Common Toxicity Criteria) and quality of life (QoL) [European Organization for Research and Treatment of Cancer QoL questionnaire (EORTC QLQ-C30)] in patients aged <70 or >or=70 years.

RESULTS

One hundred and three (13%) patients were aged >or=70 years. Patient characteristics (<70 versus >or=70 years) showed significant differences with regard to Eastern Cooperative Oncology Group performance status, residual disease and constitutional factors but not to FIGO stage, histology or grading. Elderly patients received 98%, 100% and 96% of the recommended paclitaxel, carboplatin and cisplatin dose, respectively, per cycle. Early discontinuation was more frequent in elderly, although QoL, nonhematological and hematological toxicity were comparable between elderly and younger patients, except for febrile neutropenia (5% versus <1%, P = 0.005). There were no significant differences with regard to cycle delays, dose reductions or the use of granulocyte colony-stimulating factor and antibiotics.

CONCLUSION

Platinum/paclitaxel appeared to be feasible and tolerable in elderly patients under clinical trial conditions, but there seems to be a different investigators' estimation of toxicity and less intention to maintain trial treatment in elderly.

Prospective Evaluation of the Relationship of Patient Age and Paclitaxel Clinical Pharmacology: Cancer and Leukemia Group B (CALGB 9762)

Purpose

To prospectively evaluate the pharmacokinetics and toxicity profile of paclitaxel in relation to patient age in adults ≥ 55 years old.

Patients and Methods

Paclitaxel was administered at 175 mg/m2 for 3 hours to 153 patients, 46 of whom were ≥ 75 years of age. Pharmacokinetic and toxicity assessments were performed. Data were analyzed by cohort (cohort 1, age 55 to 64 years; cohort 2, age 65 to 74 years; cohort 3, age ≥ 75 years).

Results

Paclitaxel concentration versus time (AUC) and total-body clearance (CLtb) data were available for 122 patients (cohort 1, 46 patients; cohort 2, 44 patients; cohort 3, 32 patients). Mean paclitaxel AUC increased across cohorts (P = .01). Mean (SE) AUCs were 22.4 (2.5) μmol/L × hour, 26.2 (2.8) μmol/L × hour, and 31.7 (5.6) μmol/L × hour for cohorts 1, 2, and 3, respectively. There was a corresponding significant (P = .007) age-related decrease in mean (SE) paclitaxel CLtb (cohort 1, 11.0 [0.7] L/h/m2; cohort 2, 9.3 [0.6] L/h/m2; cohort 3, 8.2 [0.6] L/h/m2). Patients in cohort 3 experienced significantly lower absolute neutrophil count nadirs than did younger groups (P = .02). There was also a significant increase in percentage of patients with ≥ grade 3 neutropenia across age cohorts (cohort 1, 22%; cohort 2, 35%; cohort 3, 49%; P = .006). However, the increased exposure of patients to paclitaxel and increased neutropenia were not reflected in adverse clinical sequelae such as hospitalization for toxicity (P = .82), receiving intravenous antibiotics (P = .21), or experiencing a temperature more than 38°C (P = .45).

Conclusion

Although paclitaxel CLtb decreases with increasing patient age, there is great interpatient variability. Cooperative group studies to evaluate the effect of aging on pharmacokinetics are feasible.

Treatment patterns by decade of life in elderly women (≥70 years of age) with ovarian cancer

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.

Poorer survival of elderly patients with ovarian cancer: a population-based study

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.

Age contrasts in clinical characteristics and pattern of care in patients with epithelial ovarian cancer

OBJECTIVE

The objective of this study was to document and highlight aspects of ovarian cancer treatment that pertain, especially, to elderly women.

METHODS

Data were collected retrospectively from all epithelial ovarian cancer patients who were diagnosed in the Gynecologic Oncology Unit at Meir Hospital, Kfar-Saba, Israel, from January 1994 to December 1998.

