Management of elderly women with cervical cancer

Deciphering age-specific molecular features in cervical cancer and constructing an angio-immune prognostic model

Cancer incidence is increasingly seen in younger individuals. Molecular distinctions between young and elderly patients at onset are understudied. This study used public databases to explore genomic, transcriptomic, and immune-related features across age groups in cervical cancer. Additionally, it aims to create a prognostic model applicable across diverse age cohorts, enabling precise patient stratification, and personalized therapies. Gene mutations, expression data, and clinicopathological information were obtained from 317 cervical cancer patients. These patients were divided into a young group and an old group based on the median age of onset. The characteristics of differential gene mutation, gene expression, and immune cells analysis were analyzed by R software. Finally, the prognostic model was constructed by univariate Cox, least absolute shrinkage and selection operator, and multivariate Cox regression analyses of angiogenic and immune gene sets. Its validity was further confirmed using an additional 300 cervical squamous cell carcinoma and endocervical adenocarcinoma tissues. Cervical cancer patients at elderly onset age exhibit a significantly higher frequency of NOTCH1 and TP53 driver mutations compared to young patients, along with a notably higher tumor mutational burden. However, there were no significant differences between the 2 groups in terms of genomic instability and age-related mutational signatures. Differential gene expression analysis revealed that the young group significantly upregulated interferon-alpha and gamma responses and exhibited significantly higher activity in multiple metabolic pathways. Immune microenvironment analysis indicated enrichment of dendritic cells and natural killer cells in the young group, while transforming growth factor-β signature was enriched in the elderly group, indicating a higher degree of immune exclusion. A multigene prognostic model based on angiogenesis and T cell immune gene sets showed excellent prognostic performance independent of clinical factors such as age. High-risk groups identified by the model exhibit significant activation of tumor-promoting processes, such as metastasis and angiogenesis. Our study reveals distinct patterns in cancer-driving mechanisms, biological processes, and immune system status between young and elderly patients at onset with cervical cancer. These findings shed light on the age-specific underlying mechanisms of carcinogenesis. Furthermore, an independent molecular prognostic model is constructed to provide valuable references for patient stratification and the development of potential drug targets.

Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Surgical Treatment Outcomes of Gynecologic Cancer in Older Patients: A Retrospective Study

This study aimed to evaluate oncologic characteristics and surgical outcomes in older patients with gynecologic cancers. This retrospective study included patients aged ≥65 years who were diagnosed with gynecologic cancers and underwent surgical treatment between 2005 and 2020. We reviewed the medical records for age at diagnosis, body mass index, American Society of Anesthesiologists score, comorbidities, postoperative complications, cancer stage, histologic type, surgical treatment, postoperative outcome, and survival rate. Data were compared between groups according to the age at the time of diagnosis: <75 years (young-old) and ≥75 years (old-old). In total, 131 patients were identified: 53 (40.5%) with ovarian or primary peritoneal cancer (OC), 44 (33.6%) with endometrial cancer (EC), 30 (22.9%) with cervical cancer, and 4 (3.1%) with leiomyosarcoma. The patients' mean age was 70 (range, 65-83) years; 106 (80.9%) were young-old and 25 (19.1%) were old-old. Postoperative complications occurred in 19 (14.5%) patients. Four patients died within six months after surgery, and three died because of disease progression. There was no difference in the survival rates between the two groups among those with OC and EC. Older patients with gynecologic cancers showed good surgical outcomes and tolerable postoperative complications. Therefore, we can safely offer surgical treatment to older patients.

Cervical Cancer Stage at Diagnosis and Survival among Women ≥65 Years in California

BACKGROUND

Through adequate screening and follow-up, cervical cancer can be prevented or detected at early-stage (stage I), which is related to excellent survival. Current guidelines recommend discontinuing screening for women ≥65 years with history of normal Pap and/or HPV tests, potentially leaving this age group vulnerable. This study examined late-stage disease in a population-based cohort.

METHODS

Using California Cancer Registry data, we identified 12,442 patients ages ≥21 years with a first primary cervical cancer diagnosed during 2009-2018. Proportions of late-stage disease (stages II-IV) and early- and late-stage 5-year relative survival are presented by the age group. Among patients ages ≥65 years, multivariable logistic regression estimated associations of sociodemographic and clinical characteristics with late-stage cervical cancer.

