Management and outcomes for elderly women with vulvar cancer over time

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1 DOI: / Gynaecological oncology Management and outcomes for elderly women with vulvar cancer over time JA Rauh-Hain, a J Clemmer, a RM Clark, a LS Bradford, a WB Growdon, a A Goodman, a DM Boruta II, a DS Dizon, b JO Schorge, a MG del Carmen a a Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Boston, MA, USA b Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Correspondence: Dr MG del Carmen, Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9, E Boston, MA 02114, USA. mdelcarmen@partners.org Accepted 25 October Published Online 24 February Objective To examine changes over time in survival and treatment for women diagnosed with vulvar squamous cell carcinoma included in the Surveillance, Epidemiology, and End Results (SEER) Program. Design Retrospective analysis. Setting USA, data obtained from the SEER Program for Population Women with vulvar squamous cell carcinoma. Methods Women were stratified by age: <50, 50 64, 65 79, and 80 years. Differences in survival and treatment patterns were analysed between age groups. Multivariate logistic regression models were constructed to examine treatment patterns. Kaplan Meier and Cox proportional hazards survival methods were used to assess survival. Main outcome measures Vital status from the date of diagnosis until death, censoring or last follow-up. Results The final study group consisted of 8553 women, 1806 (21.12%) <50 years, 2141 (25.03%) years, 2585 (30.22%) years, and 2021 (23.63%) >80 years old. After adjusting for patient and tumour characteristics, older women were less likely to have surgery and more likely to receive radiotherapy. Compared with women under 50 years, women had a two-fold higher risk of death (HR 1.91, 95% CI ); those years had a four-fold higher risk of death (HR 4.01, 95% CI ), and those 80 years had a seven-fold higher risk of death (HR 6.98, 95% CI ). These trends stayed relatively constant over the time periods studied. Conclusions Women over 50 years are at a higher risk of vulvar cancer-specific mortality, which increases with age. These trends stayed relatively constant over the time periods studied. Keywords Elderly, vulvar cancer. Please cite this paper as: Rauh-Hain JA, Clemmer J, Clark RM, Bradford LS, Growdon WB, Goodman A, Boruta II DM, Dizon DS, Schorge JO, del Carmen MG. Management and outcomes for elderly women with vulvar cancer over time. BJOG 2014;121: Introduction In the USA, vulvar cancer is an uncommon gynecologic malignancy that constitutes 5% of cancers of the female genital tract, 1 and there are approximately 4340 new cases of vulvar cancer and 940 women die from this disease every year. 2 Although representing a rare disease of elderly women with a current incidence of 2 3 per women and a median age of years old, vulvar cancer has shown an increasing incidence with concurrently decreasing median age of at onset over the past few decades. 3,4 A recent large retrospective study reported that older women had a greater mortality risk compared with younger women; the 5-year survival was 87.5% for women younger than 50 years old compared with 52.5% for older women. In the analysis, after controlling for race, stage, grade, and surgical treatment, older age was associated with almost a four-fold increased risk for death (hazard ratio [HR] 3.9, 95% CI ). 5 The population of the USA is projected to include a significant increase in elderly individuals in the next three decades. 6 Because cancer incidence increases with age, the increasing elderly demographics will probably result in dramatic increases in the number of cancers diagnosed. Therefore, interest has increased in looking at treatment and outcomes for cancer in the older woman. Studies have shown that older women receive less aggressive cancer therapy in a number of cancer sites. 7 9 However, the extent to 719

