How Should we Perform a Preoperative Multidimensional Assessment of Elderly Patients with Advanced Ovarian Cancer?

This article refers to:

Interval Debulking Surgery for Advanced Ovarian Cancer in Elderly Patients (≥70 y): Does the Age Matter?

Ovarian cancer is the most lethal gynecological tumor, which has a global estimated incidence of diagnosis of 230,000 women/year and tumor related death of 150,000 women/year [1]. Despite numerous studies ongoing, unfortunately, the diagnosis of this neoplasia at early stage is extremely challenging, because of the lack of approved strategy for screening general population [2] and because of no specific clinical presentation in patients affected, consisting in abdominal bloating, early satiety, nausea, abdominal distension, change in bowel function, urinary symptoms, back pain, fatigue, and loss of weight [3].

Primary debulking surgery (PDS) followed by chemotherapy has become the standard of care for treating advanced ovarian cancer. In a recent original research published in Journal of Investigative Surgery entitled “Interval debulking surgery for advanced ovarian cancer in elderly patients (>70 y): does the age matter?”, all the patients affected by advanced ovarian cancer were treated by neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) according to an institutional protocol. Although the use of this approach is clinically ponderable, it seems appropriate to underscore that the use of NACT followed by IDS is based on two randomized clinical trials [4,5] that have been criticized for their survival outcomes. At the moment, the choice between PDS and chemotherapy or NACT and IDS is a topic of interest. An ongoing multicenter trial (named TRUST) is randomizing patients with advanced ovarian cancer to NACT plus IDS or PDS in patients with advanced ovarian cancer (NCT02828618). Overall, complete resection of all macroscopic disease, whether performed as primary treatment or after neoadjuvant chemotherapy, remains the objective whenever cytoreductive surgery is performed [6].

This manuscript aimed to evaluate the impact of surgical approach in elderly patients (with more than 70 years) with advanced ovarian cancer. In case of an accurate pre-operative assessment, no significant differences in 30-day morbidity were observed in patients included in this study regardless of their age, with the exception of a higher incidence of postoperative cardiac arrhythmias. As a result, the authors concluded that older age should not preclude clinicians from offering ultra-radical surgical solutions in patients with advanced ovarian cancer previously undergone NACT [7]. This conclusion is extremely important as it is well known that the best prognostic factor in patients with advanced ovarian cancer is represented by surgical radicality, and that now numerous highly radical experimental approaches are being evaluated [8].

At this point, as specified in the article, the pre-operative evaluation of the elderly patient is of extreme importance and there is not specific cutoff of age suggested for performing it. For this reason, it should be adopted in a standardized way in the preoperative management of all the patients affected. Over the years, numerous scales for assessing cardiological, pulmonary, hepatic, renal, etc. comorbidity risk have been constructed, but the evaluation of the specific risks is severely limited by the lack of integrating all the individual aspects in order to obtain a single, clear and unequivocal (surgical and anesthesiologic) risk indicator for each patient; to this purpose, several tests have been developed that are intended to assess the overall functioning of elderly patient. Functional tests have the twofold advantage of allowing an overall assessment of the operating risk and of monitoring the dynamic evolution of its functional status, thus allowing to modulate the type and the intensity of integrated medical and surgical oncological therapies. Functional, cognitive, and psychological risk factors evaluated by global functional test as the ADL (activities of daily living) test, IADL (instrumental activities of daily living) score or Barthel Index have been associated with postoperative mortality. These risk factors, grounded in the geriatric assessment, give an advantage in performing an accurate surgical decision-making. We deem that incorporating these factors into the preoperative assessment is extremely important to improve post-surgical outcomes for older adults undergoing major surgical approaches as IDS or PDS [9]. Overall, the preoperative assessment should investigate several clinical aspects in elderly patient (for example the performance of cardiopulmonary system by assessment tools like cardiopulmonary exercise test [CPET], as discussed in the article) [7].

We deem that another fundamental point influencing prognostic outcome is a correct logistic surgical management of patients with advanced cancer [10]. In fact, PDS or IDS are major interventions requiring advanced surgical skills and excellent experiences to be performed optimally. In addition, given the involvement of different anatomical structures of the lower, middle and upper abdomen and of thorax, the taking charge of these patients by surgeons with expertise in gynecological oncology and in particular in ovarian cancer as well as the creation of dedicated multidisciplinary teams (involving radiologist, oncologist, radiotherapist etc.) should be considered mandatory for the current management of the disease.

Disclosure statement

No potential conflict of interest was reported by the author(s).