ELDERLY PATIENTS UNDERGOING SURGERY FOR OVARIAN CANCER: PERI-OPERATIVE ASSESSMENT AND SURGICAL CHOICES Dina Kurdiani M.D Tbilisi Cancer Center ESGO Council Member The Expert in Gynecological Oncology Ministry of labour ,Health and Social Affairs Tbilisi Georgia

Cancer is recognized as a disease of older adults, with over 50 percent of new cases being diagnosed after age 65, and over 70 percent of deaths from cancer occurring in this same age group Ovarian cancer is the seventh most common cancer in women worldwide and accounts for nearly 4 percent of all new cases of cancer in women It is also the eighth most common cause of cancer death in the world. The risk of ovarian cancer increases with age with only 10 to 15 percent of cases diagnosed before menopause

Primary cytoreductive surgery — The goal of CRS is complete resection of all disease, which has been shown to be prognostic of outcomes for women presenting with newly diagnosed ovarian cancer, regardless of age. Postoperative death — The prevalence of death following CRS ranges from 0 to 13 percent, probably as a result of the heterogeneity of the populations evaluated. In one study that included data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, main results included the following : The 30-day postoperative mortality rate among women >65 years (who underwent either primary CRS or neoadjuvant chemotherapy followed by an interval CRS )was 8.2 percent. Compared with women who underwent surgery as scheduled, those who had emergent surgery had a higher incidence of 30-day postoperative mortality (20 versus 5.6 percent, respectively). Among patients scheduled for surgery, each year over age 65 was associated with a 7.5 percent increase in the risk of 30-day mortality (95% CI 1.06-1.10). Among patients who underwent surgery emergently, each year over age 65 was associated with a 2.8 percent increase in the risk of 30-day mortality (95% CI 1.01-1.05).

In the randomized clinical trial of primary CRS versus neoadjuvant chemotherapy followed by an interval CRS conducted by the European Organization for the Research and Treatment of Cancer (EORTC 55971), almost 7 percent of those women who underwent primary CRS did not receive chemotherapy, and in most of these cases, it was due to excessive post-surgery complications or the diagnosis of another primary tumor. The results of this trial are discussed separately. (See "Neoadjuvant chemotherapy for newly diagnosed advanced ovarian cancer", section on 'EORTC 55971 trial'.) Interval cytoreductive surgery — For patients deemed to be poor candidates for primary CRS, interval CRS can be offered after initial treatment using neoadjuvant chemotherapy (NACT). Multiple randomized trials show that survival outcomes appear to be similar among women who undergo a primary versus an interval CRS. However, perioperative complications were lower in those patients receiving NACT. (See "Neoadjuvant chemotherapy for newly diagnosed advanced ovarian cancer".)

In ovarian cancer surgery, two or more complications increased the risk of death from cancer by almost 30 percent (hazard ratio [HR] 1.31, 95% CI 1.15-1.49) . This was shown in a study that utilized data from the Nationwide Inpatient Sample (NIS) registry that included almost 29,000 patients admitted for ovarian cancer surgery. Main findings included that ●Among patients <50 years, 70 to 79, or 80 years and older, the complication rates were 17.1, 29.7, and 31.5 percent, respectively. ●Patients over 70 years of age who required two or more radical procedures (ie, bowel resections, diaphragm resections) had a 33 percent major complication rate. By comparison, if only one radical procedure was required, the complication rate was 25 percent.

Appropriate preoperative medical consultations should be obtained to address medical comorbidities Overview of the principles of medical consultation and perioperative medicine". "Evaluation of cardiac risk prior to noncardiac surgery". "Perioperative management of hypertension". "Evaluation of preoperative pulmonary risk". "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea". "Perioperative management of blood glucose in adults with diabetes mellitus". "Medical management of the dialysis patient undergoing surgery". "Assessing surgical risk in patients with liver disease". "Perioperative care of the surgical patient with neurologic disease"

Cytoreductıve Surgery Older patients should undergo a geriatric assessment (GA) at their initial presentation to determine whether or not they are appropriate candidates for cytoreductive surgery (CRS). (See 'Geriatric assessment' below.) The results of the assessment can be used to determine the most appropriate treatment strategy: Patients who are candidates for CRS should proceed with primary surgical therapy. Patients who are not candidates for CRS should be offered chemotherapy, provided they are also candidates for medical treatment. Patients who are neither candidates for CRS nor for medical treatment should be referred for palliative care and hospice services. Treatment for these patients should be focused on symptom management. (See 'Palliative care' below.)

Treatment for ovarian cancer requires a multidisciplinary approach that includes consideration of both surgery and medical therapy. Therefore, all patients should be evaluated by a specialized team that includes a gynecologic oncologist whenever possible. GERIATRIC ASSESSMENT — Geriatric assessment (GA) provides clinicians with a formal way to evaluate a patient's functional status

Older patients should undergo a comprehensive geriatric assessment (CGA) at their initial presentation to determine whether or not they are appropriate candidates for cytoreductive surgery (CRS). ●GA provides clinicians with a formal way to evaluate a patient's functional status (ie, ability to live independently at home and in the community), comorbid medical conditions, cognition, psychological status, social functioning-support, and nutritional status. Several studies have demonstrated the predictive value of GA for estimating the risk of severe toxicity from chemotherapy and survival outcomes. Unfortunately, a validated instrument for assessment specifically for the older patient with ovarian cancer is not yet available. ('Preoperative assessment' .) ●The Preoperative Assessment of Cancer in the Elderly (PACE) tool was developed to combine elements of the CGA with surgical risk assessment tools. However, while promising, it has not yet been evaluated in patients who are being considered for higher-risk surgeries. ( 'Preoperative Assessment of Cancer in the Elderly (PACE)' . ●As with the preoperative assessment, there is a clear need for a simple and short screening test for older vulnerable women with ovarian cancer undergoing chemotherapy. While validated tools are available, none are routinely used in clinical gynecologic oncological practice at this time. (See 'Prior to systemic therapy' above.) ●Patients initially diagnosed with ovarian cancer should be evaluated for CRS, regardless of age. However, there will be a proportion of patients who present with advanced ovarian cancer in whom primary CRS is not indicated (eg, those with a poor performance status and/or those with radiologically or clinically unresectable disease). (See 'Primary cytoreductive surgery' above. Arti Hurria, MD Harvey Jay Cohen, MD

For patients deemed to be poor candidates for primary CRS, interval CRS can be offered after initial treatment using neoadjuvant chemotherapy (NACT). Multiple randomized trials show that survival outcomes appear to be similar among women who undergo a primary versus an interval CRS. However, perioperative complications were lower in those patients receiving NACT. ●For older women with newly diagnosed ovarian cancer, we suggest weekly dosing of both carboplatin and paclitaxel rather than every- three-week treatment (Grade 2C). This is particularly true for patients who are deemed to be at increased risk of treatment-related toxicity with every three week dosing. (See 'Weekly dosing' above.) ●For older adult patients who experience recurrent disease, we suggest pegylated liposomal doxorubicin (Grade 2C). ●For women who are not candidates for surgery or medical therapy, and those who experience recurrent disease, treatment is palliative, not curative. A discussion on goals and preferences for continuation of therapy, the incorporation of palliative care, and/or referral to hospice is important in order to individualize plans in this otherwise uniformly fatal scenario. ( "Benefits, services, and models of subspecialty palliative care".)

Age alone is not a contraindication to surgery Age alone is not a contraindication to surgery. Decisions on operability should be based upon health status and discussion of treatment options with the patient; family members or other caregivers should be involved if they participate in the care of the patient

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