RESULTS

Nearly one fifth of patients (n = 2,171, 17.4%) were ≥65 years. More women ages ≥65 years (71%) presented with late-stage disease than younger women (48% in patients ages <65). Late-stage 5-year relative survival was lower for women ≥65 years (23.2%-36.8%) compared with patients <65 (41.5%-51.5%). Characteristics associated with late-stage cervical cancer in women ≥65 years included older age [odds ratio (OR), 1.02; 95% confidence interval (CI), 1.01-1.04; each year], non-adenocarcinoma histologic subtypes, and comorbidities (OR, 1.59; 95% CI, 1.21-2.08).

CONCLUSIONS

There remains a significant burden of advanced cervical cancer in women ≥65.

IMPACT

Efforts should be made to better understand how the current screening paradigm is failing women of 65 years and older. Future work should focus on determining past screening history, lapses in follow-up care, and non-invasive testing approaches.

Comparison of oncological outcomes in elderly early-stage cervical cancer patients treated with radical surgery or radiotherapy: A real-world retrospective study with propensity score matching

Objective

To compare the oncological outcomes of radical surgery and radical radiotherapy in elderly (over 65 years) patients with early-stage cervical cancer (IB-IIA).

Methods

Elderly patients with stage IB-IIA cervical cancer treated at Peking Union Medical College Hospital from January 2000 to December 2020 were retrospectively reviewed. All patients were divided into the radiotherapy group (RT group) and the operation group (OP group) according to their primary intervention. Propensity score matching (PSM) analysis was performed to balance the biases. The primary outcome was overall survival (OS), and the secondary outcomes were progression-free survival (PFS) and adverse effects.

Results

A total of 116 patients were eligible for the study (47 in the RT group, and 69 in the OP group), and after PSM, 82 patients were suitable for further analysis (37 in the RT group, and 45 in the OP group). In the real-world setting, it was found that compared with radiotherapy, operation was more frequently selected for elderly cervical cancer patients with adenocarcinoma (P < 0.001) and IB1 stage cancer (P < 0.001). The 5-year PFS rates between the RT and OP groups were not significant (82.3% vs. 73.6%, P = 0.659), and the 5-year OS rate of the OP group was significantly better than that in the RT group (100% vs. 76.3%, P = 0.039), especially in patients with squamous cell carcinoma (P = 0.029) and tumor size of 2~4 cm with G2 differentiation (P = 0.046). There was no significant difference in PFS between the two groups (P = 0.659). In the multivariate analysis, compared with operation, radical radiotherapy was an independent risk factor of OS (hazard ratio = 4.970, 95% CI, 1.023~24.140, P = 0.047). No difference was observed in adverse effects between the RT and OP groups (P = 0.154) and in ≥grade 3 adverse effects (P = 0.852).

Conclusion

The study found that surgery was more frequently selected for elderly cervical cancer patients with adenocarcinoma and IB1 stage cancer in the real-world setting. After PSM to balance the biases, it showed that compared with radiotherapy, surgery could improve the OS of elderly early-stage cervical cancer patients and was an independent protective factor of OS in elderly early-stage cervical cancer patients.

Impact of chemotherapy cycles on oncological outcomes in elders with locally advanced cervical cancer treated with concurrent chemoradiotherapy

INTRODUCTION

To investigate the association between chemotherapy (CMT) cycles and oncological outcomes in elders with locally advanced cervical cancer (LACC) who treated with concurrent chemoradiotherapy (CCRT).

METHODS

We retrospective studied 498 elders with LACC who treated with radiotherapy (RT) or CCRT between 2002 and 2018. Patients were divided into three groups: RT, CCRT with 1-4 and CCRT with 5-6 cycles of CMT. We compared progression-free survival (PFS) and overall survival (OS) among the three groups and explored survival prognostic factors via multivariate analysis and time-varying analysis effect.

RESULTS

There were 453 eligible patients; 222, 119 and 112 patients who received RT, CCRT with 1-4 and CCRT with 5-6 cycles of CMT, respectively. Patients in the RT group had older age, poorer performance status, more treatment with conventional RT technique and earlier treatment year comparing with both CCRT groups. Patients who received 5-6 cycles of CMT were less to have underweight, comorbidities and anaemia compared with the RT group. There were patients with lower FIGO stage in 5-6 cycles than in 1-4 cycles of CMT and RT groups. The 5-year PFS and OS between RT, CCRT with 1-4 and CCRT with 5-6 cycles of the CMT group were significantly different. Performance status, comorbidity, histology, FIGO stage and total received 5-6 CMT cycles were significant prognostic factors of PFS and OS. However, the benefits of receiving 5-6 CMT cycles were evidenced only within the first 2.5 years.