RESULTS

The study group comprised 143 patients (<70 years n = 97, > or =70 years n = 46). Both groups presented with the same distribution of stages. The elderly group had fewer primary debulking surgical interventions (54.3%) than the younger group (84.5%) (P = 0.001)). Age was not a limiting factor in achieving optimal debulking in those patients who did undergo surgery (older 53%, younger 54%). Almost 92% of the younger patients entered a first-line chemotherapy regimen compared to 65.2% of the older patients (P = 0.001). The elderly patients were more likely to receive neoadjuvant chemotherapy (43.3.3% vs 13.4%, P < 0.01) and hematological toxicity was significantly more common (75% vs 36.3%; P = 0.001), although no significant difference was noted between the groups in Grade 3-4 patients (> or =70 years, 62.5% vs <70 years, 45.5%; P = 0.2). The elderly patients were more likely to have dose reductions and treatment delays compared to the younger patients (60% vs 22.4%; P < 0.001, and 46.6% vs 19.1%; P = 0.004, respectively) and they had similar overall response rates (RR) and complete response (80% vs 87.6% and 60% vs 71.9%, respectively).

CONCLUSIONS

Older women who present with the same distribution of stages as their younger counterparts are likely to be treated more conservatively than younger ovarian cancer patients. In this study, however, when surgery was performed, the optimal tumor debulking rates were similar in each group. Although high morbidity, most often hematological toxicity, occurs in elderly patients following chemotherapy, the overall RR compared favorably with that of younger patients.

Chemotherapy for advanced epithelial ovarian carcinoma

Advanced epithelial ovarian cancer (AOC) is the most common clinical presentation of ovarian cancer. Virtually all patients will require some form of chemotherapy with curative or palliative intent. Prognostic factors, first- and second-line therapy, as well as experimental approaches for AOC are reviewed.

Gynecological malignancies in elderly patients: is age 70 a limit to standard-dose chemotherapy? An Italian retrospective toxicity multicentric study

OBJECTIVE

One hundred and forty-eight consecutive gynecological oncological patients aged >or=70 were administered chemotherapy during the years 1990-2000.

METHODS

Median age was 73 years (range 70-84). Fifty-five (37.2%) women were over 75 years old. One or more comorbid conditions were present in 118 (79.7%) patients. Standard schedules were administered to 97.3% of cases, with a total number of 1046 cycles of therapy administered (median, 6; range, 1-35, per patient).

RESULTS

Of a total of 233 chemotherapy regimens globally administered, G3-G4 hematological toxicity was documented in 38.2% of cases. Only 10 (6.8%) of the 148 patients discontinued treatment because of G3-G4 hematological toxicity. No severe nonhematological toxicity was observed. Two dose reductions and three treatment delays, but no discontinuation of treatment, were required during second-line regimens. Treatment delay >7 days was required in 16.9% of cases.

CONCLUSIONS

Chronological age did not adversely influence the ability to receive aggressive treatment.

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

BACKGROUND

Intravenous cytostatic agents as second-line treatment of epithelial ovarian carcinoma have been withheld from many elderly patients because of fear of toxicity. The purpose of the study is to compare the toxicity and efficacy between elderly (older than 65 years of age) and younger (younger than 65 years of age) patients receiving intravenous second-line treatment of epithelial ovarian carcinoma.

METHODS

This study was a retrospective analysis of 286 consecutive patients with primary epithelial ovarian carcinoma. Inclusion criteria included histopathologically documented International Federation of Gynecology and Obstetrics (FIGO) Stage IC-IV epithelial ovarian carcinoma; first-line treatment with paclitaxel and a platinum analog; intravenous second-line treatment with topotecan 1.0 mg/m(2)/day for 5 days, every 3 weeks or paclitaxel (175 mg/m(2)) and carboplatin (AUC 5), every 3 weeks.

RESULTS

One hundred two patients fulfilled the inclusion criteria receiving topotecan (n = 57) or paclitaxel-carboplatin (n = 45) because of refractory or recurrent disease. The patients' age at start of second-line treatment in the younger (n = 68) and the elderly (n = 34) group were median 54.0 years (range, 34.7-64.3) and 69.5 years (range, 65.1-77.2), respectively. In the patient group aged younger than 65 years, initial performance status was more favorable than in patients aged older than 65 years (P = 0.007) whereas the groups were similar in relation to other potential prognostic factors (P > 0.05). For patients aged younger than 65 years, the overall response rate of 50% (95% confidence interval [CI], 37-63%) was similar to the response rate of 44% (95% CI, 27-62%) in patients aged older than 65 years (P = 0.29). The overall survival from the first day of second-line treatment in patients aged younger and older than 65 years were median 13.3+ months (range, 1.2-38.3+) and 11.8+ months (range, 2.0-41.0+), respectively (P = 0.25). In a multivariate Cox analysis, performance status at time of first-line treatment (0 vs.1-2; P = 0.013; hazard ratio [HR], 2.12), performance status at time of second-line treatment (0 vs. 1-2; P = 0.004; HR, 2.47), and response to second-line treatment (CR + PR vs. NC + PD; P < 0.001; HR, 4.38) were found to be independent significant factors for overall survival whereas age (younger than 65 years vs. older than 65 years) yielded no independent information (P = 0.90). No differences in the rate of postponement of treatment, neutropenia Grade 4, thrombocytopenia Grade 3-4, nor hypersensitivity reaction to either cytostatic agent between older and younger patients were noticed (P > 0.05).