2 Rauh-Hain et al. which older age influences patterns of care and mortality rates in vulvar cancer has not been extensively studied. Observing changes in mortality over time, rather than statically at a cross-sectional moment, may allow us to track progress toward reducing social and geographic disparities. The objective of this study was to examine the change over time of death trend rates and patterns of treatment between different age groups. Methods Data from the National Cancer Institute s Surveillance, Epidemiology and End Results (SEER) registry for invasive squamous cell carcinoma of the vulva cases diagnosed between 1988 and 2009 were the source for this analysis. 10 Because all information from the SEER Program data is de-identified, informed consent by the women involved in the study and approval of an ethics committee were not necessary in this investigation. Women who were diagnosed by death certificate or at autopsy or women with a previous diagnosis of malignant cancer were excluded. Variables were coded according to SEER Program criteria. Women were stratified by age into the following groups for analysis: <50, 50 64, 65 79, and 80 years old. Marital status was categorised as married, not married and unknown. Race was categorised as white, African-American, and others. Geographic location was divided into geographic area of residence: western (California, Los Angeles, New Mexico, San Francisco, San Jose, Seattle, Hawaii, Alaska), central (Utah, Detroit, Iowa, Kentucky, Louisiana), and eastern (Atlanta, rural Georgia, Connecticut, New Jersey). Tumour grade was classified as well differentiated, moderately differentiated, poorly differentiated or unknown. Because our dataset included women diagnosed before 2009, stage was determined using the revised 1994 staging criteria of the International Federation of Gynecologists and Obstetricians (FIGO). 11 The primary treatment modality was also recorded. The outcome variables included vital status and the time-to-event from the date of diagnosis until death, censoring or last follow-up, as verified by the SEER program vital status determination, including data from local death certificate, voter registration, driver s license, and medical records. Statistical analysis Age group differences in the distribution of demographic, clinical, and treatment characteristics were compared using chi-square tests. Student t-tests and analysis of variance (ANOVA) were used to assess the significance of differences in the mean values of continuous variables. Standard univariate analyses were performed, as were logistic regression models to describe predictors of surgery for vulvar cancer, lymph node dissection, radiotherapy, and the combination of surgery and radiotherapy, after adjusting for the following prognostic factors: age group, period of diagnosis, marital status, race, stage, and grade. We used the Kaplan Meier method to estimate survival curves in order to compare observed survival between age groups for a given period of diagnosis. Survival curves were constructed to show disease-specific mortality within the first 5 years of diagnosis within each cohort, although the hazard ratios (HR) and resulting P-values were calculated using all available data through last date of follow-up at the end of 2011, not only the first 5 years after diagnosis. Disease-specific mortality analyses were performed to assess the survival between age groups within diagnosis years , , , and then for all cohorts combined. Cox proportional hazards models were used to calculate adjusted age group HRs and their 95% confidence intervals (CI) to assess the importance of age group as an independent predictor of survival after adjusting for the following prognostic factors: SEER registry, race, marital status, stage, surgery, radiation, grade, and history of subsequent secondary malignancy. Seven-year diagnosis cohort was also included as a categorical variable when the entire population was analysed. All statistical tests were two-sided and differences were considered statistically significant at P < We used R version and the package survival version for all statistical analyses. Results There were women who were diagnosed with invasive squamous cell carcinoma of the vulva within the SEER 18 registries from 1988 to Of these, 1988 were excluded from the final analysis: 1956 women had a prior malignancy, 29 women that were not microscopically confirmed, and three women were excluded because the age was unknown. The final study group consisted of 8553 women, 1806 (21.12%) <50 years, 2141 (25.03%) years, 2585 (30.22%) years, and 2021 (23.63%) >80 years old. Compared with younger women, those 80 years were more frequently white (P < 0.001) and more frequently unmarried (P < 0.001).Women <50 years had a higher rate of stage I at diagnosis compared with women 80 years old (27.3% versus 15%; P < 0.001) and had a lower rate of stage III (15.7% versus 21.9%; P < 0.001) and stage IV disease (3.8% versus 7.9%; P < 0.001). Women <50 years had surgery more frequently (91.9% versus 75.1%; P < 0.001), and a higher rate of lymph node dissection (47.1% versus 40.2%; P < 0.001). Women 80 years old were more likely to receive radiotherapy compared with women <50 years (26.7% versus 17.6%; P < 0.001). Table S1 summarises the demographic and clinical characteristics of the study population. 720

