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

Efficacy and safety of niraparib in patients aged 65 years and older with advanced ovarian cancer: Results from the PRIMA/ENGOT-OV26/GOG-3012 trial

OBJECTIVE

To evaluate the impact of age on the efficacy and safety of niraparib first-line maintenance therapy in patients with newly diagnosed advanced ovarian cancer with a complete/partial response to first-line platinum-based chemotherapy.

METHODS

Post hoc analysis of the phase 3 PRIMA/ENGOT-OV26/GOG-3012 study (NCT02655016). Patients in the intent-to-treat population were categorized according to age at baseline (<65 years vs ≥65 years), and progression-free survival (PFS), safety, and health-related quality of life (HRQOL) were evaluated for each age subgroup (clinical cutoff date, May 17, 2019). Safety findings were also evaluated according to a fixed starting dose (FSD) or an individualized starting dose (ISD).

RESULTS

Of 733 randomized patients, 289 (39.4%) were ≥65 years (190 niraparib, 99 placebo) at baseline. Median PFS (niraparib vs placebo) and hazard ratios (95% CI) were similar in patients aged <65 years (13.9 vs 8.2 months; HR, 0.61 [0.47-0.81]) and ≥65 years (13.7 vs 8.1 months; HR, 0.53 [0.39-0.74]). The incidences of any-grade and grade ≥3 treatment-emergent adverse events (TEAEs) were similar across age subgroups; in the niraparib arm, TEAEs leading to dose discontinuation occurred in 7.8% of patients <65 years and 18.4% of patients ≥65 years. ISD use lowered the incidence of grade ≥3 thrombocytopenia events in niraparib-treated patients compared with the FSD (<65 years: 42.8% vs 18.0%; ≥65 years 57.0% vs 26.1%). HRQOL was comparable across age subgroups.

CONCLUSION

Niraparib efficacy, safety, and HRQOL were generally comparable across age subgroups, although patients ≥65 years had a higher rate of discontinuations due to TEAEs. ISD use reduced grade ≥3 thrombocytopenia events regardless of age.

Ovarian cancer in the older patient: where are we now? What to do next?

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.

Visual Peritoneal Evaluation of Residual Disease After Neoadjuvant Chemotherapy in Advanced Ovarian Cancer Patients: The VIPER Study

BACKGROUND

Chemotherapy induces histopathological tumor necrosis and fibrosis which results in macroscopic tissue changes, making surgeons' intraoperative visual evaluation of the disease distribution more difficult to interpret. The aim of the study was to assess the sensitivity, specificity, and accuracy of intraoperative laparoscopic visual evaluation of the diaphragmatic peritoneum and compare it with histopathological examination.

METHODS

Patients receiving diaphragmatic peritonectomy at time of IDS were retrospectively included. The population was grouped based on the surgeon's assessment of the diaphragmatic peritoneum during diagnostic laparoscopy. Group 1 included patients with a "visually pathologic" diaphragmatic peritoneum, and group 2 included patients with a "visually dubious" diaphragmatic peritoneum. Sensitivity, specificity, predictive values, and accuracy were calculated considering the final formalin-fixed pathology as the reference standard.

RESULTS

155 patients were included (92 in group 1 and 63 in group 2). The accuracy rate of visual examination was 67.1%, the negative predictive value was 19%, specificity was 100%, and sensitivity was 64.3%.

CONCLUSION

NACT strongly affects the ability of the surgeon to discern between peritoneal scars and truly pathologic peritoneum. The diaphragmatic laparoscopic visual examination showed a low overall accuracy. We propose an algorithm that can guide the surgeon towards a more tailored approach to diaphragmatic peritonectomy during IDS.

Association between Serum Biomarkers with Postoperative Complications and Delay of Adjuvant Chemotherapy Initiation in Ovarian Cancer Patients Undergoing Primary Cytoreductive Surgery: A Pilot Study

This study sought to describe and relate the factors associated with complications and delays in adjuvant chemotherapy in patients with ovarian cancer treated with primary cytoreductive surgery. Serum from patients diagnosed with ovarian cancer scheduled for primary cytoreductive surgery were analyzed for prealbumin, 25-OH Vitamin D, intracellular adhesion molecule 1 (ICAM-1), interleukin 6 (IL-6), interleukin 8 (IL-8), monocyte chemoattractant protein 1 (MCP-1), monocyte chemoattractant protein 2 (MCP-2), macrophage derived chemokine (MDC). Postoperative complications were identified using common terminology criteria for adverse events 4.0 and 30 day after surgery. Delays in adjuvant chemotherapy were defined as >1 week interval between surgery and initiation. Patients with postoperative complications (39.6%) were significantly older, had lower serum prealbumin levels, and higher serum IL-6 and IL-8 than those without. Univariate logistic regression found that age (OR: 1.12, 95%CI: 1.00-1.35) and IL-6 (OR: 1.02, 95%CI: 0.99-1.05) were associated with postoperative complications, whereas age remained significant after multivariate analysis (OR:1.14, 95%CI: 1.00-1.29). Patients with delays in chemotherapy exhibited greater BMI and lower 25-OH Vitamin D than those without. Multivariate analysis found that increasing levels of 25-OH Vitamin D were associated with a lower risk of delayed chemotherapy initiation after controlling for age, body mass index, and tumor grade (OR: 0.93, 95%CI:0.87-0.99). This work suggests that in addition to age being predictive of postoperative complications, serum 25-OH Vitamin D may a provide insight into a patient's risk for postsurgical delays in chemotherapy initiation. These findings should, however, be confirmed in a larger study including robust survival analysis.

Impact of residual disease as a prognostic factor for survival in women with advanced epithelial ovarian cancer after primary surgery

BACKGROUND

Ovarian cancer is the seventh most common cancer among women and a leading cause of death from gynaecological malignancies. Epithelial ovarian cancer is the most common type, accounting for around 90% of all ovarian cancers. This specific type of ovarian cancer starts in the surface layer covering the ovary or lining of the fallopian tube. Surgery is performed either before chemotherapy (upfront or primary debulking surgery (PDS)) or in the middle of a course of treatment with chemotherapy (neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS)), with the aim of removing all visible tumour and achieving no macroscopic residual disease (NMRD). The aim of this review is to investigate the prognostic impact of size of residual disease nodules (RD) in women who received upfront or interval cytoreductive surgery for advanced (stage III and IV) epithelial ovarian cancer (EOC).

OBJECTIVES

To assess the prognostic impact of residual disease after primary surgery on survival outcomes for advanced (stage III and IV) epithelial ovarian cancer. In separate analyses, primary surgery included both upfront primary debulking surgery (PDS) followed by adjuvant chemotherapy and neoadjuvant chemotherapy followed by interval debulking surgery (IDS). Each residual disease threshold is considered as a separate prognostic factor.

SEARCH METHODS

We searched CENTRAL (2021, Issue 8), MEDLINE via Ovid (to 30 August 2021) and Embase via Ovid (to 30 August 2021).

SELECTION CRITERIA

We included survival data from studies of at least 100 women with advanced EOC after primary surgery. Residual disease was assessed as a prognostic factor in multivariate prognostic models. We excluded studies that reported fewer than 100 women, women with concurrent malignancies or studies that only reported unadjusted results. Women were included into two distinct groups: those who received PDS followed by platinum-based chemotherapy and those who received IDS, analysed separately. We included studies that reported all RD thresholds after surgery, but the main thresholds of interest were microscopic RD (labelled NMRD), RD 0.1 cm to 1 cm (small-volume residual disease (SVRD)) and RD > 1 cm (large-volume residual disease (LVRD)).

