Gynecologic Malignancies in Older Women
Gynecologic Malignancies in Older Women
The aging population poses new challenges to all fields of medicine and to gynecologic oncology in particular. In gynecologic oncology, issues that are germane to general medicine, cancer chemotherapy, radical surgery, and routine gynecology are all encountered on a regular basis. In clinical practice, the "very old" are often thought to tolerate standard treatments poorly. While comorbid conditions may be more prevalent, management decisions should be based on an assessment of individual function and not solely on numerical age. In the article by Mirhashemi and colleagues, this theme is conveyed throughout, as they describe the current management of gynecologic malignancies in older women.
Screening for Cervical Cancer
The authors begin with an accurate summary of the aging population in the United States and other developed countries, and they discuss the screening mechanisms currently available for the early detection of gynecologic malignancies. They appropriately emphasize the fact that cervical cancer is not only a disease of young, sexually active women and that continued routine screening of older patients is warranted. In these patients, cervical screening is actually more difficult due to decreased levels of circulating estrogens, which may lead to vaginal atrophy and cervical stenosis.
Testing for the human papillomavirus (HPV) is becoming widely available and may identify early lesions at increased risk for progression to severe dysplasia. However, the usefulness of HPV screening for early detection of invasive carcinoma has yet to be demonstrated. To date, there are no data to suggest that HPV testing will either decrease the incidence of invasive cervical carcinoma or alter the natural course of dysplasia. Results from large-scale studies currently in progress may elucidate the proper role of HPV testing. The elderly may benefit from HPV testing in the presence of mild dysplasia. The triage of the abnormal Papanicolaou (Pap) smear may be improved, and the number of required invasive procedures may be minimized.
Screening for Other Gynecologic Malignancies
In sharp contrast to cervical cancer, there are few practical screening tests for ovarian or endometrial cancers. Although measurement of CA-125 levels by transvaginal sonography is often undertaken, there are no clinical trials to show that this is an efficacious method for detecting early-stage ovarian cancer. Ovarian cancer screening should be limited to clinical trials from which pooled data will lead to meaningful analyses and abnormal results can be appropriately interpreted. There is also no recommended or efficacious screening test for endometrial cancer, even for patients receiving tamoxifen (Nolvadex) therapy. Given the lack of such a test, any postmenopausal bleeding should be thoroughly evaluated with an adequate office biopsy or diagnostic hysteroscopy.
One area that requires further discussion involves the changes in mental status that occur in the elderly. Among patients over 70 years of age, 10% have clinically identifiable memory loss. Dementia is an independent risk factor for poor surgical outcome in hip fracture patients and may also contribute to poor outcomes in cancer surgery. A mental status evaluation should be part of the routine assessment of older patients with a gynecologic malignancy.
Management of Cervical and Advanced Ovarian Cancer
The authors correctly state that advances in anesthesia and postoperative care now make it possible to safely perform radical surgery in the elderly. The standard management of advanced ovarian cancer is described; however, neoadjuvant chemotherapy administered prior to debulking surgery for select patients is not discussed.
Trials are currently in progress to study the use of neoadjuvant chemotherapy in advanced ovarian cancer, and those with multiple comorbid conditions may achieve significant benefit. Additionally, consolidation with intraperitoneal therapy has been associated with long-term survival when given to patients with no clinical evidence of disease after primary treatment. Trials are also in progress to better define the role of intraperitoneal therapy in the management of ovarian cancer.
New data suggest that whole pelvic irradiation given as adjuvant therapy for endometrial cancer can be avoided in patients with stage I tumors who have undergone complete negative lymphadenectomy. This can diminish the risk of bowel and bladder complications and should be a consideration in older patients.
Cervical cancer has been treated effectively with surgery or radiation therapy for many decades, as mentioned in the article. Recent reports now suggest that a combined approach with chemotherapy and radiation therapy for stage IB2 and greater lesions will result in improved outcomes. This should be a primary consideration in the treatment of old and young patients alike.
Elderly Patients in Clinical Trials
As in all fields of oncology, treatment regimens for gynecologic malignancies should stem from the results of randomized clinical trials. Unfortunately, the elderly are underrepresented in these studies, as has been recently described. Almost one-half of ovarian cancer patients are 65 years of age or older, yet only 30% of patients in ovarian cancer clinical trials are in this age group (P < .001). Overall, 63% of cancer patients are age 65 or older, yet they comprise only 25% of participants in cancer-treatment trials.
The ability of older patients to tolerate experimental therapies is more likely to be related to underlying medical conditions than to age-related physiologic changes. No age limitation exists for entry into National Cancer Institute-sponsored clinical trials, and the participation of older patients should be encouraged, unless medically contraindicated. Advanced age is an independent prognostic factor for endometrial and ovarian cancer, but also a surrogate for advanced stage at diagnosis and high-risk histologic subtype.[5-7] Because age is both a poor prognostic factor and associated with unfavorable tumors, older patients should be treated aggressively.
This review by Mirhashemi et al calls attention to the often overlooked issue of gynecologic malignancies in the elderly. The authors provide a brief but complete overview of the changing demographics in the United States and how these trends will affect medical care in the coming decades. They have attempted to summarize a large body of literature in just a few pages.
It is important to emphasize that the treatment of older women with gynecologic malignancies should follow community standards and should only be modified as necessary for comorbid illnesses, not because of the numerical age of the patient. We applaud the authors’ efforts in drawing attention to the important issues surrounding the treatment of gynecologic malignancies in the elderly.
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2. Anderson JM, Stea B, Hallum AV, et al: High-dose rate postoperative vaginal cuff irradiation alone for stage IB and IC endometrial cancer. Int J Radiat Oncol Biol Phys 46:417-425, 2000.
3. National Cancer Institute: Concurrent chemoradiation for cervical cancer. Clinical Announcement, February 1999.
4. Hutchins LF, Unger JM, Crowley JJ, et al: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061-2067, 1999.
5. Cirisano FD, Robboy SJ, Dodge RK, et al: The outcome of stage I-II clinically and surgically staged papillary serous and clear cell endometrial cancers when compared with endometrioid carcinoma. Gynecol Oncol 77:55-65, 2000.
6. Behbakht K, Yordan EL, Casey C, et al: Prognostic indicators of survival in advanced endometrial cancer. Gynecol Oncol 55:363-367, 1994.
7. Markman M, Lewis JL, Saigo P, et al: Impact of age on survival of patients with ovarian cancer. Gynecol Oncol 49:236-239, 1993.