- Email: [email protected]
Morbidity of cytoreductive surgery in the elderly
American Journal of Obstetrics and Gynecology (2004) 190, 1398e400
www.elsevier.com/locate/ajog
Morbidity of cytoreductive surgery in the elderly Jason D. Wright, MD, Thomas J. Herzog, MD, Matthew A. Powell, MD Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Ovarian cancer Elderly Cytoreduction Debulking Complications
Objectives: While ovarian cancer is often seen in elderly patients, such women are often not treated as aggressively as younger patients. In this study, we evaluated the feasibility and morbidity of cytoreductive surgery in the elderly. Study design: A retrospective review was performed of all patients with epithelial ovarian carcinoma who underwent exploratory laparotomy. Patients were stratified by age into those younger than 70 years of age and those 70 years of age and older. Results: A total of 175 patients, 129 (74%) in the younger cohort and 46 (26%) in the older cohort, were identified. Optimal cytoreduction to a largest tumor diameter of !1 cm was possible in 82% of the younger patients vs 81% of the elderly (P = 1.00). The stage distribution, complication rate, duration of hospital stay, and survival were similar between the groups. Conclusion: Aggressive surgical cytoreduction is both safe and feasible in elderly patients. Advanced age should not be considered a contraindication to cytoreductive surgery. Ó 2004 Elsevier Inc. All rights reserved.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
In 2003, it was estimated that 25,400 new cases of ovarian cancer would be diagnosed, and that 14,300 deaths would result from the disease.1 Ovarian cancer disproportionately affects the elderly. More than 48% of all ovarian cancers occur in women over age 65.1 Mortality rates for elderly patients with ovarian cancer are higher than in young patients.2,3 In a review of the Surveillance Epidemiology and End Results (SEER) database, the 1-year survival rate for patients age 85 and over with advanced stage tumors was less than the 5-year survival rate for women under the age of 45.2 Several studies have noted that elderly patients with ovarian cancer are treated less aggressively than younger patients.2-5
Reprint requests: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, Box 8064, St Louis, MO 63110. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.078
Those elderly women who do undergo radical pelvic surgery often tolerate it well.4,6-9 We evaluated the feasibility and morbidity of cytoreductive surgery in the elderly.
Material and methods After obtaining study approval from the Washington University Human Studies Committee, a retrospective review was performed to identify patients with invasive epithelial ovarian carcinoma who underwent exploratory laparotomy for a pelvic mass between 1996 and 2002. Patients were stratified by age into two groups, those younger than age 70, and those age 70 and older. Clinical data was abstracted from inpatient and outpatient records. A hospital-based tumor registry was used to verify disease status and survival. Statistical analysis was performed with Fisher exact test and Student t test. Survival was analyzed by the Kaplan-Meier method, and compared with the log-rank test.
1399
Wright, Herzog, and Powell Table I
Characteristics of the study population
Mean age
Major comorbidities Coronary artery disease Hypertension Arrythmia Diabetes mellitus Hyperlipidemia Osteoarthritis COPD* Second malignancy Ca 125 median (U/mL) Stage I II III IV Unstaged Unknown Tumor size (cm)
!70 years
R70 years
54.1 (28-69) SDy 8.6
75.3 (70-91) SD* 4.8
3% 23% 4% 7% 8% 7% 4% 13% 1333 (SD 2310)
Table II P value !.0001
17% 47% 11%y 3% 17% 19% 8% 19% 1249 (SD 3552)
.008 .010 NS NS NS 0.045 NS NS NS NS
16 (12%) 7 (5%) 89 (69%) 9 (7%) 1 (1%) 7 (5%) 11.3 (SD 6.4)
5 (11%) 5 (11%) 33 (72%) 1 (2%) 0 (e) 2 (4%) 9.6 (SD 5.1)
NS
* Chronic obstructive pulmonary disease. y Standard deviation.
Results A total of 175 subjects who met all of the study selection criteria were identified, 129 (74%) patients younger than age 70 and 46 (26%) were age 70 or older. The demographic characteristics and medical comorbidities of the cohort are displayed in Table I. The median length of follow-up was 1.7 years. At exploration, the histologic subtypes, mean tumor diameters, and stage distribution were similar between the 2 cohorts. The intraoperative and postoperative findings for the 2 groups are displayed in Table II. The mean estimated blood loss was 758 mL in the younger patients vs 667 mL in the older cohort (P = .35). Intraoperative transfusion was required in 32% of the young vs 41% in the elderly patients (P = .33). Optimal cytoreduction to a largest tumor diameter of !1 cm was possible in 82% of the younger patients and in 81% of the elderly (P = 1.00). The mean hospital stay and the frequency and types of postoperative complications were similar between the groups. At last follow-up, 73% of the younger cohort and 67% of the older cohort were alive. A Kaplan-Meier survival analysis revealed no significant difference in survival for the 2 cohorts (P = .49) (Figure).