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible, we synthesised the data in meta-analysis. To assess the adequacy of adjustment factors used in multivariate Cox models, we used the 'adjustment for other prognostic factors' and 'statistical analysis and reporting' domains of the quality in prognosis studies (QUIPS) tool. We also made judgements about the certainty of the evidence for each outcome in the main comparisons, using GRADE. We examined differences between FIGO stages III and IV for different thresholds of RD after primary surgery. We considered factors such as age, grade, length of follow-up, type and experience of surgeon, and type of surgery in the interpretation of any heterogeneity. We also performed sensitivity analyses that distinguished between studies that included NMRD in RD categories of < 1 cm and those that did not. This was applicable to comparisons involving RD < 1 cm with the exception of RD < 1 cm versus NMRD. We evaluated women undergoing PDS and IDS in separate analyses.

MAIN RESULTS

We found 46 studies reporting multivariate prognostic analyses, including RD as a prognostic factor, which met our inclusion criteria: 22,376 women who underwent PDS and 3697 who underwent IDS, all with varying levels of RD. While we identified a range of different RD thresholds, we mainly report on comparisons that are the focus of a key area of clinical uncertainty (involving NMRD, SVRD and LVRD). The comparison involving any visible disease (RD > 0 cm) and NMRD was also important. SVRD versus NMRD in a PDS setting In PDS studies, most showed an increased risk of death in all RD groups when those with macroscopic RD (MRD) were compared to NMRD. Women who had SVRD after PDS had more than twice the risk of death compared to women with NMRD (hazard ratio (HR) 2.03, 95% confidence interval (CI) 1.80 to 2.29; I2 = 50%; 17 studies; 9404 participants; moderate-certainty). The analysis of progression-free survival found that women who had SVRD after PDS had nearly twice the risk of death compared to women with NMRD (HR 1.88, 95% CI 1.63 to 2.16; I2 = 63%; 10 studies; 6596 participants; moderate-certainty). LVRD versus SVRD in a PDS setting When we compared LVRD versus SVRD following surgery, the estimates were attenuated compared to NMRD comparisons. All analyses showed an overall survival benefit in women who had RD < 1 cm after surgery (HR 1.22, 95% CI 1.13 to 1.32; I2 = 0%; 5 studies; 6000 participants; moderate-certainty). The results were robust to analyses of progression-free survival. SVRD and LVRD versus NMRD in an IDS setting The one study that defined the categories as NMRD, SVRD and LVRD showed that women who had SVRD and LVRD after IDS had more than twice the risk of death compared to women who had NMRD (HR 2.09, 95% CI 1.20 to 3.66; 310 participants; I2 = 56%, and HR 2.23, 95% CI 1.49 to 3.34; 343 participants; I2 = 35%; very low-certainty, for SVRD versus NMRD and LVRD versus NMRD, respectively). LVRD versus SVRD + NMRD in an IDS setting Meta-analysis found that women who had LVRD had a greater risk of death and disease progression compared to women who had either SVRD or NMRD (HR 1.60, 95% CI 1.21 to 2.11; 6 studies; 1572 participants; I2 = 58% for overall survival and HR 1.76, 95% CI 1.23 to 2.52; 1145 participants; I2 = 60% for progression-free survival; very low-certainty). However, this result is biased as in all but one study it was not possible to distinguish NMRD within the < 1 cm thresholds. Only one study separated NMRD from SVRD; all others included NMRD in the SVRD group, which may create bias when comparing with LVRD, making interpretation challenging. MRD versus NMRD in an IDS setting Women who had any amount of MRD after IDS had more than twice the risk of death compared to women with NMRD (HR 2.11, 95% CI 1.35 to 3.29, I2 = 81%; 906 participants; very low-certainty).

AUTHORS' CONCLUSIONS

In a PDS setting, there is moderate-certainty evidence that the amount of RD after primary surgery is a prognostic factor for overall and progression-free survival in women with advanced ovarian cancer. We separated our analysis into three distinct categories for the survival outcome including NMRD, SVRD and LVRD. After IDS, there may be only two categories required, although this is based on very low-certainty evidence, as all but one study included NMRD in the SVRD category. The one study that separated NMRD from SVRD showed no improved survival outcome in the SVRD category, compared to LVRD. Further low-certainty evidence also supported restricting to two categories, where women who had any amount of MRD after IDS had a significantly greater risk of death compared to women with NMRD. Therefore, the evidence presented in this review cannot conclude that using three categories applies in an IDS setting (very low-certainty evidence), as was supported for PDS (which has convincing moderate-certainty evidence).

Perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in elderly women with epithelial ovarian cancer: analysis of a prospective registry

OBJECTIVE

To evaluate perioperative outcomes in elderly versus non-elderly women with advanced or recurrent epithelial ovarian cancer undergoing surgery with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A single-institution prospective registry was analyzed for women with ovarian cancer who underwent surgery with HIPEC from January 2014 to December 2020. Elderly age was defined as ≥65 years at surgery. Complications were defined according to the Accordion scale. Univariate and multivariable analysis was used to compare progression-free survival and overall survival.

RESULTS

Of 127 women who underwent surgery with HIPEC, 33.1% (n=42) were ≥65 and 17.3% (n=22) were ≥70 years old. The median age for non-elderly and elderly patients were 55.7±8.3 versus 72.0±5.4 years, respectively (p<0.001). The majority of non-elderly versus elderly patients underwent HIPEC at the time of interval cytoreductive surgery following neoadjuvant chemotherapy (52.9% vs 73.8%, p=0.024). There were no differences in moderate (15.3% vs 26.2%) or severe postoperative complications (10.6% vs 11.9%, p=0.08), acute kidney injury (7.1% vs 16.7%, p=0.12), and length of stay (5.0 vs 5.0 days, p=0.56) for non-elderly versus elderly patients. With a median follow-up of 20 months (95% CI 9.1 to 32.7 months), there was no difference in progression-free survival (18.8 vs 15.7 months, p=0.75) or overall survival (61.6 months vs not estimable, p=0.72) for non-elderly versus elderly patients. Comparing patients 65-69 versus ≥70 years, progression-free survival (33.0 vs 12.5 months, p=0.002) was significantly improved in patients aged 65-69, without difference in overall survival (not estimable vs 36.0 months, p=0.91). On multivariable analysis, age ≥65 did not impact progression-free survival (p=0.74).

CONCLUSIONS

In this prospective registry of women with ovarian cancer, perioperative morbidity is not increased for non-elderly versus elderly patients following surgery with HIPEC. While age should not exclude patients from surgery with HIPEC, additional research is needed regarding oncologic benefits in elderly women.

Efficacy and Safety of First-line Single-Agent Carboplatin vs Carboplatin Plus Paclitaxel for Vulnerable Older Adult Women With Ovarian Cancer: A GINECO/GCIG Randomized Clinical Trial

Importance

Single-agent carboplatin is often proposed instead of a conventional carboplatin-paclitaxel doublet in vulnerable older patients with ovarian cancer. Such an approach could have a detrimental effect on outcomes for these patients.

Objective

To compare the feasibility, efficacy, and safety of single-agent carboplatin every 3 weeks, weekly carboplatin-paclitaxel, or conventional every-3-weeks carboplatin-paclitaxel in vulnerable older patients with ovarian cancer.

