Individualized Approach to Treatment for the Elderly Ovarian Cancer Patient

By Stuart Lichtman, MD and William Tew, MD
Wednesday, September 12, 2012

The population of older adults (those over 65) is growing rapidly, and will account for 20 percent of the population by 2030. Unfortunately, oncologists are ill prepared for this demographic shift, as older adults have been under-represented on cancer clinical trials that have set the standard of care.

Ovarian cancer has an age-related increase in incidence and a twofold increased risk of death in women older than 65 years of age.(1) There have been various theories proposed to account for this survival disparity including more-aggressive cancer with advanced age, inherent resistance to chemotherapy, individual patient factors such as multiple comorbidities, and physician and healthcare biases toward the elderly, which lead to inadequate surgery, less than optimal chemotherapy, and poor enrollment in clinical trials.

We retrospectively reviewed the outcome and toxicity differences seen in 620 patients (70 years of age and older) enrolled on Gynecologic Oncology Group (GOG) study 182, a large phase III trial studying triplet-chemotherapy regimens for patients with newly diagnosed ovarian cancer. We found that older patients had poorer performance status, lower completion rates of chemotherapy, and increased toxicities, particularly grade 3+ neutropenia and grade 2+ neuropathy. Older women had significantly shorter overall survival (37 vs. 45 months, P<0.001), consistent across all regimens and adjusted for major prognostic factors.(2)

A French study illustrated the potential for a geriatric assessment (GA) to predict chemotherapy toxicity and overall survival in elderly patients with advanced ovarian cancer.3 Three factors were independent predictors of significant toxicity: symptoms of depression at baseline, dependence, and Eastern Cooperative Oncology Group (ECOG) performance status < 2.(3)

A cancer-specific GA was developed through the Cancer and Aging Research Group. The GA included validated measures for functional status, comorbid medical conditions, cognition, psychological state, social functioning, social support, and nutrition (Table 1). This GA is quick and mostly self-administered. In a large 500-patient study, we developed a predictive model and risk factors for grade 3-5 chemotherapy toxicity that included: 1) age ≥ 73, 2) cancer type (gastrointestinal and urologic cancer), 3) standard chemotherapy dosing, 4) poly-chemotherapy regimens, 5) falls in past six months, 6) assistance with instrumental activities of daily living (IADL), and 7) decreased social activity.(4)

We are currently conducting a prospective trial to determine the benefits of this GA for women older than 65 years with newly diagnosed advanced ovarian cancer. The study is supported through a National Comprehensive Cancer Network (NCCN) award. Patients will undergo a geriatric assessment at four time points during their chemotherapy and debulking surgery (Figure 1). Toxicity and outcomes will be monitored. The goal is to determine whether geriatric variables can predict toxicity. In addition, half of the patients will receive a weekly telephone call from a geriatric nurse who will reinforce medication compliance, offer psychosocial support, and facilitate appropriate referrals. Quality of life, use of care, and satisfaction parameters will be compared to those patients receiving standard oncology care alone. Ultimately, these results will aide the NCCN-Senior Adult Panel with the development of guidelines for the integration of a GA and nurse telephone interventions into an oncology practice.

Table 1 -- Domains and Measures in the Geriatric Assessment (GA) Questionnaire4 Enlarge Image Figure 1 -- Geriatric Assessment (GA) During Upfront Treatment for Ovarian Cancer (~6 months) Enlarge Image