JGO-00223; No. of pages: 7; 4C: J O U RN A L OF GE RI A T RI C O NC O L O G Y XX ( 20 1 4 ) XX X–XX X
Available online at www.sciencedirect.com
ScienceDirect
Meet the Experts
How I treat ovarian cancer in older women Stuart M. Lichtman⁎ 65+ Clinical Geriatrics Program, Gynecologic Oncology Disease Management Team, Memorial Sloan Kettering Cancer Center, Commack, NY, United States
AR TIC LE I N FO
ABS TR ACT
Article history:
Advancing age in patients with epithelial ovarian cancer is a risk factor for decreased
Received 5 February 2014
survival. The exact cause is unknown but part of this may be due to less than adequate
Received in revised form 29 April 2014
therapy for these patients. To optimize treatment, this paper presents the available data for
Accepted 2 June 2014
therapy and my own approach in the management of this disease. For optimal outcomes, there also needs to be a close collaboration between subspecialists (gynecologic oncology, medical oncology, pathology) in all aspects of treatment planning. Progression-free and
Keywords:
overall survival can be prolonged and patients' quality of life can be maintained with
Ovarian cancer
appropriate management.
Serous ovarian cancer
© 2014 Elsevier Ltd. All rights reserved.
Paclitaxel Carboplatin Cisplatin Intraperitoneal Elderly
Contents 1. Introduction . . . . . . . . . . . . . . . . . 2. Surgery . . . . . . . . . . . . . . . . . . . . 3. Chemotherapy . . . . . . . . . . . . . . . . 4. Relapsed Disease . . . . . . . . . . . . . . . 5. Secondary Surgical Cytoreduction . . . . . 6. Chemotherapy . . . . . . . . . . . . . . . . 7. Platinum Sensitive Recurrence . . . . . . . 8. Platinum Resistant Disease . . . . . . . . . 9. Conclusion and Future Directions. . . . . . Disclosures and Conflict of Interest Statements . References . . . . . . . . . . . . . . . . . . . . .
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⁎ 650 Commack Road, Commack, NY 11725, United States. Tel.: +1 631 623 4100; fax: + 1 631 864 3827. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.jgo.2014.06.001 1879-4068 © 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Lichtman SM., How I treat ovarian cancer in older women, J Geriatr Oncol (2014), http://dx.doi.org/10.1016/ j.jgo.2014.06.001
0 0 0 0 0 0 0 0 0 0 0
2
J O U RN A L OF GE RI A TR I C O NC OLO G Y XX ( 20 1 4 ) XX X–XXX
1. Introduction Epithelial ovarian cancer is primarily a disease of older women. The median age at diagnosis is 63 years with 45.8% aged 65 years and older. In 2013 there were an estimated 222,400 new cases diagnosed and 14,030 will die of the disease.1 High grade serous cancers compromise 80–85% of the tumors and will be the focus of this paper.2 Approximately 70% of patients will present at advanced stage and, unfortunately, there is no effective screening test to detect disease at an early stage to improve survival. Risks to the development of epithelial ovarian cancer are associated with factors producing incessant ovulation such as null or low parity. Family history is a strong risk, especially those with a breast–ovarian cancer syndrome (BRCA-1 or -2) and hereditary non-polyposis colorectal cancer syndrome (HNPCC, Lynch II syndrome). In those with hereditary mutations, onset of disease had a mean age of 42.7 years at diagnosis but can occur at any age including over age 70.3,4 Among BRCA-1 mutation carriers, the estimated lifetime risk (up to age 70 years) of developing ovarian cancer is between 24% and 39%. While more common among younger women (age < 50 years), after the age of 30 years, the risk continues to increase proportionately. The average age of onset is older among BRCA-2-linked ovarian cancers (older than age 60 years), and the incidence increases up to age 60, and then seems to decrease slightly. When compared with BRCA-1 mutations, the estimated risk of ovarian cancer is less among those with BRCA-2 mutations at 8.4–21%. HNPCC linked ovarian cancer accounts for 2% of all patients and 10–15% of inherited cases. Most patients present at ages 40–55 but cases up to the age of 80 have been reported.5 The US Preventative Services Taskforce lists recommendations on BRCA screening (http://www.uspreventiveservicestaskforce.org/uspstf12/ brcatest/brcatestsumm.htm). There are no screening recommendations which specify an upper age limit. Age at diagnosis is associated with a marked decline in overall survival. Although the reason for this is uncertain, possibilities include diagnosis, undertreatment, or biology.6 This paper will discuss the available data and how I treat older patients with ovarian cancer. Decision-making should include some form of geriatric assessment.7
2. Surgery The optimal treatment involves the appropriate integration of surgery and chemotherapy. It is critical for the medical team and gynecologists to work together in treatment planning and decision-making throughout the course of the disease. Most patients will be initially evaluated by a Gynecologic Oncologist.8 Their role is deciding whether the patient can be optimally cytoreduced. Practice patterns vary and many patients will be treated exclusively by Gynecologic Oncologists as opposed to both specialties with similar outcomes.8 The definition of optimal resection is residual disease
Available online at www.sciencedirect.com
ScienceDirect
Meet the Experts
How I treat ovarian cancer in older women Stuart M. Lichtman⁎ 65+ Clinical Geriatrics Program, Gynecologic Oncology Disease Management Team, Memorial Sloan Kettering Cancer Center, Commack, NY, United States
AR TIC LE I N FO
ABS TR ACT
Article history:
Advancing age in patients with epithelial ovarian cancer is a risk factor for decreased
Received 5 February 2014
survival. The exact cause is unknown but part of this may be due to less than adequate
Received in revised form 29 April 2014
therapy for these patients. To optimize treatment, this paper presents the available data for
Accepted 2 June 2014
therapy and my own approach in the management of this disease. For optimal outcomes, there also needs to be a close collaboration between subspecialists (gynecologic oncology, medical oncology, pathology) in all aspects of treatment planning. Progression-free and
Keywords:
overall survival can be prolonged and patients' quality of life can be maintained with
Ovarian cancer
appropriate management.
