Management of elderly women with endometrial cancer

Nomograph of cancer-specific survival in elderly patients with endometrial cancer based on SEER database

OBJECTIVE

This study aims to identify prognostic factors for elderly patients with endometrial cancer and to develop a nomogram for predicting cancer-specific survival in this population.

METHODS

Clinicopathological data of elderly patients diagnosed with endometrial cancer between 2004 and 2015 were extracted from the SEER database. Patients were randomly assigned to either a training cohort or a validation cohort at a ratio of 7:3. Univariate and multivariable Cox regression analyses were performed to identify independent prognostic factors. A nomogram was then constructed based on these factors, and its predictive accuracy and discriminative ability were assessed using the C-index, receiver operating characteristic (ROC), and calibration curve.

RESULTS

Multivariate analysis identified age, marital status, grade, Federation of International of Gynecology and Obstetrics, surgery, chemotherapy, radiation, and tumor size as independent prognostic factors for elderly patients with endometrial carcinoma. Nomograms derived from these factors demonstrated excellent calibration and discrimination. The C-indexes were 0.83 for the training set and 0.82 for the validation set. The area under the curve (AUC) values for the training set were 0.88, 0.87, and 0.86 at 1, 3, and 5 year respectively. Corresponding AUC values for the validation set were 0.89, 0.86, and 0.86. Calibration curves for both cohorts demonstrated close alignment with the diagonal, indicating robust agreement between nomogram predictions and actual outcomes.

CONCLUSION

A novel nomogram has been developed for personalized prognosis assessment in elderly patients with endometrial carcinoma, aiming to enhance tailored treatment strategies and clinical management.

Endometrial cancer in the elderly: Characteristics, prognostic and risk factors, and treatment options

Endometrial cancer incidence and related mortality are on the rise due to aging demographics. This population often presents with unfavorable features, such as myometrial invasion, non-endometrioid histology, high-grade tumors, worse prognosis, etc. The role of age as an independent prognostic factor is still debated, and screening tools addressing frailty emerge as pivotal in guiding treatment decisions; however, they are still underutilized. Treatment disparities are evident in the case of older patients with endometrial cancer, who frequently receive suboptimal care, hindering their survival. Radiotherapy and minimally invasive surgical approaches could be performed in older patients. Data on chemotherapy and immunotherapy are scarce, but their potential remains promising and data are being gathered by recent trials, contingent on optimal patient selection through geriatric assessments. Overall, we recommend personalized, screening tool-guided approaches, adherence to guideline-recommended treatments, and inclusion of older people in clinical trials to help identify the best course of treatment.

Multi-institutional study on the role of post-operative radiotherapy in elderly patients with endometrial cancer

OBJECTIVE

To investigate the prognostic factors for survival and toxicities in elderly (≥65 years) patients with endometrial cancer who underwent post-operative radiotherapy. Additionally, to compare the treatment outcomes between the older elderly (≥75 years) and younger elderly (65-74 years) patients.

METHODS

Medical records of patients with enometrial cancer treated between January 1998 and July 2019 were reviewed. Patients with stage IA to IIIC2, all histology subtypes, and any grade were included. All patients underwent total abdominal hysterectomy and received adjuvant radiotherapy with or without chemotherapy. All but 67 (8.4%) of 801 patients had lymph node dissection. Clinicopathological factors and treatment strategies were compared between the two age groups. The prognostic factors for overall survival and progression-free survival were investigated.

RESULTS

A total of 801 patients with enometrial cancer, 627 patients (78.3%) younger elderly and 174 patients (21.7%) in the older elderly group were included. Median follow-up was 74.3 months (range 0.4-224.6). The older elderly patients had significantly higher rates of grade 3 tumors (51.7% vs 40.8%; p=0.04), cervical glandular involvement (21.8% vs 14.0%; p=0.03), and cervical stromal invasion (34.5% vs 27.9%; p=0.04) than the younger elderly patients. The rates of lymph node dissection (p=0.2), radiotherapy modalities (p=0.92), and systemic chemotherapy (p=0.2) did not differ between the two groups. The 5-year locoregional control and distant metastasis rates were 88.3% and 23.8%, respectively. The 5-year cause-specific survival and progression-free survival rates for younger and older elderly patients, were 79.8% vs 74.3% (p=0.04) and 67.5% vs 57.8% (p<0.001), respectively. In multivariate analysis, larger tumor size, non-endometrioid histology, cervical stromal involvement, and stage III disease were associated with poor cause-specific survival and progression-free survival. Age was an independent predictor of worse progression-free survival, but not of cause-specific survival. There was no significant difference in acute and late gastrointestinal and genitourinary toxicities between age groups.