Design, Setting, and Participants

This international, open-label, 3-arm randomized clinical trial screened 447 women 70 years and older with newly diagnosed stage III/IV ovarian cancer by determining their Geriatric Vulnerability Score; 120 patients with a Geriatric Vulnerability Score of 3 or higher were stratified by country and surgical outcome. Enrollment took place at 48 academic centers in France, Italy, Finland, Denmark, Sweden, and Canada from December 11, 2013, to April 26, 2017. Final analysis database lock April 2019. Data analysis was performed from February 1 to December 31, 2019.

Interventions

Patients were randomized to receive 6 cycles of (1) carboplatin, area under the curve (AUC) 5 mg/mL·min, plus paclitaxel, 175 mg/m2, every 3 weeks; (2) single-agent carboplatin, AUC 5 mg/mL·min or AUC 6 mg/mL·min, every 3 weeks; or (3) weekly carboplatin, AUC 2 mg/mL·min, plus paclitaxel, 60 mg/m2, on days 1, 8, and 15 every 4 weeks.

Main Outcomes and Measures

The primary outcome was treatment feasibility, defined as the ability to complete 6 chemotherapy cycles without disease progression, premature toxic effects-related treatment discontinuation, or death.

Results

A total of 120 women were randomized. The mean and median age was 80 (interquartile range, 76-83; range, 70-94) years; 43 (36%) had a Geriatric Vulnerability Score of 4 and 13 (11%) had a Geriatric Vulnerability Score of 5; 40 (33%) had stage IV disease. During its third meeting, the independent data monitoring committee's recommendation led to the termination of the trial because single-agent carboplatin was associated with significantly worse survival. Six cycles were completed in 26 of 40 (65%), 19 of 40 (48%), and 24 of 40 (60%) patients in the every-3-weeks combination, single-agent carboplatin, and weekly combination groups, respectively. Treatment-related adverse events were less common with the standard every-3-weeks combination (17 of 40 [43%]) than single-agent carboplatin or weekly combination therapy (both 23 of 40 [58%]). Treatment-related deaths occurred in 4 patients (2 of 40 [5%] in each combination group).

Conclusions and Relevance

This randomized clinical trial shows that compared with every-3-weeks or weekly carboplatin-paclitaxel regimens, single-agent carboplatin was less active with significantly worse survival outcomes in vulnerable older patients with ovarian cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02001272.

Management of the Elderly Patients with High-Grade Serous Ovarian Cancer in the REAL-WORLD Setting

Treatment of elderly patients with neoplasia is challenging. Age is a known prognostic factor in ovarian cancer but the optimal treatment of elderly patients has not been determined. We undertook a retrospective analysis to determine clinical practice in advanced-stage ovarian cancer patients older than 70 years of age. Methods: Medical records of women with high-grade serous ovarian cancer, stage III and IV were retrospectively analyzed. Results: A total of 735 patients were identified with a median age of 61.5 years. 22.4% among them were older than 70 years of age at diagnosis. First-line Progression-Free Survival (PFS) and Overall Survival (OS) were significantly worse in elderly patients in comparison to the younger ones [mPFS 11.3 months vs. 14.8 months, (p < 0.001) and mOS 30.2 months vs. 45.6 months (p < 0.001)]. However, elderly patients were characterized by worse ECOG-Performance Status and they were more frequently treated with Neoadjuvant Chemotherapy followed by Interval Debulking Surgery, while often they were more frequently denied debulking surgery compared to patients under 70 years of age. Moreover, elderly patients received more frequently monotherapy with platinum as frontline treatment. In contrast, there was no significant difference in the outcome of the debulking surgery in comparison to the younger patients or the frequency that gBRCA test was performed. Age over 70 years did not retain its significance for either Progression-Free Survival or Overall Survival when adjusted for all other reported prognostic factors. Conclusions: Elderly ovarian cancer patients have a worse prognosis. Comprehensive geriatric assessment should be performed for the optimal treatment of these patients.

Current status of hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer in the United States

OBJECTIVES

1.) To compare frequency of HIPEC use in ovarian cancer treatment before and after publication of the phase III study by van Driel et al. in January 2018. 2.) To compare associated rates of hospital-based outcomes, including length of stay, intensive care unit (ICU) admission, complications, and costs in ovarian cancer surgery with or without HIPEC.

METHODS

We queried Vizient's administrative claims database of 550 US hospitals for ovarian cancer surgeries from January 2016-January 2020 using ICD-10 diagnosis and procedure codes. Sodium thiosulfate administration was used to identify HIPEC cases according to the published protocol. Student t-tests and relative risk (RR) were used to compare continuous variables and contingency tables, respectively.

RESULTS

152 ovarian cancer patients had HIPEC at 39 hospitals, and 20,014 ovarian cancer patients had surgery without HIPEC at 256 hospitals. Following the trial publication, 97% of HIPEC cases occurred. During the index admission, HIPEC patients had longer median length of stay (8.4 vs. 5.7 days, p < 0.001) and higher percentage of ICU admissions (63.1% vs. 11.0%, p < 0.001) and complication rates (RR = 1.87, p = 0.002). Index admission direct costs ($21,825 vs. $12,038, p < 0.001) and direct cost index (observed/expected costs) (1.87 vs. 1.11, p < 0.001) were also greater in the HIPEC patients. No inpatient deaths or 30-day readmissions were identified after HIPEC.

CONCLUSIONS

Use of HIPEC for ovarian cancer increased in the US after publication of a phase III clinical trial in a high-impact journal, though the absolute number of cases remains modest. Incorporation of HIPEC was associated with increased cost, hospital length of stay, ICU admission, and hospital-acquired complication rates. Further studies are needed in order to evaluate long-term outcomes, including morbidity and survival.

Is standard radical surgery necessary for elderly patients with early-stage epithelial ovarian carcinoma? ~Propensity score matched analysis~

OBJECTIVE

The impact of 'standard full-staged radical surgery (SRS)' on overall survival (OS) in elderly patients with early-stage epithelial ovarian cancer (EOC) remains unclear. In the current study, we investigated the impact of SRS on OS in elderly patients with early-stage EOC in a multicentric analysis using a propensity score (PS)-matching technique.

METHODS

Between 1986 and 2017, 3227 patients with EOC were registered and accumulated by the Tokai Ovarian Tumor Study Group, consisting of 14 collaborating institutions, after a central pathological review. Among them, 204 elderly patients aged older than or equal to 65 years who had a stage I EOC were analyzed, including 72 patients who had received SRS (Group I) and 132 who had undergone non-SRS limited surgery (Group II). Oncologic outcomes were compared between the two groups using a PS-matching technique to adjust for various clinicopathologic risk factors.

RESULTS

The median follow-up duration of all surviving patients was 55.9 months. Consequently, 54 patients (26.5%) developed recurrence. In addition, 33 patients (16.2%) died of the disease. In the original cohort, the 5-year OS rates of Groups I and II were 95.8 and 82.3%, respectively. We identified a marginally significant difference between the two groups (Log-rank: P = 0.086). In the PS-matched cohort after adjustment for multiple clinicopathologic factors, there was no significant difference in OS between the two groups [OS (Group I vs. II), HR: 0.766 (95% CI: 0.271-2.165), P = 0.615].

CONCLUSIONS

After adjustment for clinicopathologic factors, non-SRS limited surgery may not worsen the oncologic outcome in elderly women with early-stage EOC. A large-scale clinical study is necessary to validate the findings.