Complications and survival
Intraoperative complications EBL (mL) Transfusion EBLO1500 Surgical procedures Hysterectomy BSO* USOy Lymph node sampling Omentectomy Small bowel resection Large bowel resection Appendectomy Splenectomy Cytoreduction Optimal Suboptimal Unknown Hospital stay (d) Postoperative complications Transfusion Infection Wound complications Delirium ICU admission Arrhythmia Thromboembolic Ileus Perioperative mortalitiy Vital status Alive Dead Unknown Disease status Recurred Persistent NED Unknown
!70 years
R70 years
P value
758 (SD 551) 32% 11%
667 (SD 407) 41% 8%
NS NS NS
72% 89% 1% 32%
74% 88% 7% 42%
NS NS NS NS
84% 8%
88% 9%
NS NS
18%
14%
NS
15% 1%
14% 2%
NS NS NS
93 (72%) 21 (16%) 15 (12%) 7.30
35 (76%) 8 (17%) 3 (7%) 7.65
31% 9% 7%
38% 8% 3%
1% 8% 1% 3% 10% 0%
5% 20% 2% 1% 2% 0%
94 (73%) 30 (23%) 5 (4%)
31 (67%) 13 (28%) 2 (4%)
50 15 59 5
14 7 23 2
NS NS
NS NS
NS (39%) (12%) (46%) (4%)
(30%) (15%) (50%) (4%)
EBL, Estimated blood loss. * Bilateral salpingo-oopherectomy. y Unilateral salpingo-oopherectomy.
Comment Our findings reveal that aggressive surgical cytoreduction for ovarian cancer is both safe and feasible in elderly patients. This data is in accord with several small studies that have evaluated the treatment of ovarian
1400
Wright, Herzog, and Powell statuses are selected for exploration.10 However, patients should not be offered less aggressive treatment based upon age alone. Carefully selected elderly patients tolerate surgical cytoreduction remarkably well with a complication rate similar to that of younger women.
References
Figure
Kaplan-Meier survival analysis.
cancer in the elderly. Lawton et al examined the outcomes of 65 elderly patients with gynecologic malignancies who underwent radical pelvic surgery with curative intent. Radical surgery with few postoperative complications was carried out in all 65 elderly patients. Optimal cytoreduction was achieved in 80% of the elderly subjects.6 Marchetti et al also found that elderly ovarian cancer patients tolerated surgery well. However, the authors noted that even when elderly patients were able to undergo aggressive surgical and chemotherapeutic treatment, survival remained significantly poorer than in younger patients.9 Age remains an important prognostic factor for patients with ovarian cancer. It must be recognized that older patients often have multiple medical comorbidites, and often only those patients with good performance
1. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics 2003. CA Cancer J Clin 2003;53:5-26. 2. Yancik R. Ovarian cancer: age contrasts in incidence, histology, disease stage at diagnosis, and mortality. Cancer 1993;71:517-23. 3. Ries LAG. Ovarian cancer: survival and treatment differences by age. Cancer 1993;71:524-9. 4. Bruchim I, Altaras M, Fishman A. Age contrasts in clinical characteristics and pattern of care in patients with epithelial ovarian cancer. Gynecol Oncol 2002;86:274-8. 5. Markman M, Lewis JL, Saigo P, Hakes T, Jones W, Rubin S, et al. Epithelial ovarian cancer in the elderly. The Memorial SloanKettering Cancer Center experience. Cancer 1993;71(Suppl 2): 634-7. 6. Lawton FG, Hacker NF. Surgery for invasive gynecologic cancer in the elderly female population. Obstet Gynecol 1990;76:287-9. 7. Kirschner CV, DeSerto TM, Isaacs JH. Surgical treatment of the elderly patient with gynecologic cancer. Surg Gynecol Obstet 1990; 170:379-84. 8. Kennedy AW, Flagg JS, Webster KD. Gynecologic cancer in the very elderly. Gynecol Oncol 1989;32:49-54. 9. Marchetti DL, Lele SB, Priore RL, McPhee ME, Hreshchyshyn MM. Treatment of advanced ovarian carcinoma in the elderly. Gynecol Oncol 1993;49:86-91. 10. Cloven NG, Manetta A, Berman ML, Kohler MF, DiSaia PJ. Management of ovarian cancer in patients older than 80 years of age. Gynecol Oncol 1999;73:137-9.