3 Outcomes for elderly women with vulvar cancer Multivariate analysis of treatment patterns accounting for other clinical parameters revealed differences in treatment modalities in women <50 years compared with older women in the sample (Table 1). Women <50 years were more likely to receive surgical treatment for vulvar cancer compared with the group of women aged years (OR 0.57; 95% CI ), years (OR 0.51; 95% CI ) or 80 years (OR 0.24; 95% CI ). Among women with stage IB disease and higher, women 80 years old were less likely to have a lymph node dissection (OR 0.54; 95% CI ) compared with women <50 years. Women <50 years were less likely to receive radiotherapy compared with women years (OR 1.49; 95% CI ), years (OR 1.51; 95% CI ), and those 80 years old (OR 1.25; 95% CI ). The overall HR for vulvar cancer-specific mortality for each of the time periods and the whole group stratified by age groups is presented in Table 2. Over the entire study period, after adjusting for race, SEER registry, marital status, stage, age, treatment, grade, and history of subsequent secondary cancer, compared with women under 50 years, women had an almost two-fold higher risk of death (HR 1.91, 95% CI ); women had a four-fold higher risk of death (HR 4.01, 95% CI ), and women 80 had a seven-fold higher risk of death (HR 6.98, 95% CI ). After adjusting for the same variables, these trends stayed relatively constant over the time periods studied. Figure 1 shows Kaplan Meier survival curves for women with vulvar cancer by age group. After adjusting for race, SEER registry, marital status, stage, age, treatment, grade, and history of subsequent secondary cancer, women over 50 years showed a higher risk of vulvar cancer-specific mortality in all stages (I IV), and the risk increased with age. The largest difference was observed in stage II disease; women 80 years had a 19-fold higher risk of vulvar cancer-specific mortality (HR 19.43, 95% CI ) compared with women <50 years. In contrast, in stage IV disease we found the Table 1. Logistic regression models of factors associated with primary and adjuvant treatment modalities. SEER Program, Characteristic Surgery Radiation Lymph node dissection Surgery and radiation Age group <50 years years 0.57 ( ) 1.49 ( ) 1.00 ( ) 1.18 ( ) years 0.51 ( ) 1.51 ( ) 1.10 ( ) 1.19 ( ) 80 years 0.24 ( ) 1.25 ( ) 0.54 ( ) 0.77 ( ) Diagnosis year ( ) 1.11 ( ) 1.11 ( ) 0.95 ( ) ( ) 1.57 ( ) 0.89 ( ) 1.06 ( ) Race White African-American 0.64 ( ) 1.28 ( ) 0.63 ( ) 0.99 ( ) Other 0.84 ( ) 0.93 ( ) 0.81 ( ) 1.14 ( ) Marital status at diagnosis Married Unmarried 0.66 ( ) 1.07 ( ) 0.84 ( ) 0.94 ( ) Unknown 0.37 ( ) 0.61 ( ) 0.48 ( ) 0.57 ( ) Stage IA IB 0.55 ( ) 2.48 ( ) 1.89 ( ) INOS 0.34 ( ) 2.92 ( ) 2.07 ( ) II 0.14 ( ) 6.69 ( ) 0.73 ( ) 3.93 ( ) III 0.02 ( ) ( ) 1.64 ( ) ( ) IV 0.01 ( ) ( ) 2.12 ( ) ( ) Unknown 0.02 ( ) ( ) 0.24 ( ) 5.89 ( ) Grade I II 1.03 ( ) 1.44 ( ) 1.75 ( ) 1.72 ( ) III 1.07 ( ) 1.94 ( ) 1.73 ( ) 2.44 ( ) Unknown 0.55 ( ) 0.83 ( ) 0.43 ( ) 0.49 ( ) 721

4 Rauh-Hain et al. Table 2. Adjusted Cox proportional hazards models for vulvar cancer-specific mortality, comparing different age groups, by 7-year diagnosis cohort, and overall. SEER Program, All years Number Disease-specific HR <50 years years 2.11 ( ) 2.14 ( ) 1.76 ( ) 1.91 ( ) years 4.12 ( ) 4.01 ( ) 4.16 ( ) 4.01 ( ) 80 years 7.34 ( ) 7.11 ( ) 6.99 ( ) 6.98 ( ) Adjusted model includes race, SEER registry, marital status, stage, age group, treatment, grade, and history of subsequent cancer. For all years, 7-year diagnosis cohort was also included in the model. smallest difference in survival between the age groups; women 80 years had a three-fold higher risk of vulvar cancer-specific mortality (3.03, 95% CI ) compared with women <50 years (Table S2). Over the entire study period, survival analysis using the Cox proportional hazards model