Management and Survival of Elderly and Very Elderly Patients with Ovarian Cancer: An Age-Stratified Study of 1123 Women from the FRANCOGYN Group

Elderly women with ovarian cancer are often undertreated due to a perception of frailty. We aimed to evaluate the management of young, elderly and very elderly patients and its impact on survival in a retrospective multicenter study of women with ovarian cancer between 2007 to 2015. We included 979 women: 615 women (62.8%) <65 years, 225 (22.6%) 65–74 years, and 139 (14.2%) ≥75 years. Women in the 65–74 years age group were more likely to have serous ovarian cancer (p = 0.048). Patients >65 years had more >IIa FIGO stage: 76% for <65 years, 84% for 65–74 years and 80% for ≥75 years (p = 0.033). Women ≥75 years had less standard procedures (40% (34/84) vs. 59% (104/177) for 65–74 years and 72% (384/530) for <65 years (p < 0.001). Only 9% (13/139) of women ≥75 years had an Aletti score >8 compared with 16% and 22% for the other groups (p < 0.001). More residual disease was found in the two older groups (30%, respectively) than the younger group (20%) (p < 0.05). Women ≥75 years had fewer neoadjuvant/adjuvant cycles than the young and elderly women: 23% ≥75 years received <6 cycles vs. 10% (p = 0.003). Univariate analysis for 3-year Overall Survival showed that age >65 years, FIGO III (HR = 3.702, 95%CI: 2.30–5.95) and IV (HR = 6.318, 95%CI: 3.70–10.77) (p < 0.001), residual disease (HR = 3.226, 95%CI: 2.51–4.15; p < 0.001) and lymph node metastasis (HR = 2.81, 95%CI: 1.91–4.12; p < 0.001) were associated with lower OS. Women >65 years are more likely to have incomplete surgery and more residual disease despite more advanced ovarian cancer. These elements are prognostic factors for women’s survival regardless of age. Specific trials in the elderly would produce evidence-based medicine and guidelines for ovarian cancer management in this population.

Chemotherapy alone for patients 75 years and older with epithelial ovarian cancer-is interval cytoreductive surgery still needed?

BACKGROUND

Patients ≥75 years old with ovarian cancer experience high perioperative morbidity, but recruitment into prospective trials to assess the role of surgery continues to be challenging.

OBJECTIVE

To compare overall survival for patients ≥75 years old with ovarian cancer after chemotherapy alone vs neoadjuvant chemotherapy with interval cytoreductive surgery.

STUDY DESIGN

Data were extracted from the National Cancer Data Base from 2004 to 2014. Kaplan-Meier and Cox proportional hazards models were used for statistical analyses.

RESULTS

Of 1661 patients (median age: 79 years), most were white (88%) and had stage III-IV disease (95%), and 51% had serous histology. Of those who did not receive primary surgery, 58% had chemotherapy alone and the remainder had neoadjuvant chemotherapy with interval cytoreductive surgery. The use of neoadjuvant chemotherapy with interval cytoreductive surgery increased from 28% to 50% in years 2004-2007 to 2012-2014 (P<.001). Compared with neoadjuvant chemotherapy with interval cytoreductive surgery, chemotherapy-only patients were older (80 vs 78 years; P<.001) and had more advanced stage disease (98% vs 91%; P<.001). The 5-year overall survival of the entire study group was 14%; those who underwent neoadjuvant chemotherapy with interval cytoreductive surgery had overall survival of 25% compared with only 7% in chemotherapy alone group (P<.001). In multivariable analysis, neoadjuvant chemotherapy with interval cytoreductive surgery (hazard ratio, 0.44; 95% confidence interval, 0.36-0.54; P<.001) was an independent predictor for improved survival. Older (80-84 years) age (hazard ratio, 1.35; 95% confidence interval, 1.12-1.63; P=.002), advanced (stage III-IV) disease (hazard ratio; 2.06, 95% confidence interval, 1.37-3.09; P=.001), and clear cell histology (hazard ratio; 2.17, 95% confidence interval, 1.10-4.28; P=.03) portended for worse outcome.

CONCLUSION

Patients ≥75 years with ovarian cancer old have an overall poor prognosis. Receiving neoadjuvant chemotherapy followed by interval cytoreductive surgery is associated with greater overall survival compared to chemotherapy alone.

Lymphadenectomy in elderly patients with high-intermediate-risk, high-risk or advanced endometrial cancer: Time to move from personalized cancer medicine to personalized patient medicine!

BACKGROUND

Pelvic and paraaortic lymphadenectomy are recommended for women with high-intermediate, high-risk and advanced endometrial cancer (EC). Lymphadenectomy is less frequently performed in elderly patients than in younger patients. We examined the survival of elderly women diagnosed with high-risk EC according to whether lymphadenectomy was performed or not.

METHODS

We selected women over 70 years with high-intermediate risk, high-risk or advanced EC from a multicenter retrospective cohort of women diagnosed between 2001 and 2013. Multivariate logistic regression models and Cox proportional hazards survival methods for overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS) were used for analyses.

RESULTS

71 women had lymphadenectomy and were compared with the 213 who did not. Recurrence was similar in both groups (42% vs 33%, respectively, p = 0.17) but more deaths were reported in the group without lymphadenectomy (38% vs 23%, respectively, p < 0.001). There was no difference in adjuvant treatment in the two groups (17% vs 27%, respectively, p = 0.27). Elderly patients without lymphadenectomy had lower 3-year DFS (56% vs 71%, p = 0.076), CSS (67% vs 85%, p < 0.001) and OS (50% vs 71% p < 0.001). The Cox proportional hazard models showed independently poorer prognosis in women without lymphadenectomy (3.027, 95% CI 1.58-5.81, p < 0.001), histology type 2 (3.46, 95% CI 1.51-7.97, p = 0.003) and lymphovascular space involvement (3.47, 95% CI 1.35-8.98, p = 0.01) on 3-year CSS.

CONCLUSION

No lymphadenectomy in elderly patients with high-risk or advanced EC is independently associated with poorer prognosis. Elderly patients with EC should benefit from lymphadenectomy when indicated.

[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]

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).

Efficacy and safety of niraparib as maintenance treatment in older patients (≥ 70 years) with recurrent ovarian cancer: Results from the ENGOT-OV16/NOVA trial

OBJECTIVE

To analyze the safety and efficacy of niraparib in patients aged ≥70 years with recurrent ovarian cancer in the ENGOT-OV16/NOVA trial.

METHODS

The trial enrolled 2 independent cohorts with histologically diagnosed recurrent ovarian, fallopian tube, or peritoneal cancer who responded to platinum rechallenge, on the basis of germline breast cancer susceptibility gene mutation (gBRCAmut) status. Patients were randomized 2:1 to receive niraparib (300 mg) or placebo once daily until disease progression. The primary endpoint was progression-free survival (PFS) by blinded independent central review. Adverse events (AEs) of special interest were based on the known safety profile of poly(ADP-ribose) polymerase inhibitors.

