Commentary (Balducci): Ovarian Cancer in Elderly Women

OncologyONCOLOGY Vol 17 No 8
Volume 17
Issue 8

With the population aging,cancer in older persons isbecoming an increasinglycommon problem.[1] The benefit ofantineoplastic treatment may be diminishedand the risk enhanced byaging, due to a progressive reductionin life expectancy and in the functionalreserve of multiple organ systems.[2] To establish the most suitablecourse of action in individual cases,the practitioner needs to be able toaddress the following questions: Is thecancer going to compromise the survivalor the quality of life of the patient?Is the patient able to tolerate thepotential risk of cancer treatment?

With the population aging, cancer in older persons is becoming an increasingly common problem.[1] The benefit of antineoplastic treatment may be diminished and the risk enhanced by aging, due to a progressive reduction in life expectancy and in the functional reserve of multiple organ systems.[ 2] To establish the most suitable course of action in individual cases, the practitioner needs to be able to address the following questions: Is the cancer going to compromise the survival or the quality of life of the patient? Is the patient able to tolerate the potential risk of cancer treatment? These questions are particularly compelling when treatment may effect a cure or a substantial prolongation of survival. Lambrou and Bristow review the management of ovarian cancer-a disease that is responsive to multiple forms of chemotherapy and to aggressive surgical debulking.

Physiologic vs Chronologic Age

The authors essentially examine the patterns of care in younger vs older women and the risk of treatment complications. Based on a number of recent reviews, they report that:

• Older women and especially women over age 80 are less likely to receive adequate surgical management[ 3,4] or multimodality treatment for ovarian cancer.[5]

• According to an extensive Italian review of chemotherapy for ovarian cancer in individuals over age 70, the risk of grade 3/4 myelotoxicity was high (40%), but only a small percentage of patients (6.5%) required discontinuation of treatment.[6]

• Women over age 70 are underrepresented in clinical trials of ovarian cancer treatment.[5]

Clearly, these data suggest that older individuals may be denied the full extent of modern treatment for ovarian cancer, because age is widely thought to be associated with a poorer outcome and an unacceptable rate of treatment-related complications. Thus, it is difficult to argue with the authors' conclusion that age itself should not be a barrier to appropriate treatment or to inclusion into clinical trials, and that treatment plans should be based on the physiologic rather than chronologic age of the patient. These well-founded recommendations need to be complemented by two additional considerations.

Biologic Interaction

First, the authors conclude that the poorer prognosis of older ovarian cancer patients is due to inadequate treatment or late diagnosis. Although inadequate treatment certainly may contribute to a poorer prognosis, one should not dismiss the possibility that age by itself, through poorly defined mechanisms, may contribute to a more aggressive or less responsive disease. In fact, a recent review of the Gynecologic Oncology Group experience suggests that this may be the case,[7] and this finding is hardly new. In a number of malignancies, including acute myelogenous leukemia, non- Hodgkin's lymphoma, and breast cancer, the patient's age appears to be an independent prognostic factor.[8]

This possibility has both theoretical and practical implications. The biology of the tumor may be influenced by two factors: the intrinsic biology of the tumor cell and the ability of the tumor host to support neoplastic growth. The identification of age-related factors that may alter the tumor biology may signify the discovery of new therapeutic targets. For example, the poorer prognosis of acute myelogenous leukemia patients aged 60 and older appears to be related to the increased prevalence of multidrug resistance, which may be pharmacologically modulated.

Practical Assessment

Second, the authors fall short of recommending a practical approach to the assessment of older persons. The comprehensive geriatric assessment described in their Table 2 is time-consuming and impractical for use in the whole geriatric population. Furthermore, it is not clear how this assessment may lead to an estimate of life expectancy and treatment tolerance.

Numerous screening instruments are available to help the physician decide which older individuals need a full geriatric assessment. These include simple questionnaires, such as the one recommended by the National Comprehensive Cancer Network guidelines,[9] the Vulnerable Elders Survey (VES-13), and evaluations of physical function such as the Get Up and Go test.[8]

Functional status, assessed as the ability to perform activities of daily living and instrumental activities of daily living, is an independent prognostic factor for the risk of chemotherapy- induced myelotoxicity.[8] A simple estimate of life expectancy may be obtained with the comprehensive geriatric assessment.[10] Some laboratory tests, including serum concentrations of interleukin-6 and D-dimer, may predict the risk of functional dependence and mortality.[11]


Lambrou and Bristow make an important contribution to the study of ovarian cancer in older women by highlighting the fact that these women may be undertreated and unnecessarily excluded from clinical trials. Their review would be complemented by a more thorough discussion of the biologic interaction of cancer and age and a practical approach to the assessment of older patients.

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



Yancik RM, Ries L: Cancer and age:Magnitude of the problem, in Balducci L, LymanGH, Ershler WB (eds): ComprehensiveGeriatric Oncology, 2nd ed. London, HarwoodAcademic Publishers. In press.


Balducci L, Beghe C: The applicationsof the principles of geriatrics to the managementof the older person with cancer. Crit RevOncol Hematol 35:147-154, 2000.


Ries LA: Ovarian cancer. Survival andtreatment differences by age. Cancer 71(2 suppl):525-529, 1993.


Hightower RD, Nguyen HN, AveretteHE, et al: National survey of ovarian carcinoma.IV: Patterns of care and related survivalfor older patients. Cancer 73:377-383, 1994.


Markman M, Lewis JL, Saigo P, et al:Epithelial ovarian cancer in the elderly. TheMemorial Sloan-Kettering Cancer Center experience.Cancer 71(suppl 2):634-637, 1993.


Ceccaroni M, D’agostino G, FerrandinaG, et al: Gynecological malignancies in elderlypatients: Is age 70 a limit to standard-dosechemotherapy. An Italian retrospective toxicitymulticenter study. Gynecol Oncol 85:445-450, 2002.


Thigpen JT: Gynecologic cancer, in BalducciL, Lyman GH, Ershler WB: ComprehensiveGeriatric Oncology, pp 721-732.Amsterdam, Harwood Academic Publishers,1998.


Repetto L, Balducci L: A case for geriatriconcology. Lancet Oncol 3:289-297, 2002.


Balducci L, Yates J: General guidelinesfor the management of older patients with cancer.Oncology 14:221-227, 2000.


Walter LC, Brand RJ, Counsell SR, etal: Development and validation of a prognosticindex for 1-year mortality in older adultsafter hospitalization. JAMA 285:2987-2994,2001.


Cohen HJ, Harris T, Pieper CF: Coagulationand activation of the inflammatory pathwayin the development of functional declineand mortality in the elderly. Am J Med 114:180-189, 2003.

Related Videos
Interim data reveal favorable responses in patients with low-grade serous ovarian cancer treated with avutometinib plus defactinib, according to Susana N. Banerjee, MD.
Treatment with mirvetuximab soravtansine appears to produce a 3-fold improvement in objective response rate vs chemotherapy among patients with folate receptor-α–expressing, platinum-resistant ovarian cancer in the phase 3 MIRASOL trial.
PRGN-3005 autologous UltraCAR-T cells appear well-tolerated and decreases tumor burden in a population of patients with advanced platinum-resistant ovarian cancer.
An expert from Dana-Farber Cancer Institute discusses findings from the final overall survival analysis of the phase 3 ENGOT-OV16/NOVA trial.
Related Content