CONCLUSIONS

Post-operative radiotherapy for elderly patients with endometrial cancer is effective and well tolerated. Advanced age should not preclude appropriate treatment, especially in those with adequate quality of life, life expectancy, and functional status.

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.

Endometrial cancer of the very elderly: Management and survival in the Francogyn population

INTRODUCTION

We aimed to describe management and survival of patients with endometrial cancer (EC) ≥80 years to identify poor prognosis criteria.

METHODS

We collected clinical, histologic, surgical and follow-up data for patients with EC ≥ 80 years included in a multicenter French cohort (FRANCOGYN) who underwent primary surgical treatment from 1999 to 2019. The outcomes were overall survival (OS) and disease-free survival (DFS). We performed a descriptive analysis then a survival time analysis and comparison using the Kaplan Meier method and log-rank test.

RESULTS

Of the 1647 patients with EC who received treatment during the study period, 184 (11.17%) were ≥80 years. The mean age was 84 years (±3.34). Thirty-three patients (25.4%) died during the follow-up period and 26 relapsed (18.4%). Forty-nine patients were lost to follow-up (27.37%). The median follow-up time was 15.3 months (4.9-28.8). The median OS and DFS was 16.4 months (6.3-24.9) and 13.6 months (4.5-26.6), respectively. Eighty-three patients received adjuvant therapy (45.11%), out of 95 who had a formal or relative indication. Four patients received adjuvant chemotherapy (2.6%), out of 61 who had a formal or relative indication. Inappropriate or underuse of chemotherapy was significantly associated with a lower median OS of 12.6 months [3.73-24] versus 17.3 months [7.93-41.77] when performed appropriately (HR = 4.14, CI 95% [1.62-10.56]), and a lower median DFS of 10.83 months [3.73-24] versus 17.3 months [7.93-28.5] (HR = 9.04, CI 95% [2.04-40.12]).

CONCLUSION

Our results suggest that very elderly patients with EC should receive adjuvant chemotherapy according to the standard care guidelines.

Utilization Trend and Comparison of Different Radiotherapy Modes for Patients with Early-Stage High-Intermediate-Risk Endometrial Cancer: A Real-World, Multi-Institutional Study

This study aimed to compare the outcomes of RT modalities among patients who met different HIR criteria based on multicentric real-world data over 15 years. The enrolled patients, who were diagnosed with FIGO I-II EC from 13 medical institutes and treated with hysterectomy and RT, were reclassified into HIR groups according to the criteria of GOG-249, PORTEC-2, and ESTRO-ESMO-ESGO, respectively. The trends in RT modes utilization were reviewed using the Man-Kendall test. The rate of VBT alone increased from zero in 2005 to 50% in 2015, which showed a significant upward trend (p < 0.05), while the rate of EBRT + VBT utilization declined from 87.5% to around 25% from 2005 to 2015 (p > 0.05). There were no significant differences in OS, DFS, LRFS, and DMFS between VBT alone and EBRT ± VBT in three HIR cohorts. Subgroup analyses in the GOG-249 HIR cohort showed that EBRT ± VBT had higher 5-year DFS, DMFS, and LRFS than VBT alone for patients without lymph node dissection (p < 0.05). Thus, VBT could be regarded as a standard adjuvant radiation modality for HIR patients. EBRT should be administrated to selected HIR patients who meet the GOG-249 criteria and did not undergo lymph node dissection.

Surgical treatment in older patients with endometrial cancer: A retrospective study

INTRODUCTION

Older patients (OP) diagnosed with endometrial cancer (EC) are less likely to receive an optimal surgical treatment compared with non-older patients (NOP). This undertreatment along with the presence of more aggressive tumours at diagnosis can explain the worse prognosis of EC in OP. There is limited evidence comparing perioperative outcomes between OP and NOP, and the benefit of applying complex procedures to OP is still controversial. The primary objective of the study was to compare intraoperative and postoperative complications between NOP and OP with EC that underwent primary surgery. Secondary objectives were to compare surgical management and survival rates.

METHODS

This is a retrospective single-centre observational study including women undergoing surgery for EC between 2010 and 2019. Patients were classified according to age as NOP (younger than 75 years) or OP (75 years or older). Basal characteristics and surgical outcomes of groups were compared using Chi-square, Fisher's exact tests, student T-tests or Mann Whitney tests. Kaplan Meier analysis was used to evaluate survival.