RESULTS

Patients aged ≥70 years in the gBRCAmut cohort receiving niraparib (n = 14) had not yet reached a median PFS compared with a median PFS of 3.7 months for the same age group in the placebo arm (hazard ratio [HR], 0.09 [95% confidence interval (CI), 0.01 to 0.73]). Non-gBRCAmut patients aged ≥70 years receiving niraparib (n = 47) had a median PFS of 11.3 months compared with 3.8 months in the placebo arm (HR, 0.35 [95% CI, 0.18 to 0.71]). Median duration of follow-up in the niraparib arm was 17.3 months in patients ≥70 years and 17.2 months in patients <70 years. Frequency, severity of AEs, and dose reductions in the niraparib arm were similar in patients aged <70 and ≥ 70 years population. The most common grade ≥ 3 AEs in patients ≥70 years were hematologic: thrombocytopenia event (34.4%), anemia event (13.1%), and neutropenia event (16.4%).

CONCLUSIONS

For patients ≥70 years of age receiving niraparib as maintenance treatment in the ENGOT-OV16/NOVA trial, PFS benefits and incidence of any grade or serious treatment-emergent AEs were comparable to results in the younger population. Use of niraparib should be considered in this population.

Chemotherapy in older adult gynecologic oncology patients: Can a phenotypic frailty score predict tolerance?

OBJECTIVE

Evaluate the ability of an office-administered phenotypic frailty assessment to predict chemotherapy tolerance in older adult gynecologic oncology patients, and describe practice patterns for chemotherapy administration in this population.

METHODS

Prospective, single-institution cohort study of gynecologic oncology patients 65 or older initiating chemotherapy. Phenotypic frailty testing at an office visit encompassed components of two validated frailty assessments: Fried Score (physical testing and patient response) and FRAIL Scale (patient response only). Patients were followed through three cycles of neoadjuvant chemotherapy or six cycles of adjuvant chemotherapy. Standard statistics examined the relationship of frailty to chemotherapy regimen, ability to complete chemotherapy, and complications.

RESULTS

Eighty patients were included, 65% with ovarian and 34% with endometrial cancer. On average 57% of patients were fit, 32% intermediately frail, and 11% frail. 68% received adjuvant chemotherapy versus 32% neoadjuvant. The majority (81%) received IV chemotherapy on a 21-day cycle and 81% initially received a regimen consistent with standard-of-care chemotherapy (SOCC). Age was not associated with receiving SOCC, or tolerance or completion of chemotherapy. Frailty was associated with non-initiation of SOCC in all patients and inability to complete SOCC in adjuvant patients. Complications and regimen alterations were common but were not associated with frailty.

CONCLUSIONS

There is a need to develop tools to help physicians predict chemotherapy tolerance among older adult gynecologic oncology patients in order to prevent both under- and over-treatment while minimizing morbidity. However, in this study phenotypic frailty assessment had limited predictive utility. Among adjuvant chemotherapy patients, frailty was associated with inability to complete SOCC and thus may be helpful in selecting patients appropriate for less aggressive chemotherapy regimens.

Treatment and outcome of elderly patients with advanced stage ovarian cancer: A nationwide analysis

OBJECTIVE

To provide an overview of treatment strategies for elderly patients with advanced stage epithelial ovarian cancer (EOC) in daily practice, evaluate changes over time and relate this to surgical mortality and survival.

METHODS

All women diagnosed with advanced stage (FIGO IIB and higher) EOC between 2002 and 2013 were selected from the Netherlands Cancer Registry (n=10,440) and stratified by age, stage and period of diagnosis. Elderly patients were defined as aged ≥70years. Time trends in treatment patterns and postoperative mortality were described by age category and tested using multivariable logistic regression. Relative survival was calculated.

RESULTS

With advancing age, less patients received ((neo-)adjuvant) treatment. Over time, elderly patients were less often treated (OR 2002-2004 versus 2011-2013: 0.73; 95%CI:0.58-0.92). But if treated, more often standard treatment was provided and 30-day postoperative mortality decreased from 4.5% to 1.9% between 2005 and 2007 and 2011-2013. In all age categories treatment shifted from primary surgery towards primary chemotherapy, in patients aged 70-79years combination therapy increased (+5%) between 2002 and 2004 and 2011-2013. Five-year relative survival for patients diagnosed in 2008-2010 aged <70years was 34% compared to 18% for elderly patients.

CONCLUSION

Large treatment differences exist between younger and elderly patients. Over time, selection of elderly patients eligible for curative surgical treatment may have improved. More elderly patients were treated with neoadjuvant chemotherapy while less patients underwent surgery and simultaneously postoperative mortality decreased. However, the large and increasing number of elderly patients without treatment and the large survival gap suggests opportunities for further improvements in the care for elderly EOC patients.

Prognostic value of preoperative lymphocyte-monocyte ratio in elderly patients with advanced epithelial ovarian cancer

Objective

To investigate the prognostic significance of preoperative lymphocyte-monocyte ratio (LMR) in elderly patients with advanced epithelial ovarian cancer (EOC) receiving primary cytoreductive surgery and adjuvant platinum-based chemotherapy.

Methods

A total of 42 elderly patients (≥65 years) diagnosed with EOC who are receiving primary cytoreductive surgery and adjuvant platinum-based chemotherapy from 2009 to 2012 was included. LMR was calculated from complete blood cell count sampled before operation. Receiver operating characteristic (ROC) curves were used to calculate optimal cut-off values for LMR. Prognostic significance with respect to overall survival (OS) and progression-free survival (PFS) were determined using log-rank test and Cox regression analysis.

Results

The optimized LMR cut-off value determined by ROC curve analysis was 3.63 for PFS and OS. The high LMR group (LMR ≥3.63) was found to be significantly more associated with optimal debulking (P=0.045) and platinum response (P=0.018) than the low LMR group. In addition, Kaplan-Meier analysis revealed the LMR-high group was significantly more associated with high PFS and OS rates (P=0.023 and P=0.033, respectively), and univariate analysis revealed that a high LMR, histology type, and optimal debulking and platinum responses were significantly associated with prolonged PFS and OS. However, subsequent Cox multivariate analysis showed only optimal debulking and platinum response were independent prognostic factors of PFS or OS.

Conclusion

This study suggests that LMR might be associated with treatment and survival outcomes in elderly patients with EOC receiving standard oncology treatment.

Patterns of care and the survival of elderly patients with high-risk endometrial cancer: A case-control study from the FRANCOGYN group

BACKGROUND

The standard of care of endometrial cancer involves complex procedures such as pelvic and para-aortic lymphadenectomy and omentectomy, particularly for high-risk endometrial cancer. Few data are available about these complex surgical procedures and adjuvant therapy in elderly women. We aim to examine treatment and survival of elderly women diagnosed with high-risk endometrial cancer.

STUDY DESIGN

We performed a case-control study of women diagnosed between 2001 and 2013 with high-risk endometrial cancers. Women older than 70 years (n = 198) were compared with patients <70 years (n = 198) after matching on high-risk for recurrence and LVSI status.

RESULTS

Elderly patients had lymphadenectomies less frequently compared with younger patients (76% vs 96%, p < 0.001) and no adjuvant treatment more frequently (17% vs 8%, p = 0.005) due to less chemotherapy being administered (23% vs 46%, p < 0.001). The 3-year DFS, CSS and OS of patients ≥70 years was 52% (43-61), 81% (74-88) and 61% (53-70), respectively. These were significantly lower than the 3-year DFS, CSS, and OS of younger patients, which was 75% (68-82) (p < 0.001), 92% (87-96) (p < 0.008) and 75% (69-82) (p = 0.018), respectively. Cox proportional hazard models found that elderly women had 57% increased risk of recurrence (hazard ratio 1.57, 95% CI 1.04-2.39) compared with younger patients.

