Date Published: October 1, 2017
Publisher: JKL International LLC
Author(s): Lucia Tortorella, Giuseppe Vizzielli, Domenico Fusco, William C. Cho, Roberto Bernabei, Giovanni Scambia, Giuseppe Colloca.
Ovarian cancer is the most common cause of death from gynecological cancers in developed countries. It is a common disease of older women at or above 63 years upon diagnosis. Thanks to advance in new treatments, mortality from ovarian cancer has declined in developed countries in the last decade. This decline in mortality rate is unevenly distributed across the age-spectrum. While mortality in younger women has decreased 21.7%, for elderly women it has declined only 2.2%. Even if ovarian cancer is clearly a disease of the elderly, older women are underrepresented in clinical trials, and scant evidence exists for the treatment of women older than 80 years. Moreover, older women are frequently undertreated, receive less chemotherapy and less combination of surgery and chemotherapy, despite the fact that this is considered the optimal treatment modality. This may be mainly due to the lack of evidence and physician’s confidence in the management of elderly women with ovarian cancer. In this review, we focus on the management of older women with ovarian cancer, considering geriatric features tied to this population.
Older women with cancer present with some medical and physiological conditions that deserve special attention in planning treatment for ovarian cancer. Multimorbidity, disability and polypharmacotherapy have been shown to predict adverse outcomes in cancer patients. In particular comorbidity was associated with mortality and surgical complications in older women with ovarian cancer (7,8).
Elderly patients often do not receive standard chemotherapic treatments compared to younger patients because of the presence of multimorbidity, poor physical or cognitive performance and the risk of mortality. Common chemotherapy toxicities in the oldest old are grade 3-4 hematologic and gastroenterologic toxicities and grade 3-4 neutropenia.
It has been demonstrated the survival improvement in patients affected by peritoneal malignancies (pseudomyxoma peritonei, colon cancer, peritoneal mesothelioma) treated with HIPEC and cytoreductive surgery. In advanced ovarian carcinoma, there are not prospective, randomized studies but the results of the use of HIPEC after cytoreduction in primary or recurrent ovarian cancer appears to be encouraging.
The introduction of immunotherapy causes a paradigm shift in the treatment of a number of cancers. Presence of tumor infiltration lymphocytes and PDL1 expression have been reported to affect prognosis in ovarian cancer (50-52)
The number of elderly people diagnosed with cancer and living with cancer will grow over the coming decades due to longer life expectancy and increased survival, further highlighting the importance of research in the elderly in order to provide a culturally competent and rational management. Further research needs to be done to identify elderly patients who could benefit from active treatment, whereas treatment decisions based mainly on chronologic age should be avoided. The construction of an oncogeriatric team could improve the selection of high-risk patients ensuring tailored treatment.