RESULTS

In total 281 patients underwent primary surgery for EC between 2010 and 2019 in our centre. At diagnosis, 184 patients were younger than 75 years while 97 were 75 and older. No differences were found in disease characteristics. Most of our patients (83,3%) underwent laparoscopic surgery. Pelvic (58,2% vs. 37,1%, p = 0,001) and para-aortic (46,7% vs. 23,7%, p < 0,001) lymphadenectomies were performed more frequently in NOP compared with OP. Rates of intra-operative (6,5% vs. 12,4%, p = 0,116) and post-operative (13,0% vs. 20,6%, p = 0,120) complications were not statistically different between NOP and OP, and neither was the rate of severe complications according to Clavien-Dindo classification (5,4% vs. 8,2% of complications grade III-V respectively, p = 0,387). The 5-year disease-specific survival (DSS) rate tended to be lower in the OP than in the NOP (74,8% vs. 82,5%, p = 0,071). Considering only patients in whom complete surgical staging was performed, OP presented similar DSS to NOP, with comparable complication rate.

CONCLUSIONS

OP do not present a significantly higher rate of perioperative complications compared to NOP. However, they underwent fewer lymphadenectomies and tended to present poorer DSS. Further studies are needed to standardize the surgical management of these patients.

Surgical and oncological outcomes of sentinel lymph node sampling in elderly patients with intermediate to high-risk endometrial carcinoma

OBJECTIVE

We aimed to evaluate the surgical and oncological outcomes of elderly patients with intermediate to high-risk endometrial cancer undergoing staging with sentinel lymph node (SLN) sampling and pelvic lymphadenectomy.

METHODS

We conducted a retrospective study of elderly (>65-year-old) patients diagnosed with endometrial cancer between December 2007 and August 2017. These patients had been treated at a single center in Montreal, Canada. We compared the surgical and oncological outcomes of three cohorts undergoing surgical staging in non-overlapping eras: 1) lymphadenectomy, 2) lymphadenectomy and SLN sampling, 3) SLN sampling alone. Using life tables, Kaplan-Meier survival curves and log-rank tests, we analyzed 2-year progression-free survival, overall survival, and disease-specific survival.

RESULTS

Our study included 278 patients with a median age of 73 years (range; 65-91): 84 (30.2%) underwent lymphadenectomy, 120 (43.2%) underwent SLN sampling with lymphadenectomy, and 74 (26.6%) had SLN sampling alone. The SLN sampling alone group had shorter operative times with a median duration of 199 minutes (range, 75-393) compared with 231 (range, 125-403) and 229 (range, 151-440) minutes in the SLN sampling with lymphadenectomy and lymphadenectomy cohorts; respectively (p<0.001). The SLN sampling alone group also had lower estimated blood loss with a median loss of 20 mL (range, 5-150) vs 25 mL (range, 5-800) and 40 mL (range, 5-400) in the SLN sampling with lymphadenectomy and lymphadenectomy cohorts, respectively (p=0.002). The 2 year overall survival and progression-free survival were not significantly different between the three groups (p=0.45, p=0.51, respectively). On multivariable analysis after adjusting for age, American Society of Anesthesiologists (ASA) score, stage, grade, and lymphovascular space invasion, adding SLN sampling was associated with better overall survival, (HR 0.2, CI [0.1 to 0.6], p=0.006) and progression-free survival (HR 0.5, CI [0.1 to 1.0], p=0.05).

CONCLUSION

Sentinel lymph node-based surgical staging is feasible and associated with better surgical outcomes and comparable oncological outcomes in elderly patients with intermediate and high-risk endometrial cancer.

Management of Metastatic Endometrial Cancer: Physicians' Choices Beyond the First Line. A MITO Survey

Background

Endometrial cancer (EC) therapeutic and diagnostic approaches have been changed by the development of a new prognostic molecular classification, the introduction of dostarlimab in microsatellite instability (MSI) high pre-treated advanced EC patients with further expected innovation deriving from lenvatinib plus pembrolizumab regardless MSI status. How this is and will be translated and embedded in the clinical setting in Italy is not known; this is why we developed Multicentre Italian Trials in Ovarian cancer and gynaecologic malignancies (MITO) survey on the current practice and expected future changes in EC.

Methods

We designed a self-administered, multiple-choice online questionnaire available only for MITO members for one month, starting in April 2021.

Results

75.6% of the respondents were oncologists with a specific focus on gynaecologic malignancies and 73.3% of the respondents declared the availability of clinical trials in second line treatment for advanced EC. The therapeutic algorithm in second line was heterogeneous, being the most frequent choice administering anthracyclines followed by endocrine therapy or enrolling in clinical trials. While more than half of the clinicians declared that they performed the molecular classification, only six/45 respondents (13.3%) ran all the tests needed for it. On the other hand, 80% of them declared regular assessment of MSI status with IHC as recommended. The therapeutic approach in MSI high advanced EC patients has changed since dostarlimab approval. Indeed the most frequent choice in second line has been chemotherapy (53.3%) before its availability, while dostarlimab has been preferred in more than three-fourths of the cases (75.6%) after its approval. As for MSS patients, 77.8% of clinicians would choose lenvatinib plus pembrolizumab for them in second line once approved.

