Drug therapy for gynaecological cancer in older women

A substantial proportion of all women dying from gynaecological malignancies are aged >75 years. Many reports have indicated that the survival of these patients is decreased compared with younger patients. Differences in biological behaviour, stage of the disease at presentation, and reluctance to undergo aggressive treatment with its associated morbidity are among the factors thought to be responsible for this difference in outcomes. However, investigations also indicate that elderly patients may receive less surgical and chemotherapeutic treatment without obvious clinical rationale. This overview is aimed at providing a guideline of chemotherapy appropriate for patients with epithelial ovarian, uterine (corpus and cervix), and vulvar cancer, aged 70 to 75 years and over. Platinum-based chemotherapy is the cornerstone of drug treatment in patients with ovarian cancer. Patients aged between 70 and 75 years with a good performance status can be treated with cisplatin- or carboplatin-based chemotherapy. Carboplatin, either in combination or as a single-agent, may offer advantages in patients aged >75 years and in those with a poor performance status. For patients with early recurrence there is no standard treatment, but several cytostatic and hormonal agents can be used with palliative intent. Patients with a late recurrence are probably best retreated with a platinum-based regimen. In metastatic endometrial cancer, hormonal therapy is the first choice in tumours expressing a progesterone receptor. Poorly differentiated tumours infrequently respond to endocrine therapy. In this situation, and for patients with tumours that have become resistant to hormonal manipulation, platinum-based chemotherapy may be used. The use of carboplatin-based regimens seems preferable in elderly patients, particularly in those with a decreased performance status. The usefulness of chemotherapy in elderly patients with cervical cancer is limited. In case of recurrent or metastatic disease, the use of single agent (low-dose) cisplatin should be balanced against best supportive care. Although overall chemoradiation seems superior than radiotherapy alone in patients with locally advanced cervical cancer, the feasibility of this approach in elderly patients needs further investigation. Chemoradiation might also be considered in patients with locally advanced vulvar cancer. However, treatment-related morbidity can be considerable and randomised studies are lacking to prove a survival benefit. Our understanding of the tolerance and effectiveness of chemotherapy in elderly patients is still incomplete due to a paucity of trials that specifically focus on this subset of patients. However, there appears no argument to withhold chemotherapy based purely on age.