IGCS 2010, 23-26 October, Prague

Treatment of elderly gynaecological cancer patients

Dr Thomas Herzog – Columbia University, New York, USA

At this meeting you’ve had various presentations regarding treating elderly gynaecological patients, either for ovarian cancer or also endometrial cancer. Can you maybe summarise some of the data?

I think there has been a large amount of angst in the oncology community of how to deal with elderly patients. We all have our individual experiences but we really have quite a bit of shortage in terms of hard data to rely upon guiding treatment decisions. Our group, led by Dr Jason Wright, actually presented some data that was very provocative on the oldest old, over 80 years old, and I know that changes as you get older; I used to think of the oldest old being over 60, now it’s over 80, I’m sure in a few years I’ll think it’s over 100. But the data was very interesting, we clearly found they received less treatment, which wasn’t surprising, but when you even adjusted for treatment their mortality was higher. So probably not all that surprising in terms of comorbidities, but even where you can adjust for trying to balance comorbidities and performance status and whatnot, we still find that they do worse. So is it a worse biology, is it just so much harder to treat those patients in terms of tolerance of therapy? We need to get to the root of that and certainly we have now data emerging in endometrial cancer but we’re really looking at that now in ovarian cancer as well. So we have a symposium this afternoon that looks at the whole aspects of age and its interaction with comorbidity and treatment for ovarian cancer. So we’re looking to hopefully come up with some treatment strategies that are more effective in this age group and also increase the awareness of treating physicians of looking at comorbidity and making adjustments.

But from the endometrial data did you learn anything regarding treating the elderly?

What we need to do is figure out how to get in adequate treatment and it probably takes more gross support factors and other treatment adaptations. With ovarian cancer, getting back to the symposium this afternoon, certainly there are a lot of things that can be done in terms of the choice of the platinum compound, the choice of the taxane compound; substituting pegylated liposomal doxorubicin for doxorubicin; perhaps looking in the recurrent setting at substituting pegylated liposomal doxorubicin for some of the other drugs that we would normally use that cause more in the way of toxicity that’s especially exacerbated in elderly patients. So these are the types of things that we’re looking at. The GOG, the gynaecologic oncology group, actually has a study coming out in the elderly and it’s still undergoing formulation; it’s being led by Dr Vivian von Gruenigan, it’s GOG502. What it looks at is actually using just single dose platinum versus using combination of a lower dose with growth factor and actually using neoadjuvant chemo as a choice by the physician as well. So it’s a bit of a registry in a sense because the physicians have the choice and it was felt that if it was very proscriptive we would under-enrol, and our hope is to get more information and more data such as we’ve done in the endometrial setting. So that’s the hope with ovarian cancer as well, that we’re able to formulate a database so that we can generate hypotheses that then can be tested prospectively.

So the meeting here in Prague, in your opinion what have been the highlights from this meeting?

I think it’s been a fantastic meeting first of all; I think the breadth and depth of the programme has been very impressive. I think that as a field, what we’re still doing is unravelling and digesting some of the data that’s been presented during this year and this meeting was a nice time to reflect on some of the updates from the large trials, such as GOG218 looking at bevacizumab and the recently presented ICON7 data with bevacizumab, both in the front line setting. So as these data mature we will have better insights in terms of the role of antiangiogenesis in front line ovarian cancer which at this point we, as a community, are really struggling with due to the fact that we do have a positive trial now, times two, but the cost of the drug is quite high. It’s really are we going to see a survival advantage, at least in ICON7, so there are a lot of things that we’re waiting to see what happens.

I also think it was a very interesting debate forum that went on yesterday in several of the rooms, actually, at the same time. I was involved in one of them but I was able to run next door and see the other. Our debate was about lymph nodes in ovarian cancer and the LION trial being done by the AGO will help answer that question; right now we have no level 1 evidence to support that. The other part that I thought was fascinating was the debate going on next door with the use of lymph nodes in endometrial cancer, and one of the things that is most provocative is the Mayo Clinic data showing that two-thirds of the patients actually have nodal metastases above the inferior mesenteric artery when there are positive nodes in the pelvis. So I think that’s something that we really need to be aware of in terms of looking at the adequacy of our lymph node dissections in endometrial cancer as well. So, as a whole, I just think it has been a great meeting in terms of trying to synthesise some of the data that has emerged piecemeal over the year.

So there may be a future for therapy for ovarian and various gynaecological cancers, things are changing?

Right, things are changing rapidly and certainly the meeting had a lot of targeted agent type of data presented. Right now we’re still lacking the biomarkers to identify who should be treated with what which will hopefully help boost the response rate and the survival that we see with treating patients with targeted agents. We’re at the beginning but I think it’s a very exciting time.