Conclusions

Despite the selected sample of respondents from Italian MITO centres showing good knowledge of diagnostic and therapeutic innovations in EC, these are not fully implemented in everyday clinics, except for MSI status assessment.

Oncologic outcomes in elderly patients who underwent hysterectomy for endometrial cancer: a multi-institutional survey in Kinki District, Japan

BACKGROUND

The goal of this study is to assess the oncologic outcomes of elderly patients who underwent hysterectomy for endometrial cancer across three variables: hysterectomy approach, lymph node resection, and adjuvant therapy.

METHODS

Hospital records of patients aged ≥ 70 years who underwent hysterectomy for endometrial cancer were obtained from 19 institutions. Patients were categorized into three risk groups: low, intermediate, and high. In each group, disease-free survival and overall survival were compared according to hysterectomy approach, lymph node resection, and adjuvant therapy using Kaplan-Meier method. Cox regression analysis with a 95% confidence interval was performed to estimate relative risk (RR) of death.

RESULTS

A total of 1246 patients were included. In the low-risk group, the adjusted RR for death for minimally invasive surgery (MIS) versus laparotomy and lymph node resection versus no lymph node resection were 0.64 (0.24-1.72) and 0.52 (0.24-1.12), respectively. In the intermediate-risk group, the adjusted RR for death for MIS versus laparotomy, lymph node resection versus no lymph node resection, and adjuvant therapy versus no adjuvant therapy were 0.80 (0.36-1.77), 0.60 (0.37-0.98), and 0.89 (0.55-1.46), respectively. In the high-risk group, the adjusted RRs for death for lymph node resection versus no lymph node resection and adjuvant therapy versus no adjuvant therapy were 0.56 (0.37-0.86) and 0.60 (0.38-0.96), respectively.

CONCLUSIONS

MIS is not inferior to laparotomy in uterine-confined diseases. Lymph node resection improved the outcome for all disease stages and histological types. In contrast, adjuvant therapy improved the outcomes only in high-risk patients.

Prognostic factors of endometrial cancer in elderly patient group and their effects on survival

OBJECTIVE:

The objective of the study was to investigate the prognostic factors of the elderly group and their effects on survival by examining the histopathological features, surgical treatment protocols, and treatment modalities of patients diagnosed with endometrial cancer (EC).

METHODS:

The records of 397 EC patients who completed their treatment and follow-up at a single center between 2012 and 2019 were evaluated retrospectively. The patients were evaluated in two groups as <70 years old (n: 301; 75.8%) and >70 years old (n: 96; 24.2%). Following the evaluation of histopathological features and treatment protocols, independent risk factors influencing survival were investigated with the Cox regression model.

RESULTS:

The incidence of non-endometrioid histology (16.3% vs. 32.3%, p: 0.001), high-grade tumors (50.5% vs. 69.8%; p: 0.001), and >50 myometrial invasion (19.6% vs. 36.5%, p: 0.003) in the >70 age group was more frequent than that in the <70 age group. The independent risk factors on overall survival in the >70 age group were determined as non-endometrioid histology (HR: 5.9; 95% CI: 1.4– 24.7) and lymph node metastasis (HR: 6.4; 95% CI:1.6–25.0). In the <70 age group, non-endometrioid histology (HR: 11.3; 95% CI: 4.0–32.0) was identified as the only independent risk factor affecting 5-year survival.

CONCLUSION:

EC, with non-endometrioid histology, which is observed at a higher rate in elderly patients despite equal surgery and adjuvant therapy, is the primary factor that affects survival.

Refusal of surgery and survival outcomes in endometrial cancer

OBJECTIVES

The goal of this study was to determine the impact refusal of surgery has on overall survival in patients with endometrial cancer.

METHODS

From January 2004 to December 2015, the National Cancer Database was queried for patients with pathologically proven endometrial cancer who were recommended surgery and refused. Inverse probability of treatment weighting was used to account for differences in baseline characteristics between patients who underwent surgery and those who refused. Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling were used to analyze overall survival.

