Patients who present with endometrial cancer tend to be older, but the impact of their age on clinical outcomes is difficult to study. Most available data are retrospective, looking back at the charts of patients who were treated and their age at diagnosis, so these individuals are not necessarily representative of the whole population of older patients with endometrial cancer. For example, you may be more likely to operate on patients who are physically healthier than those who have significant comorbidities, independent of their age. So, patients’ comorbidities, performance statuses, and frailty are really what determine their eligibility for surgery, not just age.

Some data suggest that individuals who are older are not getting all of the standard-of-care treatments, but I think that most of the study data are retrospective, and it is really difficult to know what decisions are being made for individual patients. In clinical practice, each person is different, so we rely on our clinical judgment, communication with the patient, and collaboration with other clinicians to help manage comorbidities and accurately assess the risks and benefits of each treatment option. The hope is that we might offer patients of all ages the best treatment possible for their endometrial cancer.

One challenge with endometrial cancer is that its incidence tends to increase with age, as does the incidence of comorbidities that limit treatment options. For example, a 45-year-old woman with mild hypertension and obesity but no other comorbidities is likely to tolerate every treatment, including chemotherapy, radiation therapy, and surgery. Conversely, a 74-year-old woman with peripheral neuropathy, cardiovascular disease, and hypertension has limited treatment options and is more likely to have treatment-related side effects. Although some older women are lucky and have no comorbidities and have good performance status, a combination that allows them to be eligible for all of the treatment options that are available to younger patients, this is uncommon. 

The chemotherapeutic agents carboplatin and paclitaxel can cause peripheral neuropathy—paclitaxel more so than carboplatin—as can the other agents that are routinely offered. So, if a patient has preexisting diabetic neuropathy, you are limited in how much and how long you can administer these agents. Similarly, anthracyclines are contraindicated in patients with significant cardiac problems, such as cardiomyopathy and heart failure.  

Advanced age and frailty are not completely associated, but that association is very common. Frailty is a variable that we measure that tells us about a patient’s ability to withstand stress. As frailty increases, a patient’s ability to bounce back from injuries becomes more and more compromised.

In addition to the challenges that may be associated with giving older patients systemic therapies, frailty is a concern with respect to open surgery. I think that this was one of the reasons that minimally invasive surgery was rapidly incorporated into the standard treatment of endometrial cancer.

Several instruments can quantify frailty in a variety of ways and should be considered every time we treat. Even if a patient has already tolerated treatment, someone with disease recurrence may be frailer as a result of prior therapy, particularly if they received radiation and chemotherapy. Thus, frailty is something that we need to assess every time we plan a new intervention so that we can be more confident that the patient is going to withstand it.