CONCLUSION

Elders with LACC who received 5-6 cycles of CMT concurrently with RT can improve PFS and OS, but the benefit persisted only within the first 2.5 years.

Current treatment status of older patients with gynecological cancers

The percentage of older patients with gynecological malignancies has recently been on the rise. Although prospective studies focusing on the treatment of older patients have been conducted for ovarian cancer, mainly in Europe, there have been scarce literature on cervical and endometrial cancers, and information on their treatment is currently lacking. One of the characteristics of older patients is that not only their performance status but also other factors, such as physical, mental and social factors, cause a large variability, and individual differences in their response to treatments. One of the major issues in the treatment of older patients is how to objectively measure these individual differences and link them to the appropriate treatment selection. In this review, clinical evidence for the guided treatment of older patients with gynecological cancer will be reviewed.

Evaluation of elderly women with uterin cervical cancer

Background

Uterine cervical cancer rates also increase with aging. Especially, the primary treatments of patients with cervical cancer include surgery, chemotherapy, and radiotherapy.

Aim

Our aim is to discuss the effect of clinical and histopathological risk factors on survival in patients over 65 years old with invasive cervical cancer in the light of the literature.

Methods and Results

The files of 60 patients aged 65 and over who were diagnosed, examined, and treated for invasive cervical uteri cancer between 2004 and 2021 by the gynecological oncology clinic of Akdeniz University were analyzed retrospectively after obtaining approval from the Akdeniz University ethics committee with the number KAEK‐110. Detailed written consent was obtained from all patients and their relatives for data analysis. Patients aged 65 and over who were diagnosed with invasive cervical uteri cancer at all stages who accepted treatment were included in the study. The patients who were not included in the study were those who did not accept treatment, did not continue their follow‐up regularly, were under 65 years of age, had preinvasive cervical lesion, had a second primary cancer, had an unknown stage, and died due to accidents or similar reasons.

When the demographic data of 60 cases were examined, the mean age was 70.5, the youngest age was 65, and the oldest age was 84. When we divided them into two groups by age groups, 76.7% were between 65 and 75 years old and 23.3% were over 75 years old. When the data of 60 patients who were referred to our hospital, which was a tertiary center in the 15 years duration, were examined, the mean disease‐progression free survival (PFS) of patients with locally advanced stage was 45 months, however, it was 4 months for metastatic patients, this difference was significant and a statistically significant difference was found between the two groups (p: .001). When the total survival was examined, the mean was 108.7 months in the locally advanced stage group, while it was 2.9 months in metastatic cases, and this difference was also statistically significant between the two groups (p: .001). When we divide the cases into two groups as between 65 and 75 and over 75 years of age, the mean age of disease‐free survival is 76.9 months in the 65–75 years old group, while 16 months in the 76–85 years old group, however, the p value of this difference in PFS between the two groups was not significant (p: 0.154). However, when the total survival was examined, it was seen that the mean was 140.4 in the 65–75 years old group, while it was 56 months in the 76–85 years old group and this difference was significant between the two groups (p: .046).

Conclusion

In parallel with the increased population worldwide, advanced age cancer rates are increasing. In parallel with the population growth, it should be remembered that the patients over 65 years of age who were diagnosed with invasive uterine cervical cancer had difficulty in accessing screening tests, late diagnosis and inadequate treatment regimens due to concomitant diseases, resulting in recurrence in a short time and poor clinical symptoms due to short total survival.

Minimal-invasive or open approach for surgery of early cervical cancer: the treatment center matters

PURPOSE

The aim of the study was to compare recurrence-free survival (RFS) and overall survival (OS) of patients with early stage cervical cancer in dependence of surgical approach and treatment center.

PATIENTS AND METHODS

A population-based cohort study including women with early stage IA1-IIB2 cervical cancer treated by radical hysterectomy between January 2010 and December 2015 was performed.