RESULTS

Of the 300 675 patients identified, 534 patients (0.2%) were recommended surgical treatment but refused: 18% (95/534) were age ≤40 years. The 5-year overall survival for all patients who refused surgery was significantly decreased compared with patients who underwent surgery (29.2% vs 71.9%, P<0.01). This was demonstrated at ages 41-64 years (65.5% vs 91.0%, P<0.01) and ≥65 years (23.4% vs 75.3%, P<0.01). The 5-year overall survival did not meet statistical significance at age ≤40 years (90.1% vs 87.8% P<0.19). However, there were few patients in this cohort. On multivariate analysis, factors associated with refusal of surgery included: Medicaid insurance, Black race, Hispanic Race, Charlson Comorbidity Index scores of 2 or greater, stage II or III, and if patient received external beam radiation therapy alone. Factors associated with undergoing surgery included: age greater than 41, stage IB, and if the patient received brachytherapy.

CONCLUSIONS

Refusal of surgery for endometrial cancer is uncommon and leads to decreased overall survival.

Exclusive 3D-brachytherapy as a good option for stage-I inoperable endometrial cancer: a retrospective analysis in the gynaecological cancer GEC-ESTRO Working Group

PURPOSE

Analyse outcomes of stage-I inoperable endometrial cancer (EC) patients from seven European centres treated with 3D-image-guided brachytherapy (IGBT) alone.

MATERIALS AND METHODS

From 2004 to 2018, 62 patients (41 stage-IA and 21 IB) were retrospectively studied, analysing anaesthetic procedure, applicator type, BT-planning imaging, clinical target volume (CTV), BT schedule, overall daily-dose equivalent to 2 Gy (EQD2_{(α/β=4.5 or 3)}) to the CTV_(α/β=4.5) and D2 cm³_(α/β=3) for organs at risk. Complications were evaluated using CTCAEv4 scores. The 2 and 5 year survival was calculated [cancer-specific survival (CSS), disease-free survival (DFS), local relapse-free survival (LRFS), loco-regional relapse-free survival (LRRFS) and distant metastasis-free survival (DMFS)]. Descriptive analysis and the Kaplan-Meier method were used for survival analysis.

RESULTS

Mean follow-up: 32.8 months (SD 33.7). Spinal anaesthesia (38/62) followed by none (16/62) were the most common. Y-shaped Rotte applicators were used in 74% of patients. High-dose rate brachytherapy was administered in 89%. Median D90 to the CTV was 58.9 Gy (8.66-144 Gy). Eight patients presented relapse: four uterine, four nodal and four distant. The 2 and 5 year CSS was 93.3 and 80.5%, DFS 84.8 and 80.5%, LRFS was 93.1 and 88.7%, LRRFS was 91 and 91% and DMFS was 90.2 and 90.2%, respectively, CSS was better in stage-IA vs. IB (p = 0.043). Late vaginal and bladder G3-complication rates were 2.1%, respectively.

CONCLUSION

Inoperable EC patients can be safely treated by BT with 2 and 5 year CSS of 93 and 80.5%, respectively, with even better results for IA cases. Prospective studies on 3D-IGBT are necessary to better analyse EC patient outcomes based on dose and treated volumes.

Long-term quality of life and sexual function of elderly people with endometrial or ovarian cancer

Background

With the growing number of older endometrial cancer (EC) and ovarian cancer (OC) survivors, data on long-term health-related quality of life (HRQoL) became an important issue in the management of older patients. So, the aim of this study was to describe and compare according to age long-term HRQoL, sexual function, and social deprivation of adults with either EC or OC.

Methods

A cross-sectional study was set up using data from the Côte d’Or gynecological cancer registry. A series of questionnaires assessing HRQoL (SF-12), sexual function (FSFI), anxiety/depression (HADS), social support (SSQ6) and deprivation (EPICES) were offered to women with EC or OC diagnosed between 2006 and 2013. HRQoL, sexual function, anxiety/depression, social support and deprivation scores were generated and compared according to age (< 70 years and ≥ 70 years).

Results

A total of 145 women with EC (N = 103) and OC (N = 42) participated in this study. Fifty-six percent and 38% of EC and OC survivors respectively were aged 70 and over. Treatment did not differ according to age either in OC or EC. The deprivation level did not differ between older and younger survivors with OC while older survivors with EC were more precarious. The physical HRQoL was more altered in older EC survivors. This deterioration concerned only physical functioning (MD = 24, p = 0.012) for OC survivors while it concerned physical functioning (MD = 30, p < 0.0001), role physical (MD = 22, p = 0.001) and bodily pain (MD = 21, p = 0.001) for EC survivors. Global health (MD = 11, p = 0.011) and role emotional (MD = 12, p = 0.018) were also deteriorated in elderly EC survivors. Sexual function was deteriorated regardless of age and cancer location with a more pronounced deterioration in elderly EC survivors for desire (p = 0.005), arousal (p = 0.015) and orgasm (p = 0.007). Social support, anxiety and depression were not affected by age regardless of location.

Conclusion

An average 6 years after diagnosis, the impact of cancer on HRQoL is greatest in elderly survivors with either EC or OC.