CONCLUSION

Although we found an independently significant lower DFS in elderly patients with high-risk endometrial cancer when compared with young patients, elderly women are less likely to be treated with lymphadenectomy and chemotherapy. Specific guidelines for management of elderly patients with high-risk endometrial cancer are required to improve their prognosis.

Age is associated with prognosis in serous ovarian carcinoma

Purpose

The survival duration of elderly patients with epithelial ovarian carcinoma is shorter than that of their younger counterparts. This variation in survival duration is likely attributed to differences in the distribution of histological type or grade, International Federation of Gynecology and Obstetrics (FIGO) staging, and undertreatment, but this observation remains controversial. This study aimed to investigate the biological factors other than selection bias associated with the decreased survival of elderly patients with ovarian carcinoma.

Methods

A total of 314 serous ovarian cancer (SOC) patients from Jiangsu Institute of Cancer Research (JICR, PRC) between 2002 and 2012 were retrospectively analyzed, and 774 cases from MD Anderson Cancer Center (MDACC, USA) between 1992 and 2012 were used for validation. The 8-hydroxy-2′-deoxyguanine (8-OHdG) concentration in leukocyte DNA was evaluated by using commercially available enzyme-linked immunosorbent assay kits, and tissue expression was assayed through immunohistochemistry. The associations between survival durations and covariates were assessed by using a Cox proportional hazards model and by conducting a log-rank test.

Results

Advanced age ≥ 65 years was correlated with high histological grade (p = 0.02), performance status (p = 0.03), primary treatment (p = 0.00), and suboptimal surgery outcome (p = 0.04) in SOC patients from JICR. Age, FIGO stage, histological grade, and optimal surgery were independently associated with the progression-free survival (PFS; p = 0.03, p = 0.03, p = 0.02, and p = 0.04, respectively) and overall survival (OS; p = 0.02, p = 0.04, p = 0.02, and p = 0.02, respectively) of the SOC patients from JICR. The 8-OHdG concentration in the leukocyte DNA was higher in the elderly patients than in the younger cases. The high 8-OHdG concentration in the leukocyte DNA indicated poorer median OS (30.0 months, confidence interval [CI]: 23.5–36.5 vs. 42.8 months, [CI] 38.3–47.2) and PFS (14.6 months, [CI] 11.9–17.2 vs. 18.9 months, [CI] 14.4–23.4) than those of their corresponding counterparts in the SOC patients who achieved a clinical complete response from primary treatment.

Conclusions

Compared with younger cases, elderly patients with SOC were commonly characterized by high tumor grade, poor performance status, and undertreatment. High 8-OHdG concentration in leukocyte DNA was associated with advanced age and poor prognosis in SOC patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13048-017-0331-6) contains supplementary material, which is available to authorized users.

Evaluation of the efficacy and toxicity profile associated with intraperitoneal chemotherapy use in older women

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.

Chemotherapy completion in elderly women with ovarian, primary peritoneal or fallopian tube cancer - An NRG oncology/Gynecologic Oncology Group study

PURPOSE

A simple measure to predict chemotherapy tolerance in elderly patients would be useful. We prospectively tested the association of baseline Instrumental Activities of Daily Living (IADL) score with ability to complete 4 cycles of first line chemotherapy without dose reductions or >7days delay in elderly ovarian cancer patients.

PATIENTS AND METHODS

Patients' age ≥70 along with their physicians chose between two regimens: CP (Carboplatin AUC 5, Paclitaxel 135mg/m2) or C (Carboplatin AUC 5), both given every 3weeks either after primary surgery or as neoadjuvant chemotherapy (NACT) with IADL and quality of life assessments performed at baseline, pre-cycle 3, and post-cycle 4.

RESULTS

Two-hundred-twelve women were enrolled, 152 selecting CP and 60 selecting C. Those who selected CP had higher baseline IADL scores (p<0.001). After adjusting for age and PS, baseline IADL was independently associated with the choice of regimen (p=0.035). The baseline IADL score was not found to be associated with completion of 4 cycles of chemotherapy without dose reduction or delays (p=0.21), but was associated with completion of 4 cycles of chemotherapy regardless of dose reduction and delay (p=0.008) and toxicity, with the odds ratio (OR) of grade 3+ toxicity decreasing 17% (OR: 0.83; 95%CI: 0.72-0.96; p=0.013) for each additional activity in which the patient was independent. After adjustment for chemotherapy regimen, IADL was also associated with overall survival (p=0.019) for patients receiving CP.

CONCLUSION

Patients with a higher baseline IADL score (more independent) were more likely to complete 4 cycles of chemotherapy and less likely to experience grade 3 or higher toxicity.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review

BACKGROUND

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery.

AIMS

We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions.

PATIENTS AND METHODS

A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc.

RESULTS

Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%.

DISCUSSION

Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients.

CONCLUSIONS

In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

Skilled nursing facility placement in hospitalized elderly patients with colon cancer

BACKGROUND

The current study sought to determine predictive risk factors and inpatient resource utilization associated with discharge to skilled nursing facility (SNF) in hospitalized elderly patients with colon cancer.

MATERIALS AND METHODS

Inpatient data from U.S. community hospital discharges from 2003 to 2011 was analyzed in a retrospective cohort study using the Healthcare Cost and Utilization Project, National Inpatient Sample (HCUP-NIS). Subjects included hospitalized postoperative colon cancer patients over age of 65 (N = 98,797).

RESULTS

The proportion of elderly colon cancer patients discharged to a SNF increased by 16.67% from 2003 to 2011 (18-21%). Elderly patients discharged to a SNF had increased hospitalization costs (+$10,293.70, p < 0.01) compared to elderly colon cancer patients discharged home. Hospitalization predictive risk factors associated with SNF placement include age above 75 (OR, 4.07; 95% CI, 3.90, 4.25; p < 0.01), paralysis (OR, 3.60; 95% CI, 3.06-4.23; p < 0.01), length of stay (LOS) 10 days or more (OR, 3.00; 95% CI, 2.88-3.13; p < 0.01), psychoses (OR, 2.91; 95% CI, 2.56-3.32; p < 0.01), and neurological disorders (OR, 2.34; 95% CI, 2.17-2.52; p < 0.01).

CONCLUSIONS

Despite increased costs and worse clinical outcomes associated with SNF placement, over 40% increase of hospital discharge to SNF should be anticipated from this population over the next 20 years. Neurologic and psychiatric comorbidities have significantly negative clinical impacts and increase the likelihood of colon cancer patients' discharge to a SNF.

Tolerance of weekly metronomic paclitaxel and carboplatin as neoadjuvant chemotherapy in advanced ovarian cancer patients who are unlikely to tolerate 3 weekly paclitaxel and carboplatin

OBJECTIVE

There are little data regarding safety and effectiveness of neoadjuvant chemotherapy (NACT) in patients who are considered unfit for receiving 3 weekly paclitaxel and carboplatin. The aim of this study was to examine the toxicity and response rates of weekly paclitaxel and carboplatin as NACT in such cohort of patients.

METHODS

Study population included advanced ovarian cancer patients who were unlikely to tolerate 3 weekly paclitaxel and carboplatin and hence received weekly paclitaxel (80 mg/m(2)) and carboplatin AUC-2 as NACT. The data regarding the baseline characteristics, chemotherapy tolerance, completion rates, toxicity (Common Terminology Criteria for Adverse Events version 4.02), and radiological response rates are presented. SPSS version 16 was used for analysis. Descriptive statistics is presented.

