Commentary (Bryan/Berek): Ovarian Cancer in Elderly Women

As the population ages over the next 50 years, the number of cancer patients is expected to double from the current 1.3 million to 2.6 million, and the majority of those patients will be at least 75 years old.[1] Projected increases in life expectancy account for this change. For women living in industrialized countries, it is estimated that the average life span in future decades will reach 90 years.[2] Most cancers increase in incidence and mortality as a population ages, although the causal link between oncogenesis and senescence remains complex and elusive. Within the context of an upsurge in cancer incidence, an analysis of the inequitable treatment of older patients afflicted with cancer takes on an urgent need.

Presentation Patterns

Reviewing data from the Surveillance, Epidemiology, and End Results Program for 1973 to 1987, 55% of deaths related to ovarian cancer occurred in women aged 65 years and older.[3] The peak incidence of ovarian cancer was between age 70 and 74, with the apogee of mortality at age 80 to 84. In light of these data, Lambrou and Bristow compellingly delineate the pervasiveness of suboptimal treatment provided to older women with ovarian cancer and the need to institute the current therapeutic standard of care, which has been proven to extend life. As is well recognized, ovarian cancer is best treated with primary surgical cytoreduction followed by platinum- and taxanebased chemotherapy.

The histopathologic prevalence of ovarian tumor types alters according to age. Young women (age 30 to 40) tend to have tumors of low malignant potential, whereas older women have more invasive forms of ovarian cancer, such as papillary serous carcinoma.[ 4] Prior studies also reveal that older patients usually present with more advanced disease (stage III to IV) than younger patients.

Although they are at the greatest risk, over 40% of women age 85 or older never receive treatment for their cancer. If treated, older women generally undergo surgery alone or receive a single chemotherapeutic agent.[5,6] Underlying the lack of aggressive treatment in this age group is a complex mixture of psychosocial issues encompassing physician and patient attitudes regarding cancer and advanced age, an unfamiliarity with managing comorbid disease concomitantly with surgery/chemotherapy (ie, caring for the "frail" patient), and perceptions of quality of life.[2]

The Age Factor

Although it is tempting to believe that "age at time of diagnosis" is an independent prognostic factor in ovarian carcinoma, prior studies of this subject are too simplistic.[7,8] Comorbid conditions and social barriers to treatment are inadequately accounted for within their analysis, while proven means for evaluating elder "frailty" (ie, the comprehensive geriatric assessment) are never utilized.

Unfortunately, the majority of studies examining age in relation to clinical care and outcome for ovarian cancer crudely separate the elderly from the young patient cohorts based on the conventional demarcation of "65 years or older." Patients within this"elder" group are quite heterogeneous with respect to performance status and disease comorbidities. Age should never serve as a substitute for the appropriate application of performance status.

Geriatric research has dealt with these differences by referring to women who are 65 to 74 years of age as "the young-old," those between 75 to 84 years as the "older-old," and women aged 85 or more as the "oldestold."[ 6] Combining these groups for purposes of clinical analysis prevents a sophisticated assessment of outcome and prognostic indicators.

Treatment Tolerance

Lambrou and Bristow present good evidence that older patients can tolerate surgery and chemotherapy, as long as they are individually assessed for their medical, psychological, and functional capabilities before therapeutic intervention is initiated. However, the majority of studies published on geriatric ovarian cancer are retrospective reviews that suffer from selection bias. Older women who have undergone surgery or chemotherapy have done so because they had a good performance status.[9-11]

Although the best treatment regimen remains undefined for older women with poor performance status, it is possible that different approaches with lower toxicity will be developed to permit equally efficacious results compared to the current standard. Unfortunately, clinical trials, an irreplaceable resource for identifying cutting-edge interventions, continue to be underrepresented by patients 65 years or older. Since 1998, only 25% to 28% of this population was enrolled in phase I to III National Cancer Institute (NCI)-sponsored trials.[1]

In 1991, the National Institute on Aging, the NCI, and the American Cancer Society cosponsored a multidisciplinary conference, "Perspectives on Ovarian Cancer in Older-Aged Women," and findings were presented in 1993.[12] Much of what Lambrou and Bristow have overviewed about the need for improved oncologic care in elderly women with ovarian cancer was known at that time. Despite this awareness, Cress et al recently published a Northern California population-based study indicating that women 75 years of age and older were significantly less likely than younger women to be given chemotherapy, receive care by oncology specialists, or undergo adequate primary cytoreductive surgery.[13]

Conclusions

Overall, we have fallen short in the implementation of adequate health care for geriatric ovarian cancer patients. Future analyses must attempt to explain why elderly women continue to receive suboptimal management despite clinical evidence refuting an age-based treatment model. Any analysis of this topic must maintain the awareness that the objectivity of clinical facts too often masks a more powerful subjective reality-in this case, the flourishing ageism of our culture.[14] The myth of chronologic age as a sole determinant of function maintains a strong hold in both patients and physicians despite evidence to the contrary. Ageism serves as the barrier between what is known to be clinically true, and what is actually practiced.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

Disclosures:

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

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Bryan D, Bryan V: Women Warriors: AHistory of Courage in the Battle Against Cancer,p 104. Bloomington, Indiana, First BooksLibrary, 2002.