Age is an independent predictor of outcome in endometrial cancer patients: An Israeli Gynecology Oncology Group cohort study

INTRODUCTION

Advanced age is considered an adverse factor in endometrial cancers but may be a surrogate for other conditions that impact outcomes. The study objective was to assess the association of age with endometrial cancer features, treatment and prognosis.

MATERIAL AND METHODS

In this multicenter cohort study, consecutive women with endometrial cancer treated at 10 Israeli institutions between 2000 and 2014 were accrued in an assimilated database. Postmenopausal women were stratified into age groups with a cut-off of 80. Clinical, pathological and treatment data were compared using t test or Mann-Whitney test for continuous variables, and Chi-square Test or Fisher's Exact test for categorical variables. Main outcome measures included disease recurrence and disease-specific and overall survival; these were plotted using the Kaplan-Meier method and compared using the log-rank test. The association between age and recurrence and survival, adjusted for other clinical and pathological factors, was assessed using multivariable Cox regression modeling.

RESULTS

A total of 1764 postmenopausal women with endometrial cancer were identified. Adverse pathological features were more prevalent in older women, including high-risk histologies (35% vs 27%, P = .025), deep myoinvasion (44% vs 29%, P = .001) and lymphovascular involvement (22% vs 15%, P = .024). Surgical staging was performed less frequently among older women (33% vs 56%; P < .001). Chemotherapy was less often prescribed, even for non-endometrioid histologies (72% vs 45%; P < .001). On multivariable analysis, age remained a significant predictor for recurrence (HR = 1.75, P = .007), death of disease (HR = 1.89, P = .003) and death (HR = 2.4, P < .001).

CONCLUSIONS

Older age in women with endometrial cancer is associated with more adverse disease features, limited surgery and adjuvant treatment, and worse outcomes. On multivariable analysis, age remains an independent prognosticator in this population.

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.

Systematic lymphadenectomy in early stage endometrial cancer

BACKGROUND

The positive effect of systematic lymphadenectomy on survival of patients with endometrial cancer is a topic of ongoing debate.

METHODS

We aimed to investigate whether systemic lymphadenectomy is beneficial for patients with early endometrial cancer. For this purpose, we analyzed a population-based registry with of 2392 women with endometrioid endometrial cancer, stage I and II at intermediate and high risk of recurrence. The primary outcome measure was overall survival.

RESULTS

After exclusions, 868 women were eligible for analysis. Of those, 511 and 357 were categorized as intermediate (pT1A G3 and pT1B G1-2) and high risk (pT1B G3 and pT2 G1-3) early stage endometrial cancer, respectively. Lymphadenectomy was performed in 527 (60.7%) of the cases. Patients in the lymphadenectomy group were significantly younger, presented with more tumors of intermediate or undifferentiated grade and exhibited significantly lower co-morbidity rates and Eastern Cooperative of Oncology Group (ECOG) performance status. Median follow-up was 6.7 years. Recurrence-free survival was not improved by lymphadenectomy in the intermediate and high-risk group of patients. During the follow-up period, 111 (12.8%) women had disease recurrence and 302 (34.8%) died. Systematic lymphadenectomy was associated with significant improvement of overall survival in the pT1A G3 and pT1B G3 patient subgroups. Notably, adjustment for patient age and ECOG status abolished the improvement of overall survival by systematic lymphadenectomy in all groups. Thus, lymphadenectomy did not improve recurrence-free survival in the intermediate risk or the high-risk group of patients CONCLUSIONS: Systematic pelvic and para-aortic lymphadenectomy did not improve the survival of patients with early stage I and II endometrioid endometrial cancer at intermediate and high risk of recurrence.

Baseline Serum HE4 But Not Tissue HE4 Expression Predicts Response to the Levonorgestrel-Releasing Intrauterine System in Atypical Hyperplasia and Early Stage Endometrial Cancer