RESULTS

Eleven patients received this schedule. Nine patients completed nine cycles of NACT. Except one, all patients completed NACT with an average relative dose intensity of >0.8. There was no chemotherapy-related mortality. Grade 3-4 life-threatening complications were seen in two patients. The post NACT response rate was 100%.

CONCLUSIONS

Weekly paclitaxel and carboplatin chemotherapy is safe and efficacious in patients who are unsuitable for 3 weekly paclitaxel and carboplatin chemotherapy schedules.

The Application and Outcome of Standard of Care Treatment in Elderly Women with Ovarian Cancer: A Literature Review over the Last 10 Years

The rising number and increasing longevity of the elderly population calls for improvements and potentially a more personalized approach to the treatment of cancer in this group. Elderly patients frequently present with a number of comorbidities, complicating surgery and chemotherapy tolerability. In the case of ovarian cancer, elderly women present with more advanced disease, making the issue of providing adequate treatment without significant morbidity critical. Most studies support the application of standard of care treatment to elderly women with ovarian cancer, yet it seems to be offered less frequently in the elderly. The objective of this review is to examine the application and outcome of standard of care treatment in elderly women with ovarian cancer. The aim is to ultimately improve the approach to treatment in this group.

Management for Elderly Women With Advanced-Stage, High-Grade Endometrial Cancer

OBJECTIVE

To examine the treatment and survival of elderly women diagnosed with advanced-stage, high-grade endometrial cancer.

METHODS

We performed a retrospective cohort study of women diagnosed between 2003 and 2011 with advanced-stage, high-grade endometrial cancers (grade 3 adenocarcinoma, carcinosarcoma, clear-cell carcinoma, and uterine serous carcinoma) using the National Cancer Database. Women were stratified by age: younger than 55, 55-64, 65-74, 75-84, and 85 years old or older. Multivariate logistic regression models and Cox proportional hazards survival methods for all-cause mortality were used for analyses.

RESULTS

Twenty thousand four hundred sixty-eight patients were included, 14.9% younger than 55 years, 30.9% 55-64 years, 31.1% 65-74 years, 18.8% 75-84 years, and 4.3% 85 years old or older. Patients younger than 55 years had surgery more frequently compared with patients 75-84 years (97.2% compared with 95.8%; P<.001) and 85 years or older (97.2% compared with 94.8%; P<.001) and a higher rate of lymph node dissection (78.7% compared with 70.5%; P<.001 and 78.7% compared with 59.5%; P<.001, respectively). Women younger than 55 years old were more likely to receive chemotherapy compared with those 75-84 years (63.9% compared with 42.2%; P<.001) and 85 years old or older (63.9% compared with 22%; P<.001). After adjusting for prognostic factors, women ages 75-84 and 85 years or older were less likely to have received chemotherapy compared with women younger than 55 years (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.29-0.38 and OR 0.12, 95% CI 0.10-0.14). The same was true with surgery (OR 0.63, 95% CI 0.45-0.88 and OR 0.46, 95% CI 0.30-0.70) and radiotherapy (OR 0.61, 95% CI 0.53-0.70 and OR 0.45, 95% CI 0.37-0.56). The Cox regression model showed that in women with stage III disease, women 75-84 years had a twofold higher risk of death (hazard ratio [HR] 2.38, 95% CI 2.14-2.65) and those 85 years or older had a threefold higher risk (HR 3.16, 95% CI 2.76-3.61) compared with patients younger than 55 years. Patients with stage IV and age 75-84 years had a 24% increased risk of death (HR 1.24, 95% CI 1.11-1.40) and those 85 years or older had a 52% increased risk (HR 1.52, 95% CI 1.29-1.79).

CONCLUSION

Elderly women with high-grade endometrial cancer are less likely to be treated with surgery, chemotherapy, or radiation.

LEVEL OF EVIDENCE

II.

Benefits of Minimal Access Surgery in Elderly Patients with Pelvic Cancer

An increasing proportion of patients requiring treatment for malignancy are elderly, which has created new challenges for oncologic surgeons. Aging is associated with an increasing prevalence of frailty and comorbidities that may affect the outcome of surgical procedures. By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. In addition to age, surgeons should take into account factors, such as frailty and comorbidities that correlate with outcome.

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.

Impact of robotics on the outcome of elderly patients with endometrial cancer

OBJECTIVE

To evaluate the impact of introducing a robotics program on clinical outcome of elderly patients with endometrial cancer.

METHODS

Evaluation and comparison of peri-operative morbidity and disease-free interval in 163 consecutive elderly patients (≥70years) with endometrial cancer undergoing staging procedure with traditional open surgery compared to robotic surgery.

RESULTS

All consecutive patients ≥70years of age with endometrial cancer who underwent robotic surgery (n=113) were compared with all consecutive patients ≥70years of age (n=50) before the introduction of a robotic program in December 2007. Baseline patient characteristics were similar in both eras. Patients undergoing robotic surgery had longer mean operating times (244 compared with 217minutes, p=0.009) but fewer minor adverse events (17% compared with 60%, p<0.001). The robotics cohort had less estimated mean blood loss (75 vs 334mL, p<0.0001) and shorter mean hospital stay (3 vs 6days, p<0.0001). There was no difference in disease-free survival (p=0.61) during the mean follow-up time of 2years.

CONCLUSION

Transitioning from open surgery to a robotics program for the treatment of endometrial cancer in the elderly has significant benefits, including lower minor complication rate, less operative blood loss and shorter hospitalization without compromising 2-year disease-free survival.

Delivering High-Quality Cancer Care: The Critical Role of Quality Measurement

In 1999, the Institute of Medicine (IOM) published Ensuring Quality Cancer Care, an influential report that described an ideal cancer care system and issued ten recommendations to address pervasive gaps in the understanding and delivery of quality cancer care. Despite generating much fervor, the report's recommendations-including two recommendations related to quality measurement-remain largely unfulfilled. Amidst continuing concerns regarding increasing costs and questionable quality of care, the IOM charged a new committee with revisiting the 1999 report and with reassessing national cancer care, with a focus on the aging US population. The committee identified high-quality patient-clinician relationships and interactions as central drivers of quality and attributed existing quality gaps, in part, to the nation's inability to measure and improve cancer care delivery in a systematic way. In 2013, the committee published its findings in Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, which included two recommendations that emphasize coordinated, patient-centered quality measurement and information technology enhancements: Develop a national quality reporting program for cancer care as part of a learning health care system; and,Develop an ethically sound learning health care information technology system for cancer that enables real-time analysis of data from cancer patients in a variety of care settings. These recommendations underscore the need for independent national oversight, public-private collaboration, and substantial funding to create robust, patient-centered quality measurement and learning enterprises to improve the quality, accessibility, and affordability of cancer care in America.

Chemotherapy in elderly patients with gynecological cancer

OBJECTIVE

The aim of this study was to determine the tolerability, safety and feasibility of chemotherapy in very elderly patients with gynecological cancers.

METHODS

We included all patients ≥ 75 years of age affected by endometrial, ovarian or cervical cancer treated with neoadjuvant, adjuvant or palliative chemotherapy. Data regarding age, stage of the disease, comorbidities, performance status (PS), chemotherapy regimen and dosing, toxicity, treatment delay and dose adjustments were recorded.