www.elsevier.com/locate/ajog
Morbidity of cytoreductive surgery in the elderly Jason D. Wright, MD, Thomas J. Herzog, MD, Matthew A. Powell, MD Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, Missouri
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Ovarian cancer Elderly Cytoreduction Debulking Complications
Objectives: While ovarian cancer is often seen in elderly patients, such women are often not treated as aggressively as younger patients. In this study, we evaluated the feasibility and morbidity of cytoreductive surgery in the elderly. Study design: A retrospective review was performed of all patients with epithelial ovarian carcinoma who underwent exploratory laparotomy. Patients were stratified by age into those younger than 70 years of age and those 70 years of age and older. Results: A total of 175 patients, 129 (74%) in the younger cohort and 46 (26%) in the older cohort, were identified. Optimal cytoreduction to a largest tumor diameter of !1 cm was possible in 82% of the younger patients vs 81% of the elderly (P = 1.00). The stage distribution, complication rate, duration of hospital stay, and survival were similar between the groups. Conclusion: Aggressive surgical cytoreduction is both safe and feasible in elderly patients. Advanced age should not be considered a contraindication to cytoreductive surgery. Ó 2004 Elsevier Inc. All rights reserved.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
In 2003, it was estimated that 25,400 new cases of ovarian cancer would be diagnosed, and that 14,300 deaths would result from the disease.1 Ovarian cancer disproportionately affects the elderly. More than 48% of all ovarian cancers occur in women over age 65.1 Mortality rates for elderly patients with ovarian cancer are higher than in young patients.2,3 In a review of the Surveillance Epidemiology and End Results (SEER) database, the 1-year survival rate for patients age 85 and over with advanced stage tumors was less than the 5-year survival rate for women under the age of 45.2 Several studies have noted that elderly patients with ovarian cancer are treated less aggressively than younger patients.2-5
Reprint requests: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, 4911 Barnes Hospital Plaza, Box 8064, St Louis, MO 63110. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.078
Those elderly women who do undergo radical pelvic surgery often tolerate it well.4,6-9 We evaluated the feasibility and morbidity of cytoreductive surgery in the elderly.
Material and methods After obtaining study approval from the Washington University Human Studies Committee, a retrospective review was performed to identify patients with invasive epithelial ovarian carcinoma who underwent exploratory laparotomy for a pelvic mass between 1996 and 2002. Patients were stratified by age into two groups, those younger than age 70, and those age 70 and older. Clinical data was abstracted from inpatient and outpatient records. A hospital-based tumor registry was used to verify disease status and survival. Statistical analysis was performed with Fisher exact test and Student t test. Survival was analyzed by the Kaplan-Meier method, and compared with the log-rank test.
1399
Wright, Herzog, and Powell Table I
Characteristics of the study population
Mean age
Major comorbidities Coronary artery disease Hypertension Arrythmia Diabetes mellitus Hyperlipidemia Osteoarthritis COPD* Second malignancy Ca 125 median (U/mL) Stage I II III IV Unstaged Unknown Tumor size (cm)
!70 years
R70 years
54.1 (28-69) SDy 8.6
75.3 (70-91) SD* 4.8
3% 23% 4% 7% 8% 7% 4% 13% 1333 (SD 2310)
Table II P value !.0001
17% 47% 11%y 3% 17% 19% 8% 19% 1249 (SD 3552)
.008 .010 NS NS NS 0.045 NS NS NS NS
16 (12%) 7 (5%) 89 (69%) 9 (7%) 1 (1%) 7 (5%) 11.3 (SD 6.4)
5 (11%) 5 (11%) 33 (72%) 1 (2%) 0 (e) 2 (4%) 9.6 (SD 5.1)
NS
* Chronic obstructive pulmonary disease. y Standard deviation.
Results A total of 175 subjects who met all of the study selection criteria were identified, 129 (74%) patients younger than age 70 and 46 (26%) were age 70 or older. The demographic characteristics and medical comorbidities of the cohort are displayed in Table I. The median length of follow-up was 1.7 years. At exploration, the histologic subtypes, mean tumor diameters, and stage distribution were similar between the 2 cohorts. The intraoperative and postoperative findings for the 2 groups are displayed in Table II. The mean estimated blood loss was 758 mL in the younger patients vs 667 mL in the older cohort (P = .35). Intraoperative transfusion was required in 32% of the young vs 41% in the elderly patients (P = .33). Optimal cytoreduction to a largest tumor diameter of !1 cm was possible in 82% of the younger patients and in 81% of the elderly (P = 1.00). The mean hospital stay and the frequency and types of postoperative complications were similar between the groups. At last follow-up, 73% of the younger cohort and 67% of the older cohort were alive. A Kaplan-Meier survival analysis revealed no significant difference in survival for the 2 cohorts (P = .49) (Figure).