CONCLUSIONS

Modality of second-line treatment of epithelial ovarian carcinoma should be determined more by assessment of performance status than age per se. Second-line treatment with topotecan or paclitaxel-carboplatin can be safely administered in the aged.

Advanced ovarian cancer in the elderly: results of consecutive trials with cisplatin-based chemotherapy

From 1982 through 1996, 547 untreated advanced ovarian cancer patients were entered onto Gruppo Oncologico Nord-Ovest (GONO) consecutive randomized trials including cisplatin-based chemotherapy. End points of analysis included the influence of age on prognosis, toxicity, clinical/surgical response rates, progression-free survival and survival. Of the entire study group, 116 patients were 65 years of age or older at diagnosis. WHO main toxicity (any grade) consisted of: emesis (93% of patients), myelotoxicity (leukopenia in 52%, anemia in 51% and thrombocytopenia in 17% of patients), nephrotoxicity in 13% of patients and neurotoxicity in 10% of patients. No significant difference in toxicity was evident between patients > or = or <65 years. Refusal of CT and early (< or =2 courses) interruption of CT due to toxicity were more frequent in elderly patients (3.4 vs. 1.4%; 3.4 vs. 0.7%, respectively). After a median follow-up of 71 months no difference was observed in survival and progression-free survival between younger and older patients. Cox multiple regression analysis of the entire study population demonstrated that age >65 years per se was not a negative prognostic factor.

Advances in the systemic treatment of cancers in the elderly

Cancer is a disease of the elderly. More than 50% of all cancers and deaths occur in people over 65 years. Older cancer patients are less likely to be referred to centers or to be given adequate chemotherapy. The elderly are under-represented in Phase I and II trials. Some of this hesitancy to give chemotherapy is related to the increased presence of co-morbid conditions in the elderly. Toxicity is another concern. This review summarizes data from literature on the effectiveness, outcome, and toxicity of chemotherapy in selected tumors. Information is presented on age related effects. In addition, a summary of new agents and biologics is presented that needs to be looked at for age related effects. Some comments are made on the pharmacokinetic impact of physiologic changes in the elderly on chemotherapy drugs. As the world's population ages, we need to include the elderly in trials to get data on age related effects. Most of the information presented shows that effective chemotherapy can be given safely to the elderly and the outcomes and toxicity are equivalent for many of the common solid tumors.

Management of ovarian cancer in patients older than 80 years of Age

OBJECTIVE

The objective of this study was to examine the treatment, associated morbidity, and survival in very elderly patients with epithelial ovarian cancer.

METHODS

A retrospective analysis of patients 80 years of age and older treated for epithelial ovarian cancer by the Gynecologic Oncology faculty at the University of California Irvine was performed.

RESULTS

Eighteen patients were older than 80 years of age at the time of diagnosis of ovarian cancer. Median age was 83 years (range 80-86 years). There were 2 stage I, 10 stage IIIC, 4 stage VI, and 2 unstaged patients. One patient had a tumor of low malignant potential, 4 patients had grade II tumors, and 10 patients had tumors that were grade III. Eighty-three percent of patients had one or more preexisting medical illnesses. Cardiac disease, stroke, and hypertension were most common. Sixteen of 18 patients (88%) underwent primary debulking surgery. American Society of Anesthesiologists physical status classification was as follows: 7/16 (44%) class II, 6/16 (38%) class III, and 2/16 (13%) class IV. The procedures performed included 16 bilateral salpingo-oophorectomies, 11 total abdominal hysterectomies, 16 omentectomies, 3 lymph node dissections, and 7 bowel resections. Four (25%) patients were optimally cytoreduced to <1 cm of residual disease. Seventy-five percent of surgical patients received blood transfusions of 2 or more units PRBC. Mean EBL was 600 cc (range 200-4200 cc). Thirty-eight percent of patients experienced major postoperative morbidity. There were 7 patients with postoperative congestive heart failure, 3 with sepsis, 1 with aspiration pneumonia, and 2 postoperative deaths. Seventy-five percent of patients spent time in the intensive care unit. Median number of days was 3 (range 1-22 days). Mean postoperative stay was 8 days (range 6-57 days). Sixty-five percent of patients were discharged to home. The other patients were discharged to intermediate care facilities or nursing homes. Eighty-three percent of patients received chemotherapy. Of the 10 patients (63%) receiving adjuvant chemotherapy, the mean interval from surgery to initiation of therapy was 3 weeks (range 1-4 weeks). Overall median survival was 6 months (range 1-45 months). Median survival in patients with optimal debulking was 32.5 months (range 7-45 months) compared to 3.5 months (range 1-41 months) in patients suboptimally debulked.

