Ovarian cancer in the elderly - the role of surgery and systemic treatment (#22)
The incidence of ovarian cancer increases with age. The average age of women at the first diagnosis of ovarian cancer in Australia is 64 years. The mortality rate from the disease also rises with age. Whereas 61% of ovarian cancers are diagnosed in women aged 60 years and over, 77% of deaths occur in this age group1.
It has been demonstrated that older women present with a more advanced stage at diagnosis, are more likely to receive less aggressive surgery and standard chemotherapy. Undertreatment is just one of the possible reasons that older women have poorer outcomes. Others include the presence of more aggressive disease and the increased likelihood of significant comorbidities.
The population of women in clinical trials of treatment for ovarian cancer is significantly younger than the general population of women with this disease. It is thus difficult to generalize and apply the results gained from these trials to older women who would have been excluded from trial participation. Whilst some trials have been performed specifically in older women, most information is gained from subset analysis of older patients in large phase III trials. In the largest of these reviews (GOG 0182; 620 patients aged >70 years in a total of 3066), age over 70 years was associated with lower completion rates of prescribed chemotherapy, increased toxicity and decreased survival.
The current standard of care for women with late stage epithelial ovarian cancer is cytoreductive surgery followed by 6 cycles of combination carboplatin and paclitaxel chemotherapy. In select cases intraperitoneal chemotherapy and dose dense carboplatin and paclitaxel may be appropriate.
There is no evidence to suggest that older women should not receive combination chemotherapy; 3 weekly carboplatin and paclitaxel is reasonably well tolerated even in older patients.
Neoadjuvant chemotherapy followed by interval cytoreduction has been shown to result in reduced toxicity, reduced surgical complications and equivalent overall survival. This approach may be particularly pertinent to the older patient population and result in improved surgical outcomes.
Treatment of older women with significant comorbidities often requires a different approach. Some form of geriatric assessment is important to improve overall care of this patient population. Modified first-line treatment regimens including single agent carboplatin and low dose, weekly chemotherapy may be beneficial if 3 weekly combination therapy is considered likely to cause unacceptable toxicity. The evidence for this approach will be outlined in the presentation.
There is limited evidence for the use of newer therapies such as angiogenesis inhibitors in the elderly patient population and there is some evidence that older women may suffer increased toxicity with these agents. Further clinical research is required to study the safety and efficacy of drugs such as bevacizumab in this patient group.1
Comprehensive geriatric assessment and guided intervention is useful in older women with ovarian cancer at many timepoints in their cancer journey. Adequate assessment in the preoperative, chemotherapy and even post therapy periods can lead to the institution of appropriate therapies and supportive care measures. A multidisciplinary yet individualised approach is vital to ensure appropriate therapy.
- Australian Institute of Health and Welfare & Cancer Australia 2012. Gynaecological cancers in Australia: an overview. Cancer series no. 70. Cat. no. CAN 66. Canberra: AIHW.