Incidences of ovarian cancer are on the rise due to increased life expectancy. The paradox of ovarian cancer is that, while it is a disease that impacts older women, statistics show that the older a woman is the less likely she may be considered for full treatment to eradicate the disease.
This article will review some of the recent literature and interviews with two oncologists to provide some insight into why older women are sometimes treated differently than younger women suffering from the disease.
A study in BMC Cancer stated that elderly women with ovarian cancer were three times less likely to have chemotherapy and surgery compared to their younger counterparts (2015;15:937). Researchers cited the reasons for the discrepancy in care can be related to more advanced disease or to functional impairment in the elderly, which may be incompatible with the implementation of the recommended treatment.
The consensus of the study was acknowledging that under-treatment of elderly patients is the first step in the broader process of improving therapeutic management of these patients. Geriatric assessment can help determine which patients are too frail to undergo standard treatment and is essential for the initiation of treatment, particularly burdensome therapy.
Another analysis of outcome data explained that elderly patients are often excluded from participation in randomized clinical trials, even if the disease of interest primarily occurs in the elderly (Gynecol Oncol 2018;149(2):270-274). This is because elderly patients have a low performance score and more comorbidity, which poses challenges to study design and recruitment. This anomaly results in evidence-based guidelines based on outcomes from younger patients, while evidence for optimal treatment for frail and elderly patients is scarce.
In response to some of the literature and studies on the subject, Lauren Cobb, MD, Assistant Professor of the Department of Gynecologic Oncology and Reproductive Medicine at the University of Texas MD Anderson Cancer Center, Houston, said, “The overall message is that clinicians often use age alone as a predictor of how well a patient will tolerate chemotherapy and perhaps give inadequate dosing to the elderly for fear of toxicity. Instead of focusing on age, we should focus on functional status. Functional status can vary greatly by age and is much more predictive of overall prognosis and ability to tolerate chemotherapy than age alone.”
Diagnosis & Treatment
Currently there is no screening test for ovarian cancer other than the CA 25 test. Women with a hereditary risk are encouraged to see their gynecologist every 6 months for an ultrasound.
“Definitive diagnosis is made surgically, however, there are times when a patient is not a candidate for an extensive surgery due to medical comorbidities, or because their disease is unresectable or is present outside of the abdominal cavity. In these situations, a diagnosis can be made in a less-invasive way via an image-guided biopsy,” said Cobb.
Ovarian cancer typically affects women who are 60 years and older. Jayanthi Lea, MD, Associate Professor of Obstetrics & Gynecology for UT Southwestern Medical Center, Dallas, noted that most of the treatment regimens are geared toward the average morbidity risk of a 60-70 year-old woman.
“It's really the octogenarian 80 years and above where we become concerned. In my experience, [a woman that age] can't tolerate extensive debulking and the standard chemotherapy we administer to patients is between the ages of 60 and 70,” Lea noted.
“When I look at my patients that are 75 years of age and older, to me 75 is a number. What you are looking for is what is their level of frailty? How sick are they? What is their functional and nutritional status? If I have a 75-year-old who has a high degree of functionality, who is well with a good nutritional profile, then I'm going to offer what I would offer to a younger patient,” she continued. “Depending on her cancer status and how extensive the disease is, if I thought she would benefit from surgery, then I would offer it. If I didn't think she would benefit, then I would offer her chemotherapy first, then surgery.”
Cobb agreed: “Age alone is not a reason for denial of care. Older women can still have good outcomes. Our ability to treat older women with surgery and chemotherapy depends more on their medical comorbidities, functional status, and ability to tolerate treatment.”
Some patients over 75 can tolerate surgery upfront followed by chemotherapy. Other patients reach out to their physician after the second dose of chemotherapy saying they can't tolerate it and they are done with treatment. “I talk to my patients who have lower functionality about being treated by using carboplatin and CarboTaxol together, but at a lower dose,” explained Lea.
According to Cobb, the treatment of ovarian cancer for women of all ages is personalized and treatment recommendations depend on the extent of disease (whether the disease is surgically resectable at the time of diagnosis), the patient's overall health, and clinical status. If the disease is not felt to be surgically resectable or if the patient is not healthy enough to undergo an extensive surgery, then neoadjuvant chemotherapy is a good option.
Lea said that 80 percent of her patients have widely spread metastatic disease and in some cases an extensive debulking surgery would be highly morbid for them. She looks at each case individually to determine if she can do a brief, minimally invasive surgery followed by chemotherapy, or if she has to do chemo first followed by surgery. Each case is different based on the extent of the disease, the health condition of the patient, and their tolerance of chemotherapy treatment.
Bridget Barry Thias is a contributing writer.