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a conservative management option for atypical hyperplasia (AH) and low grade early stage endometrial cancer (EEC), but around 1 in 3 patients fail to respond to treatment. The aim of this study was to investigate if serum and/or tissue HE4 expression could predict response to LNG-IUS therapy. Patients with AH or presumed Stage I EEC had serum and endometrial samples taken at baseline and at 3-month intervals over 12 months post-insertion of LNG-IUS. 74 patients were recruited and baseline demographics recorded. Of 57 patients for whom response was histologically determinable, 39 (68%) were responders and 18 (32%) non-responders. Mean baseline serum HE4 was significantly lower in responders (62.1 ± 1.1 pM, 95% confidence interval (CI) 52.7–73.2), compared to non-responders (125.6 ± 1.3 pM, 95% CI 74.5–211.7, p = 0.014), including when considering age, BMI, menopausal status, smoking status, and histological grade as covariables (p = 0.005). Baseline tissue HE4 expression was not significantly different in responders compared to non-responders (p = 0.999). Responders showed a significant mean reduction (−9.8 ± 3.4%, 95% CI −16.7 to −2.8%, p = 0.008) in serum HE4 between baseline and 3 months (p = 0.008), whereas non-responders showed no significant change (p = 0.676). Neither responders nor non-responders showed a significant percentage change in serum HE4 from baseline beyond 3 months (p > 0.05). Change in serum HE4 between baseline and 3 and 6 months and tissue HE4 tissue expression between baseline and 3, 6, and 12 months was not significantly different in responders compared to non-responders (p > 0.05). This study suggests that baseline serum HE4, but not baseline tissue HE4 expression, is independently predictive of response to the LNG-IUS and could be used to guide management decisions.

Management of endometrial cancer in patients aged 80 years and older: Identifying patients who may benefit from a curative treatment

OBJECTIVE

The goal of this study was to evaluate the demographic characteristics, pathology, treatment, prognostic factors and survival rates in elderly patients with endometrial cancer, and to compare their results with those of younger ones, in order to define the specific characteristics of this malignancy in this population.

STUDY DESIGN

Retrospective analysis of all endometrial cancer patients managed at the University Hospital of the Canary Islands (Spain) between 1990 and 2016. Survival curves were calculated by using the Kaplan-Meier method and compared with the log-rank test. Logistic regression analysis was used to assess the independent effect of different variables on cancer-specific survival. Statistical significance was considered for p < 0.05.

RESULTS

The study included 1799 endometrial cancer patients; 170 of them (9.4%) were 80 years old or older. Elderly patients received less surgery (68.2% vs. 92.4%), lymphadenectomy (10.3% vs. 26.2%) and adjuvant treatment (37.1% vs. 51.2%) than younger ones, and presented higher probability of receiving palliative treatment (27.6% vs. 4%). Endometrioid tumors were more frequently diagnosed in younger patients (78.8% vs. 62.9%), while type 2-endometrial cancer was more frequently diagnosed in elderly ones (37.1% vs. 21.2%). Cancer-specific survival in older patients was significantly poorer than in younger ones, with a mean of 61.4 months (95%CI 51.7-71.1) versus 226 months (95%CI 218.9-233.1), respectively. In a multivariate analysis: age, FIGO stage, histology, tumor differentiation and adjuvant treatment were independently associated with survival.

CONCLUSION

Although endometrial cancer is more aggressive in older patients, they are less likely to receive optimal treatment, which negatively affects their survival. Specific guidelines for the management of this population, including a comprehensive geriatric assessment, should be developed to improve their prognosis.

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.

miR-495 promotes apoptosis and inhibits proliferation in endometrial cells via targeting PIK3R1

Endometrial cancer (EC) is a huge threat to women's health. The aims of this study were to investigate the role of microRNA (miR)-495 in the proliferation and apoptosis of EC cells in vitro. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was performed to detect the mRNA levels. In addition, dual-luciferase reporter assay was used to verified that PIK3R1 was a target of miR-495. After transfection with miR-495 mimics, Cell Counting Kit 8 (CCK-8) assay was performed to evaluate the cell viability of EC cells. The protein expression of PIK3R1, vascular endothelial growth factor (VEGF), Bcl-2, Bax, caspase 3 after transfection was analyzed using western blotting. Furthermore, cell apoptosis rate of EC cells was evaluated by flow cytometry. These results showed that miR-495 was significantly down-regulated in tumor tissues compared with the adjacent normal tissues, while PIK3R1 was up-regulated. The proliferation of the EC cells that were transfected with miR-495 mimics was markedly inhibited, and apoptosis was significantly promoted. In addition, downregulated expression of PIK3R1, Bcl-2, VEGF expression and upregulated expression of Bax and caspase 3 expression were observed after transfected with miR-495 mimic. Together these findings indicated that miR-495 acts as a tumor suppressor gene by directly targeting PIK3R1 at the post-transcriptional level in EC cells in vitro.

Endometrial cancer subtypes are associated with different patterns of recurrence

PURPOSE

To evaluate the pattern of endometrial cancer recurrence according to its biological subtype in a large cohort of patients.

PATIENTS AND METHODS

Patients were stage eligible if they had a description of registry risk of recurrence status and were not primary metastatic. Data were prospectively collected. The primary endpoints were the subtype-dependent pattern and time of recurrence.