identified an independent association of age, race, stage, surgery, radiotherapy, grade, and history of subsequent cancer with mortality rates (Table 3). The Cox model demonstrated that the strongest quantitative predictor of death was stage at the time of diagnosis, with more advanced stages having higher mortality rates. Discussion Main findings The proportion of elderly persons has increased in most countries during the last decades, and will increase further in the coming years. The number of Americans over the age of 65 is projected to double by the year ,13 Cancer incidence typically increases with age and a disproportionate fraction of cases occur among the elderly. There is a large discrepancy in the incidence of vulvar cancer by decade of life, women 75 years and older have a incidence two to three times than their counterparts aged years. Likewise, vulvar cancer is times more likely to occur after age 50 years than before. 14 As the population of women over 65 increases, vulvar cancer in older individuals has and will continue to become more prevalent. To better understand vulvar cancer trends and patterns of disparities in mortality, we examined survival between different age groups with invasive squamous cell carcinoma of the vulva over time. Our analyses indicate that, compared with younger women, older women were more likely to present with advanced disease and less likely to undergo surgery and lymph node dissection, but were more likely to receive primary radiation. After adjusting for standard treatment and other confounders, there was a difference in vulvar cancer-specific survival for older women in all the time periods analysed. When looking at the survival for the entire cohort, older women also had significantly worse disease-specific survival. Strengths and limitations This investigation includes a large population-based cohort of patients with up to 20 years of follow-up. SEER data not only provide reliable information on tumour stage, grade, and demographics, but also include information on long-term follow-up of vital status. However, there are some limitations to the present analysis that must be considered when interpreting the data. First, our investigation may have benefitted from adjustment for co-morbid conditions, health insurance, or socio-economic status. In addition, a possible confounding factor in our study is that elderly women are more likely to die of causes other than their vulvar cancer, resulting in an apparent decrease in survival. For that reason we evaluated cancer-specific survival. Misclassification of the cause of death is possible in the SEER dataset; however, our method of censoring cases by cause of death would have resulted in a bias toward underestimation of the effect of age on cancer-related deaths in our analysis. In addition, evidence suggests that the accuracy of cause-of-death coding for cancer patients on death certificates and in SEER is high. Furthermore, analysing temporal differences in survival using the SEER dataset can be complicated by a number of factors that could bias the results, including changes in disease classification, different staging systems utilised over time and improvements in diagnostic tests For example, staging information was missing in a number of women in our study. Additionally, outcomes may be affected by differences in treatment protocols, health care access, health behaviour attitudes, regional customs, socio-economic status and environmental exposures. 20 Finally, chemotherapy is not available in SEER and was not included in our analysis. 722

5 Outcomes for elderly women with vulvar cancer Stage I Stage II Percent survival P < Percent survival P < Survival time (Months) Survival time (Months) Stage III Stage IV Percent survival P < Percent survival P < Age group < Survival time (Months) Survival time (Months) Figure 1. Kaplan Meier survival curves showing mortality for women diagnosed with vulvar cancer by age group. Interpretation The literature on the relation of age and vulvar cancer survival is sparse. Based on SEER data, Kumar et al. 5 reported a significant survival difference between younger and older women with squamous cell vulvar cancer. In their study, survival was compared between women younger that 50 years and women 50 years and older diagnosed between 1998 and After controlling for race, stage, grade, and surgical treatment, older women had an almost a four-fold increased risk for death. In a study by Stroup et al. 21 utilising cases identified from the National Cancer Institute s Patterns of Care Study (POC) with SEER data, the authors analysed survival among women with vulvar cancer diagnosed in the USA in In their analysis, women 75 years and older and women with invasive disease had a greater risk of cancer death compared with women <50 years old and women with in situ disease, respectively. The present analysis supports these findings. Over the entire study period, after adjusting for treatment and prognostic factors, younger age remained significantly associated 723