RESULTS

The median follow-up time was 5.6 years. After exclusions, 413 patients were eligible for analysis: 111 (26.9%) underwent minimal-invasive surgery (MIS) and 302 (73.1%) open surgery. Both treatment groups were well balanced regarding the clinical and pathological characteristics. The mean age of the patients was 51.0 years. MIS was associated with improved RFS and OS compared with the open surgery. The 5-year RFS rates were 89.2% in the MIS group and 73.4% in the open surgery group (p = 0.004). The 5-year OS rates were 93.7% in the MIS group and 81.8% in the open surgery group (p = 0.016). After adjustment for other prognostic covariates, the MIS was further associated with improved RFS (HR = 0.45, 95% CI 0.24-0.86; p = 0.015) but not with OS. Nevertheless, after adjustment for treatment center, the surgical approach was not associated with significant difference in RFS (HR = 0.61, 95% CI 0.31-1.19; p = 0.143). Overall survival of patients treated in university cancer centers was significantly increased compared to patients treated in non-university cancer centers. The treatment center remains a strong prognostic factor regarding RFS (HR = 0.49, 95% CI 0.28-0.83; p = 0.009) and OS (HR = 0.50, 95% CI 0.26-0.94; p = 0.031).

CONCLUSIONS

The treatment center but not the surgical approach was associated with the survival of patients treated with radical hysterectomy for early stage cervical cancer.

Conditional relative survival of cervical cancer: a Korean National Cancer Registry Study

Objective

Conditional relative survival (CRS) considers changes in prognosis over time and may offer more useful estimates for survivors. We aimed to investigate CRS among patients with cervical cancer stratified by various factors that influence survival probability.

Methods

This nationwide retrospective study used data from the Korean Central Cancer Registry. We included 78,606 patients diagnosed with cervical cancer as their first cancer between January 1, 1996 and December 31, 2015, and who were followed until December 31, 2016. CRS and the conditional probabilities of death for the following 1 year were stratified by age at diagnosis, histology, cancer stage, treatment, year of diagnosis, and social deprivation index.

Results

The 5-year relative survival rate at the time of diagnosis was 80.6% for all cases. The probability of surviving an additional 5 years conditioned on having already survived 1, 2, 3, 4, and 5 years after diagnosis was 85.7%, 90.6%, 93.5%, 95.3%, and 94.3%, respectively. Patients with poorer initial survival estimates (older, advanced stage, non-squamous cell histology) generally showed the largest increases in CRS over time. Patients aged ≥70 years had the highest probability of death in the first year after diagnosis (24.5%), but the conditional probability of death in the 2nd, 3rd, 4th, and 5th years declined abruptly to 13.1%, 7.5%, 5.4%, and 3.9%, respectively.

Conclusions

The CRS rates for patients with cervical cancer improved over time, particularly among patients with poorer initial prognoses. Our estimates enable patients to make better informed decisions regarding follow-up care and their personal life.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review

PURPOSE

The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms.

METHODS

We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability.

RESULTS

Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%).

CONCLUSION

Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

Differences in Treatment Outcomes and Prognosis between Elderly and Younger Patients Receiving Definitive Radiotherapy for Cervical Cancer

The aim was to compare the clinical outcomes and prognostic factors of cervical cancer between elderly and younger women, and to explore which treatment strategy is more appropriate for elderly patients. We retrospectively reviewed patients with cervical cancer receiving definitive radiotherapy (RT) between 2007 and 2016, and divided them into two age groups: age < 70 vs. age ≥ 70. The clinical outcomes were compared between the two age groups. The median follow-up was 32.2 months. A total of 123 patients were eligible, 83 patients in group 1 (age < 70), and 40 patients in group 2 (age ≥ 70). Patients in group 2 received less intracavitary brachytherapy (ICRT) application, less total RT dose, and less concurrent chemoradiotherapy (CCRT), and tended to have more limited external beam radiotherapy (EBRT) volume. The treatment outcomes between the age groups revealed significant differences in 5-year overall survival (OS), but no differences in 5-year cancer-specific survival (CSS), 66.2% vs. 64.5%, and other loco-regional control. In multivariate analyses for all patients, the performance status, pathology with squamous cell carcinoma (SCC), International Federation of Gynecology and Obstetrics (FIGO) stage, and ICRT application were prognostic factors of CSS. The elderly patients with cervical cancer had comparable CSS and loco-regional control rates, despite receiving less comprehensive treatment. Conservative treatment strategies with RT alone could be appropriate for patients aged ≥ 70 y/o, especially for those with favorable stages or histopathology.

Characteristics and Treatments of Patients Aged 65 Years or Over with Cervical Cancer

Purpose

Although the mortality of elderly women with cervical cancer is high, their characteristics and prognosis have not attracted sufficient attention. This study aims to clarify the prognostic factors of cervical cancer patients aged ≥65.