RESULTS

The median follow-up time was 84 months. The highest 10-year recurrence-free and overall survival were seen in the group of patients at low risk of recurrence, 83.1 and 94.1%, respectively. The 10-year recurrence-free survival for intermediate and high risk group was 65.7 and 56.2%, respectively, whereas the estimated 10-year overall survival for both groups was 84.5 and 79.3%, respectively. Patients at high risk demonstrated the highest levels of disease recurrence in the first 3-4 years after diagnosis and the most common site of metastasis was the lung. In contrast, the rate of recurrence for patients at intermediate and low risk of recurrence in the first 5 years was relatively low but remained continuous up to 10 years of follow-up. Overall, the most common site of relapse was local recurrence.

CONCLUSION

Endometrial cancer subtypes are associated with different times and patterns of recurrence and this should be considered when determining the treatment strategy.

Ovarian metastasis in patients with endometrial cancer: risk factors and impact on survival

BACKGROUND

Oophorectomy is generally performed in patients with endometrial cancer despite the rate of ovarian metastasis being relatively low.

PATIENTS AND METHODS

A multicenter retrospective registry-based study was performed in 2329 patients with endometrial cancer. The outcome measures were the incidence of ovarian metastasis and the impact on overall survival.

RESULTS

Median follow-up was performed at 84 months. A total of 2158 women were eligible for analysis, of which 131 (6.1%) had ovarian metastasis. Women with ovarian metastasis were more likely to have > 50% myometrial invasion, undifferentiated nonendometrioid tumors, and lymph and vascular space invasion. The presence of < 50% myometrial invasion, endometrioid histology, well-differentiated cancer, and negative lymph and vascular space invasion were associated with a very low rate (0.5%) of ovarian metastasis. Notably, after matching for tumor histology and grade, myometrial invasion, and lymph and vascular space invasion, ovarian metastasis was not associated with a reduced median overall survival.

CONCLUSIONS

Ovarian preservation should be offered to premenopausal women with endometrial cancer in whom myometrial invasion is less than 50%, the histological type is endometrioid and well-differentiated, and lymph and vascular space invasion is not involved.

Management of elderly women with cervical cancer

BACKGROUND

Elderly women with cervical cancer receive less therapy in comparison with their younger counterparts. The exact reason(s) for this treatment strategy remains unclear.

PATIENTS AND METHODS

We performed a multicenter, retrospective registry-based study of 1559 patients with cervical cancer. The primary outcome was the reason for not performing the indicated treatment.

RESULTS

Median follow-up was 67.8 months. A total of 956 women were eligible for analysis: 693 (64.2%) were younger than 60 years and 387 (35.8%) were aged 61 years old and older. Elderly women were more likely to have undifferentiated cervical cancer at an advanced stage. For early stage (stage IA1-IIA), tumors patients 61 years old and older were less likely to receive surgery [odds ratio (OR) 0.39; 95% CI 0.20-0.77] and radiochemotherapy (OR 0.37; 95% CI 0.21-0.66) compared with the group of patients aged < 60 years. The rate of lymphadenectomy was similar in both age groups. Patients 61 years old and older with advanced stage (IIB-IV) cervical cancer were also less likely to receive surgery [odds ratio (OR) 0.42; 95% CI 0.27-0.66], lymphadenectomy (OR 0.30; 95% CI 0.12-0.51) and radiochemotherapy (OR 0.31; 95% CI 0.20-0.48) compared with patients aged < 60 years. Notably, the rate of indicated but not performed therapies proportionally increased with an increase in patient age and the most important reason for this phenomenon was the failing of recommendation.

CONCLUSIONS

Elderly women with cervical cancer are undertreated and this is more likely because the therapy was not recommended.

Age Is Not a Limiting Factor in Interventional Radiotherapy (Brachytherapy) for Patients with Localized Cancer

This review examines the role of interventional radiotherapy (IRT otherwise known as brachytherapy) in cancer treatment for elderly patients. Despite their advanced age and associated comorbidities, elderly patients should receive definitive cancer therapies, including surgery and radiotherapy (RT). In fact, RT becomes first-line option for patients who are not eligible for surgery (due to comorbidities, anticoagulant drugs, and risk of disfigurement) or those who refuse it. It emerged from this review of the literature as effective, simple, safe, and comfortable and was associated with good local control, low toxicity rates, and excellent cosmesis and provided a cost benefit. IRT may be used as sole treatment for small cancers or as a useful adjunct to surgery or external beam radiotherapy (EBRT) in more advanced (or lymph node positive) cases, especially when the aim is local control with adequate preservation of normal tissue function. As palliative treatment, IRT preserves quality of life and/or improves survival. It is to be hoped that this review will serve as a helpful guide for members of multidisciplinary teams that are involved in treating elderly patients with cancer.