CONCLUSIONS

In patients older than 80 years of age who undergo debulking surgery for ovarian cancer, serious medical comorbidity and advanced ASA status are common. Despite aggressive surgical effort and frequent blood transfusions, optimal debulking to less than 1 cm is achieved in only 25% of patients. Impressive morbidity and mortality occurs in this group of patients, but most patients are discharged to home and are able to receive postoperative chemotherapy.

Age and sex are independent predictors of 5-fluorouracil toxicity. Analysis of a large scale phase III trial

BACKGROUND

Cancer is most common in older age groups, but little information is available with regard to the impact of age on chemotherapy toxicity. This study was undertaken to determine if age is an independent risk factor for 5-fluorouracil (5-FU) toxicity.

METHODS

Toxicity data from a prospective, randomized, multiinstitution trial of 5-FU-based treatment for advanced colorectal cancer were analyzed. Toxicity for each organ system was graded. Individual organ toxicity proportions were compared using chi-square analysis. A logistic regression was performed using age (younger than 70 years vs. 70 years or older), sex, treatment arm, performance status, and length of therapy as model parameters to predict severe toxicity. Toxicity in 331 patients was analyzed.

RESULTS

Advanced age was significantly associated with the occurrence of any severe toxicity (58 vs. 36%, P < 0.001), leukopenia (24 vs. 10%, P < 0.005), diarrhea (24 vs. 14%, P = 0.01), vomiting (15 vs. 5%, P = 0.01), severe toxicity in more than 2 organ systems (10 vs. 3%, P = 0.02), and treatment mortality (9 vs. 2%, P = 0.01). By univariate analysis, age (P < 0.001) and sex (P < 0.0001) were independent predictors of severe toxicity. Twenty-two of 27 women age 70 years or older had severe toxicity.

CONCLUSIONS

Age 70 years or older and sex are risk factors for severe toxicity from 5-FU-based chemotherapy. Advanced age does not contraindicate the use of this type of chemotherapy, but close monitoring for multiple organ toxicities and vigorous supportive care of those with toxicity are required. Dosing decisions in older patients are difficult and must integrate assessments of organ function, comorbidities, overall physical status, and goals of treatment, in an effort to ensure the best possible outcome for these patients.

Paclitaxel. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential in the treatment of cancer