6 Rauh-Hain et al. Table 3. Effect of various factors on mortality in patients with vulvar cancer. SEER Program, Characteristic Vulvar cancer mortality, HR Age group <50 years years 1.91 ( ) years 4.01 ( ) 80 years 6.98 ( ) Surgery No surgery Surgery 0.38 ( ) Unknown 1.09 ( ) Diagnosis year ( ) ( ) Race White African-American 0.72 ( ) Other 0.82 ( ) Marital status at diagnosis Married Unmarried 1.05 ( ) Unknown 0.89 ( ) SEER Registry Central East 0.91 ( ) West 0.86 ( ) Stage IA IB 1.95 ( ) INOS 2.24 ( ) II 3.58 ( ) III 7.56 ( ) IV ( ) Unknown 4.52 ( ) Grade I II 1.38 ( ) III 1.60 ( ) Unknown 0.70 ( ) Radiation No radiation Radiation 1.44 ( ) Unknown 1.50 ( ) Malignancies One Multiple 0.53 ( ) with improved vulvar cancer-related mortality compared with older age. This was also confirmed in all the time periods analysed. Prior studies suggest that older women diagnosed with cancer are less likely to receive standard cancer treatment compared with younger patients, even though such treatments are potentially curative. 22,23 Consistent with these reports, in the current analysis we found that older age at diagnosis was highly associated with an increasing likelihood for surgical undertreatment. In addition, in the present investigation the largest differences in survival between the groups were more evident in women with early stage disease. These findings are concerning because surgical resection of localised vulvar cancer is essential for the best possible survival outcomes. Performing surgical resection of localised vulvar cancer in older women involves weighing potential long-term benefits against an increased risk of peri-operative morbidity and death. Plausible explanations for decreased utilisation of surgery in the elderly in the present analysis may include the higher rate of advanced stage at diagnosis; however, it is unlikely that the difference observed in the rates of advanced stage could explain the entire difference, particularly because stage was included in the logistic regression model. High burden of medical co-morbidities, financial and geographic barriers to care, and patient preferences might also influence treatment. 24,25 It is clear from these data that there is a delay in early and accurate diagnosis of vulvar cancer in the elderly population. These findings have important clinical implications. Older women are less likely to conduct home self-examinations of the vulva or undergo routine gynecologic examinations, and frequently do not seek medical treatment for complaints associated with vulvar dysplasia. In addition, studies suggest that physicians contribute to the delay in diagnosis by providing treatment for the incorrect diagnosis for up to 1 year before obtaining a biopsy or considering referral. 26 Therefore, it is essential that women recognise the need for continued gynecologic examinations and the importance of the evaluation of vulvar lesions. Although there are no supporting data, expert opinion recommends routine annual visual inspection of the external genitalia, even if the woman is no longer receiving annual Papanicolaou smears. This recommendation may be even more relevant in the setting of new cervical cancer screening guidelines suggesting that screening can be discontinued in women after age 65 provided they have had adequate recent screening. 27,28 In addition, teaching women about vulvar self-examination as part of their preventive health care routine has also been advocated Conclusion The current study uses a national, population-based data sample to show that there are significant survival differences by age in women with vulvar cancer. Specifically, we found that women over 50 years are at a higher risk of vulvar cancer-specific mortality, which increases with age, and these trends stayed relatively constant over the time periods 724