Complications and survival
Intraoperative complications EBL (mL) Transfusion EBLO1500 Surgical procedures Hysterectomy BSO* USOy Lymph node sampling Omentectomy Small bowel resection Large bowel resection Appendectomy Splenectomy Cytoreduction Optimal Suboptimal Unknown Hospital stay (d) Postoperative complications Transfusion Infection Wound complications Delirium ICU admission Arrhythmia Thromboembolic Ileus Perioperative mortalitiy Vital status Alive Dead Unknown Disease status Recurred Persistent NED Unknown
!70 years
R70 years
P value
758 (SD 551) 32% 11%
667 (SD 407) 41% 8%
NS NS NS
72% 89% 1% 32%
74% 88% 7% 42%
NS NS NS NS
84% 8%
88% 9%
NS NS
18%
14%
NS
15% 1%
14% 2%
NS NS NS
93 (72%) 21 (16%) 15 (12%) 7.30
35 (76%) 8 (17%) 3 (7%) 7.65
31% 9% 7%
38% 8% 3%
1% 8% 1% 3% 10% 0%
5% 20% 2% 1% 2% 0%
94 (73%) 30 (23%) 5 (4%)
31 (67%) 13 (28%) 2 (4%)
50 15 59 5
14 7 23 2
NS NS
NS NS
NS (39%) (12%) (46%) (4%)
(30%) (15%) (50%) (4%)
EBL, Estimated blood loss. * Bilateral salpingo-oopherectomy. y Unilateral salpingo-oopherectomy.
Comment Our findings reveal that aggressive surgical cytoreduction for ovarian cancer is both safe and feasible in elderly patients. This data is in accord with several small studies that have evaluated the treatment of ovarian
1400
Wright, Herzog, and Powell statuses are selected for exploration.10 However, patients should not be offered less aggressive treatment based upon age alone. Carefully selected elderly patients tolerate surgical cytoreduction remarkably well with a complication rate similar to that of younger women.
References
Figure
Kaplan-Meier survival analysis.
cancer in the elderly. Lawton et al examined the outcomes of 65 elderly patients with gynecologic malignancies who underwent radical pelvic surgery with curative intent. Radical surgery with few postoperative complications was carried out in all 65 elderly patients. Optimal cytoreduction was achieved in 80% of the elderly subjects.6 Marchetti et al also found that elderly ovarian cancer patients tolerated surgery well. However, the authors noted that even when elderly patients were able to undergo aggressive surgical and chemotherapeutic treatment, survival remained significantly poorer than in younger patients.9 Age remains an important prognostic factor for patients with ovarian cancer. It must be recognized that older patients often have multiple medical comorbidites, and often only those patients with good performance
1. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics 2003. CA Cancer J Clin 2003;53:5-26. 2. Yancik R. Ovarian cancer: age contrasts in incidence, histology, disease stage at diagnosis, and mortality. Cancer 1993;71:517-23. 3. Ries LAG. Ovarian cancer: survival and treatment differences by age. Cancer 1993;71:524-9. 4. Bruchim I, Altaras M, Fishman A. Age contrasts in clinical characteristics and pattern of care in patients with epithelial ovarian cancer. Gynecol Oncol 2002;86:274-8. 5. Markman M, Lewis JL, Saigo P, Hakes T, Jones W, Rubin S, et al. Epithelial ovarian cancer in the elderly. The Memorial SloanKettering Cancer Center experience. Cancer 1993;71(Suppl 2): 634-7. 6. Lawton FG, Hacker NF. Surgery for invasive gynecologic cancer in the elderly female population. Obstet Gynecol 1990;76:287-9. 7. Kirschner CV, DeSerto TM, Isaacs JH. Surgical treatment of the elderly patient with gynecologic cancer. Surg Gynecol Obstet 1990; 170:379-84. 8. Kennedy AW, Flagg JS, Webster KD. Gynecologic cancer in the very elderly. Gynecol Oncol 1989;32:49-54. 9. Marchetti DL, Lele SB, Priore RL, McPhee ME, Hreshchyshyn MM. Treatment of advanced ovarian carcinoma in the elderly. Gynecol Oncol 1993;49:86-91. 10. Cloven NG, Manetta A, Berman ML, Kohler MF, DiSaia PJ. Management of ovarian cancer in patients older than 80 years of age. Gynecol Oncol 1999;73:137-9.