Patient and Methods

The incidences and characteristics of patients diagnosed with cervical cancer (aged ≥65 and <65) during 2004–2015 were obtained through the Surveillance, Epidemiology, and End Results Program (SEER) database. The differences of distributions of characteristics between two age groups were compared by chi-squared (χ²) test. Kaplan–Meier survival method, Log-rank test, Cox-regression and visual nomogram were utilized for survival analysis.

Results

The annual incidences of two age groups with cervical cancer were (5.5–7.5)/100,000 and (3.4–3.9)/100,000, respectively, during 2004–2015. The 1-year and 5-year cancer-specific survival rates of old patients were both lower than those of young patients (P <0.001). The proportions of unmarried state and advanced International Federation of Gynecology and Obstetrics (FIGO) stage in old patients were higher than those in relatively young patients, and fewer elderly patients received surgery. Univariate and multivariate survival analysis showed non-squamous cell carcinoma, poor differentiation and late FIGO stage were independent poor prognostic factors for patients aged ≥65. Treatments improved the outcomes of elderly patients, and the effect of surgery was better than non-surgical treatment on elderly patients with FIGO I. Besides, geriatric score and survival probability could be accomplished by our nomogram with a c-index of 0.7945.

Conclusion

Delayed diagnosis and insufficient treatment were two distinct features of elderly patients and correlated with their poor clinical outcomes. More attention and active treatments should be adopted in elderly women based on their general condition.

Challenges and advances in cervix cancer treatment in elder women

With population ageing, cancer treatments in elder patients is becoming a true public health care issue. There is an authentic dilemma between patient's frailty, residual life expectancy and the toll that take anticancer treatments. Since elder patients are almost always excluded from clinical trials, it is hard to get robust scientific data on the tolerability of oncologic treatments and to set in place recommendations. Cervix cancer is traditionally diagnosed in younger women but it has a 2nd incidence peak between 60 and 70 years old. Cervix cancer in elder patients is a subject to many questions in terms of screening and is a therapeutic challenge. This article reviews literature data on these different aspects, from screening to surgery, from radiotherapy to brachytherapy, from chemotherapy to supportive care, from immunotherapy to geriatric assessment. We tried to show how modern therapeutic innovations may benefit elder patients. Expected benefits in terms of efficacy and toxicity may overcome the long-lasting tendency to undertreatment in elder patients and improve their quality of life after cancer treatment. In 2020, there seems to be less and less reasons justifying that elder women with cervix cancer may not receive the appropriate treatment.

Benefit of Cisplatin With Definitive Radiotherapy in Older Women With Cervical Cancer

Background: Cisplatin with definitive radiotherapy (RT) is considered the standard of care for cervical cancer; however, older women are frequently undertreated and have worse outcomes compared with younger patients. Because women aged ≥65 years have been disproportionately underrepresented in clinical trials, uncertainties exist regarding how much they benefit from the addition of cisplatin to RT. Patients and Methods: Women aged ≥65 years with nonmetastatic cervical cancer treated with definitive external-beam RT and brachytherapy were identified in the SEER-Medicare database. Death attributable to cervical cancer (cancer-specific mortality [CSM]) was evaluated against competing risks of death using Gray’s test. Propensity score analysis and the Fine-Gray multivariable regression model were used to adjust for baseline differences, including comorbidity. Results: The total cohort comprised 826 patients, of whom 531 (64%) received cisplatin, 233 (28%) were FIGO stage I, 374 (45%) were stage II, and 219 (27%) were stage III–IVA. Older age and chronic kidney disease significantly predicted omission of cisplatin. Virtually all cisplatin dosing was weekly, with a median of 5 cycles. Death from cervical cancer was significantly lower with cisplatin than without (5-year CSM, 31% vs 39%; P=.02; adjusted hazard ratio, 0.72; P=.02), which persisted in propensity score analysis. Receiving ≥5 cycles was required for benefit, as no difference in CSM was seen in patients receiving 1 to 4 cycles versus no cisplatin. Subgroup analyses revealed that the benefit of cisplatin persisted in women aged ≥75 years and those with early-stage disease. Incidence of cytopenia, nausea/vomiting, and hypovolemia increased in patients treated with cisplatin. Conclusions: Administration of cisplatin with definitive RT in women aged ≥65 years was associated with a significant benefit in the incidence of death attributable to cervical cancer, despite competing risks for mortality in an older population. Receiving at least 5 cycles of weekly cisplatin was required for benefit.