Considerations in the surgical management of ovarian cancer in the elderly

Opinion statement: Elderly patients with advanced epithelial ovarian cancer present a complex treatment dilemma. On the one hand, patients can be treated with primary debulking surgery to achieve the ideal oncologic outcomes but at the expense of risk of surgical morbidity and mortality. On the other hand, they can be treated with alternative, less morbid approaches, reducing toxicity, but sacrificing the survival benefits of low residual disease by surgical cytoreduction. Retrospective studies have attempted to identify risk factors for poor surgical outcome. Although there is no consensus to define "elderly" or "frail," current evidence identifies age, performance status, nutritional status, and surgical complexity as major risk factors for surgical morbidity. Accepting the shortcomings of these retrospective data, candidates for primary debulking surgery can be assessed for risk of surgical morbidity. Age is likely a contributor to morbidity, particularly in the face of comorbid conditions. Clinicians should strive to treat elderly patients with a standard approach of primary debulking surgery and adjuvant chemotherapy when healthy and in the absence of other risk factors. Elderly patients with the following are poor surgical candidates and an alternative treatment approach should be considered: poor nutritional status (characterized by serum albumin <3.0 g/dL), or poor performance status (ASA ≥3), and stage IV disease. Several of these factors are modifiable by treating the underlying cancer. These patients should be treated with two to three cycles of neoadjuvant chemotherapy and reassessed for surgical debulking. Patients with improvement in their nutritional or performance status can undergo interval debulking with the goal to resect all visible disease.