Serous ovarian cancer
© 2014 Elsevier Ltd. All rights reserved.
Paclitaxel Carboplatin Cisplatin Intraperitoneal Elderly
Contents 1. Introduction . . . . . . . . . . . . . . . . . 2. Surgery . . . . . . . . . . . . . . . . . . . . 3. Chemotherapy . . . . . . . . . . . . . . . . 4. Relapsed Disease . . . . . . . . . . . . . . . 5. Secondary Surgical Cytoreduction . . . . . 6. Chemotherapy . . . . . . . . . . . . . . . . 7. Platinum Sensitive Recurrence . . . . . . . 8. Platinum Resistant Disease . . . . . . . . . 9. Conclusion and Future Directions. . . . . . Disclosures and Conflict of Interest Statements . References . . . . . . . . . . . . . . . . . . . . .
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⁎ 650 Commack Road, Commack, NY 11725, United States. Tel.: +1 631 623 4100; fax: + 1 631 864 3827. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.jgo.2014.06.001 1879-4068 © 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Lichtman SM., How I treat ovarian cancer in older women, J Geriatr Oncol (2014), http://dx.doi.org/10.1016/ j.jgo.2014.06.001
0 0 0 0 0 0 0 0 0 0 0
2
J O U RN A L OF GE RI A TR I C O NC OLO G Y XX ( 20 1 4 ) XX X–XXX
1. Introduction Epithelial ovarian cancer is primarily a disease of older women. The median age at diagnosis is 63 years with 45.8% aged 65 years and older. In 2013 there were an estimated 222,400 new cases diagnosed and 14,030 will die of the disease.1 High grade serous cancers compromise 80–85% of the tumors and will be the focus of this paper.2 Approximately 70% of patients will present at advanced stage and, unfortunately, there is no effective screening test to detect disease at an early stage to improve survival. Risks to the development of epithelial ovarian cancer are associated with factors producing incessant ovulation such as null or low parity. Family history is a strong risk, especially those with a breast–ovarian cancer syndrome (BRCA-1 or -2) and hereditary non-polyposis colorectal cancer syndrome (HNPCC, Lynch II syndrome). In those with hereditary mutations, onset of disease had a mean age of 42.7 years at diagnosis but can occur at any age including over age 70.3,4 Among BRCA-1 mutation carriers, the estimated lifetime risk (up to age 70 years) of developing ovarian cancer is between 24% and 39%. While more common among younger women (age < 50 years), after the age of 30 years, the risk continues to increase proportionately. The average age of onset is older among BRCA-2-linked ovarian cancers (older than age 60 years), and the incidence increases up to age 60, and then seems to decrease slightly. When compared with BRCA-1 mutations, the estimated risk of ovarian cancer is less among those with BRCA-2 mutations at 8.4–21%. HNPCC linked ovarian cancer accounts for 2% of all patients and 10–15% of inherited cases. Most patients present at ages 40–55 but cases up to the age of 80 have been reported.5 The US Preventative Services Taskforce lists recommendations on BRCA screening (http://www.uspreventiveservicestaskforce.org/uspstf12/ brcatest/brcatestsumm.htm). There are no screening recommendations which specify an upper age limit. Age at diagnosis is associated with a marked decline in overall survival. Although the reason for this is uncertain, possibilities include diagnosis, undertreatment, or biology.6 This paper will discuss the available data and how I treat older patients with ovarian cancer. Decision-making should include some form of geriatric assessment.7
2. Surgery The optimal treatment involves the appropriate integration of surgery and chemotherapy. It is critical for the medical team and gynecologists to work together in treatment planning and decision-making throughout the course of the disease. Most patients will be initially evaluated by a Gynecologic Oncologist.8 Their role is deciding whether the patient can be optimally cytoreduced. Practice patterns vary and many patients will be treated exclusively by Gynecologic Oncologists as opposed to both specialties with similar outcomes.8 The definition of optimal resection is residual disease