Paclitaxel is a new anticancer agent with a novel mechanism of action. It promotes polymerisation of tubulin dimers to form microtubules and stabilises microtubules by preventing depolymerisation. In noncomparative trials, continuous infusion of paclitaxel 110 to 300 mg/m2 over 3 to 96 hours every 3 to 4 weeks produced a complete or partial response in 16 to 48% of patients with ovarian cancer and 25 to 61.5% of patients with metastatic breast cancer, many of whom were refractory to treatment with cisplatin or doxorubicin, respectively. 23 to 100% of patients with ovarian cancer achieved complete or partial responses with paclitaxel in combination with cisplatin, carboplatin, cyclophosphamide, altretamine and/or doxorubicin. Similarly, response rates of 30 to 100% were observed with paclitaxel plus doxorubicin, cisplatin, mitoxantrone and/or cyclophosphamide in patients with metastatic breast cancer. Comparative trials in patients with advanced ovarian cancer showed paclitaxel therapy to produce greater response rates than treatment with parenteral hydroxyurea (71 vs 0%) or cyclophosphamide (when both agents were combined with cisplatin) [79 vs 63%]. Paclitaxel was also more effective than mitomycin in 50 patients with previously untreated breast cancer (partial response in 20 vs 4% of patients). Paclitaxel therapy also produced promising results in patients with advanced squamous cell carcinoma of the head and neck, malignant melanoma, advanced non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), germ cell cancer, urothelial cancer, oesophageal cancer, non-Hodgkin's lymphoma or multiple myeloma, and was successfully combined with cisplatin, carboplatin and/or etoposide in patients with NSCLC, SCLC or advanced squamous cell carcinoma of the head and neck. Hypersensitivity reactions were initially a concern with administration of paclitaxel, although current dosage regimens have reduced the incidence of these events to less than 5%. The major dose-limiting adverse effects of paclitaxel are leucopenia (neutropenia) and peripheral neuropathy. Other haematological toxicity was generally mild. Cardiac toxicity was reported in small numbers of patients and most patients developed total alopecia. Several aspects of paclitaxel use remain to be clarified, including the optimal treatment schedule and infusion time, confirmation of the tolerability profile and efficacy of combination regimens in an expanded range of malignancies. Long term follow-up of paclitaxel recipients will also allow the effects of the drug on patient survival to be determined. Nevertheless, paclitaxel is a promising addition to the current therapies available, with significant activity reported in patients with advanced ovarian or breast cancer or other types of tumors.(ABSTRACT TRUNCATED AT 400 WORDS)

National survey of ovarian carcinoma. IV: Patterns of care and related survival for older patients

BACKGROUND

An analysis was conducted by the American College of Surgeons Cancer Commission evaluating the patterns of care of ovarian cancer patients diagnosed in 1983 and 1988. The purpose of this study was to investigate whether there was a difference in the care patterns of elderly ovarian cancer patients and its impact on survival.

METHODS

Data were collected from 25 consecutive patients whose disease was diagnosed initially at 904 participating hospitals with cancer programs in 1983 and 1988. The survival and care of patients greater than or equal to 80 years of age were compared to those less than 80 years of age.

RESULTS

Of the 12,316 patients evaluated, 1,115 were 80 years or older. A significant reduction in survival was noted among patients 80 years and older as compared to their younger counterparts (P = 0.03-0.00001). The 5-year survivals were: stage I, 89% versus 79%; stage II, 58% versus 40%; stage III, 25% versus 11%; and stage IV, 13% versus 3%, respectively, for those less than 80 years old as compared to those greater than or equal to 80 years old. Most elderly ovarian cancer patients were cared for by nononcologists such as general surgeons (31%) and obstetricians/gynecologists (29%). As a group, older patients had fewer total abdominal hysterectomies, bilateral salpingo-oophorectomies, and omentectomies than their younger counterpart (P < 0.00001). As further evidence for a less aggressive surgical approach, the optimal tumor debulking rates of women greater than or equal to 80 years were significantly less than those of younger patients (P < 0.001). There was no significant increase in anesthesia complications between age groups. Generally, older patients are less likely to receive adjuvant chemotherapy than younger patients (42% versus 69%, P < 0.0001).

CONCLUSION

It appears that conservative treatments contributed to the decreased survival of older ovarian cancer patients.

The taxoids: paclitaxel (Taxol) and docetaxel (Taxotere)

The taxoids, paclitaxel (Taxol) and docetaxel (Taxotere), represent a novel class of antineoplastic drugs. Paclitaxel and docetaxel share a similar mechanism of action: the promotion of microtubule assembly and inhibition of microtubule disassembly. The clinical development of paclitaxel was initially hampered by hypersensitivity reactions (HSRs). The use of premedications and prolongation of the infusion time to 24h has reduced these reactions and allowed this drug's clinical development. Although paclitaxel's clinical activity has not been fully investigated, clinical trials have demonstrated its activity against ovarian, breast, and bronchial carcinomas. Because phase I studies of docetaxel noted occasional HSRs and these observations increased with further clinical experiences, those premedications employed with paclitaxel have now been instituted in many phase II studies of docetaxel. Docetaxel is currently being investigated in ovarian, breast, and bronchial carcinomas and has shown impressive clinical activity. The dose-limiting toxicity of both these agents is neutropenia; myalgias, mucositis, neuropathies, and alopecia have also been observed with both drugs. Additionally, a fluid retention syndrome and cutaneous toxicities have been noted in patients treated with docetaxel. Future studies of the taxoids will allow further comparisons of the toxicity and efficacy of these agents.