RESULTS

Forty-nine patients were included in the study. Their median age was 77.5 years. The vast majority of patients (89.8%) presented with advanced neoplastic disease. Twenty-nine of the 49 patients were treated with full-dose chemotherapy; 41% were subjected to the weekly dose. One toxic death was recorded; grade 2 anemia was reported in 8 patients, and grade 2 and 3 neutropenia was recorded in 2 and 3 patients, respectively. Sixty-one percent of the patients completed the planned treatment.

CONCLUSION

Chemotherapy in very elderly patients is feasible with an acceptable toxicity profile. Careful evaluation of PS and assessment of physical and psychological health are necessary to predict tolerability of chemotherapy. A weekly schedule is better tolerated in this setting.

Risk-scoring model for prediction of non-home discharge in epithelial ovarian cancer patients

BACKGROUND

Identification of preoperative factors predictive of non-home discharge after surgery for epithelial ovarian cancer (EOC) may aid counseling and optimize discharge planning. We aimed to determine the association between preoperative risk factors and non-home discharge.

STUDY DESIGN

Patients who underwent primary surgery for EOC at Mayo Clinic between January 2, 2003 and December 29, 2008 were included. Demographic, preoperative, and intraoperative factors were retrospectively abstracted. Logistic regression models were fit to identify preoperative factors associated with non-home discharge. Multivariable models were developed using stepwise and backward variable selection. A risk-scoring system was developed for use in preoperative counseling.

RESULTS

Within our cohort of 587 EOC patients, 12.8% were not discharged home (61 went to a skilled nursing facility, 1 to a rehabilitation facility, 1 to hospice, and there were 12 in-hospital deaths). Median length of stay was 7 days (interquartile range [IQR] 5, 10 days) for patients dismissed home compared with 11 days (IQR 7, 17 days) for those with non-home dismissals (p < 0.001). In multivariable analyses, patients with advanced age (odds ratio [OR] 3.75 95% CI [2.57, 5.48], p < 0.001), worse Eastern Cooperative Oncology Group (ECOG) performance status (OR 0.92 [95% CI 0.43, 1.97] for ECOG performance status 1 vs 0 and OR 5.40 (95% CI 2.42, 12.03) for score of 2+ vs 0; p < 0.001), greater American Society of Anesthesiologists (ASA) score (OR 2.03 [95% CI 1.02, 4.04] for score ≥3 vs < 3, p = 0.04), and higher CA-125 (OR 1.28 [95% CI 1.12, 1.46], p < 0.001) were less likely to be discharged home. The unbiased estimate of the c-index was excellent at 0.88, and the model had excellent calibration.

CONCLUSIONS

Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

Does neoadjuvant chemotherapy decrease the risk of hospital readmission following debulking surgery?

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.

Elderly and very elderly advanced ovarian cancer patients: does the age influence the surgical management?

BACKGROUND

To examine the surgical treatment and clinical outcome of elderly and very elderly advanced epithelial ovarian cancer patients.

METHODS

We retrospectively analyzed FIGO stage IIIC-IV ovarian cancer patients, divided in elderly (Group A, >65 and <75 years) and very elderly patients (Group B, ≥ 75 years) treated by primary debulking surgery (PDS) or by interval debulking surgery (IDS) at the Catholic University at Rome and Campobasso, Italy.

RESULTS

164 patients were included: 123 (Group A) and 41 (Group B). Complete cytoreduction was achieved in 60 patients (60.6%) in Group A and in 20 patients (62.5%) in Group B (p = 0.75). In the remaining cases, optimal cytoreduction was performed (39 cases (39.4%) in Group A and 12 (37.5%) in Group B; p = 0.75). In Group A complete/optimal debulking was achieved in 53 patients (53.5%) at PDS and in 46 patients (46.5%) at IDS (p = 0.55). In the Group B a higher rate of patients was debulked at IDS with respect to PDS (10 (31.3%) vs. 22 patients (68.7%); p = 0.02). In Group A patients debulked at PDS showed better DFS (p = 0.007) and OS (p = 0.003) with respect to patients submitted to successful IDS, whereas in group B we did not observed any survival difference according to time of cytoreduction.

CONCLUSIONS

Our data suggest that elderly and very elderly patients may tolerate radical and ultra-radical surgery. These patients should be managed in a gynecologic oncology unit, with prudent but complete approach.

Doublet chemotherapy in the elderly patient with ovarian cancer

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

The implications of age and comorbidity on survival following epithelial ovarian cancer: summary and results from a Centers for Disease Control and Prevention study

BACKGROUND

Advances in treatment have improved ovarian cancer survival for most women, although less for the elderly. We report on this disparity and add further evidence about the relationship among age, comorbidity, and survival after ovarian cancer.

METHODS

To examine age and comorbidity, Centers for Disease Control and Prevention (CDC)-funded cancer registries examined 2367 women residing in New York and Northern California diagnosed with epithelial ovarian cancer (1998-2000). Subjects were identified through tumor registries, treatment data were supplemented with physician survey, and comorbidity was identified through hospital discharge database linkages. Proportional hazards modeling was used to estimate the risk of death by age and comorbidity, adjusting for clinical and sociodemographic factors.

RESULTS

Crude survival at 1 year and 3 years was 71.9% and 50.1%, respectively. Within stage, age-specific survival rates were lower in the oldest groups, particularly for those with advanced disease. For age 75+, 3-year survival was 13% vs. 50% in those <35 (stage IV). For all stages, women without comorbidity had higher survival rates than those with comorbidity. Older age and comorbidity were both associated with advanced stage and less aggressive treatment. The adjusted risk of death was 40%, and it was 80% higher for the 65-74 and 75+ groups, respectively, compared to women 35-64 (p<0.00). Comorbidity increased the risk of death by 40% (p<0.00).

CONCLUSIONS

This study confirmed the independent adverse effects of age and comorbidity on survival following ovarian cancer. As the population ages, the co-occurrence of ovarian cancer and comorbidity will increase. Further work identifying critical conditions that impact survival could potentially inform complex treatment decisions.

Neoadjuvant chemotherapy (NACT) is an effective way of managing elderly women with advanced stage ovarian cancer (FIGO Stage IIIC and IV)

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.

Trabectedin plus pegylated liposomal doxorubicin in the treatment of patients with partially platinum-sensitive ovarian cancer: current evidence and future perspectives

The effectiveness of platinum re-treatment in relapsed ovarian cancer depends on relapse-free/treatment-free intervals. Platinum agents can be effectively readministered to platinum-sensitive patients (relapsing >12 months after platinum), but efficacy is lower in partially platinum-sensitive (PPS) disease (relapsing 6-12 months after platinum). There is no clear standard treatment challenging PPS patients. Survival data in this subset with chemotherapy combinations such as pegylated liposomal doxorubicin (PLD) plus carboplatin or gemcitabine plus PLD are available from phase II trials ranging from 16 to 21 months. Recent results from OVA-301 phase III randomized trial evaluating trabectedin plus PLD showed the longest median overall survival ever reported in PPS patients (23 months). Subsequent chemotherapy (including platinum-based regimens) was administered later and survival in patients receiving third-line platinum was longer in patients treated with trabectedin plus PLD compared with those treated with PLD alone. These results suggest that prolonging platinum-free interval (PFI) with an effective non-platinum regimen improves outcome with subsequent third-line platinum treatment. An ongoing phase III trial (INOVATYON) aims to demonstrate if the results observed with trabectedin plus PLD in PPS patients are due to PFI extension, and if PFI extension with non-platinum combination prolongs response to subsequent platinum and survival in this population.