Advanced epithelial ovarian cancer in the older patient: a retrospective cohort study of six UK Gynaecological Cancer centers

Objective

We aimed to analyze management and survival outcomes of older people (≥75 years) with stage II+ epithelial ovarian cancer (EOC) across six gynaecological cancer centers in the United Kingdom.

Methods

Retrospective cohort study performed using the IMPRESS project dataset. Clinical information for patients diagnosed with EOC from six sites of varying size and population demographics, was collated between 1/1/2018 and 31/12/2019. We compared treatment of patients aged ≥75 years with those <75, within and between centers, using multi-variate analysis, to understand effects on outcomes.

Results

After exclusions, we assessed 721 people for overall survival (OS) and 702 for progression-free survival (PFS). The ≥75s had poorer performance status, more comorbidities and were less likely to receive combination treatment with surgery and chemotherapy (in either order) (overall = 392/721 (54.4%) overall; <75 cohort = 320/495 (64.6%); ≥75 cohort = 72/226 (31.9%). Treatment proportions varied between sites, with some having no active treatment rates of nearly 50% for ≥75s. Those ≥75 years had twice the relative risk of death compared to those <75 (Relative Risk (RR) = 1.98, 95% confidence intervals (CI) 1.63 to 2.39, P<0.001). Adjustment for confounders individually caused only a relatively modest reduction in magnitude and strength of association. Adjustment for treatment led to this association essentially disappearing (RR = 1.10, 95% CI 0.88 to 1.38; 99% reduction in Chi2), though with significant variation in association between age and OS between treatment groups (p-heterogeneity: 0.0004).

Conclusion

Older women may do as well as younger women in terms of survival, if treated similarly, although this varies depending on treatment groups. Treatments varied between and within sites, with some sites treating older women more differently than others. Some differences may be appropriate, but significant differences in rates of no active treatment between sites suggests that not all variation may be appropriate.

Key messages

What is already known on this topic?

• Older patients with ovarian cancer are under-represented in clinical trials.

• Optimal management of advanced ovarian cancer requires a combination of surgery and chemotherapy.

• Management of older patients remains a challenging area due to the lack of consensus regarding optimal treatment strategies tailored to this population.

• Evidence suggests that older patients often receive less aggressive treatment than younger counterparts, partly due to concerns about comorbidities and treatment tolerance, despite similar attitudes to treatment.

What this study adds?

• Treatment of older patients varied between and within centers.

• A greater percentage of older patients died within 30 or 90 days of diagnosis.

• Older patients were less likely to have combination treatment with surgery and chemotherapy, especially in some centers.

• Older patients who had combination treatment had similar outcomes to the younger cohort.

How this study might affect research, practice or policy?

• Further work is needed to understand which older patients will do better if treated with surgery and/or chemotherapy and in which order, and to improve shared decision-making with our patients.

• This study suggests that age alone should not be a barrier to enrolment in clinical studies and active recruitment of older people should be encouraged.