7 Outcomes for elderly women with vulvar cancer studied. Furthermore, we observed that older age at diagnosis was highly associated with an increasing likelihood for surgical undertreatment. These results suggest that more progress is needed towards addressing disparities in the approach to vulvar cancer and the need for better treatments of this fairly rare disease. As the life expectancy has been increasing, older women represent a growing population with this disease. As chronological age is a poor descriptor of functional age, studies in elderly women should investigate factors other than chronological age, such as functional and nutritional status, presence of other co-morbidities, cognitive functioning or presence of adequate of social support. 30 Understanding the potential benefits, as well as compliance and refusal reasons, of the care for vulvar cancer in the elderly and providing relevant approaches will be an important tool to aid in clinician s daily practice and decision-making, because excellent modalities exist to diagnose and treat vulvar cancer. Disclosure of interests The authors declare that there are no conflicts of interest. Contribution to authorship JAR made substantial contributions to the conception and design of the study, acquisition, analysis and interpretation of data and drafting and revising the manuscript. JC substantially contributed to the acquisition, analysis and interpretation of data and drafting and revising the manuscript. RMC substantially contributed to the analysis and interpretation of data and drafting and revising the manuscript. LSB made substantial contributions to the conception and design of the study, interpretation of data and drafting and revising the manuscript. WBG made substantial contributions to the analysis and interpretation of data and drafting and revising the manuscript. AG substantially contributed to the conception and design of the study, analysis and interpretation of data and drafting and revising the manuscript. DB substantially contributed to the conception and design of the study, analysis and interpretation of data and drafting and revising the manuscript. DD made substantial contributions to the conception and design of the study, acquisition, analysis and interpretation of data and drafting and revising the manuscript. JOS made substantial contributions to the conception and design of the study, acquisition, analysis and interpretation of data and drafting and revising the manuscript. MGD made substantial contributions to the conception and design of the study, acquisition, analysis and interpretation of data and drafting and revising the manuscript. All authors approved the final version. Details of ethics approval Because all information from the Surveillance, Epidemiology, and End Results (SEER) Program data is de-identified, informed consent by the women involved in the study and approval of an ethics committee were not necessary in this investigation. Funding This work was supported by The Deborah Kelly Center for Outcomes Research, Massachusetts General Hospital. Acknowledgement This work was supported by The Deborah Kelly Center for Outcomes Research, Massachusetts General Hospital. Supporting Information Additional Supporting Information may be found in the online version of this article: Table S1. Demographic and clinical characteristics of the study population: SEER Program, Table S2. Cox proportional hazards models for vulvar cancer-specific mortality comparing age groups, stratified by stage. SEER Program, & References 1 Judson P, Habermann E, Baxter N, Durham S, Virnig B. Trends in the incidence of invasive and in situ vulvar carcinoma. Obstet Gynecol 2006;107: Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin 2011;61: Beller U, Quinn M, Benedet J, Creasman W, Ngan H, Maisonneuve P, et al. Carcinoma of the vulva. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006;95(Suppl 1):S Woelber L, Trillsch F, Kock L, Grimm D, Petersen C, Choschzick M, et al. Management of patients with vulvar cancer: a perspective review according to tumour stage. Ther Adv Med Oncol 2013;5: Kumar S, Shah JP, Bryant CS, Imudia AN, Morris RT, Malone JM Jr. A comparison of younger vs older women with vulvar cancer in the United States. Am J Obstet Gynecol 2009;200:e Fuh KC, Berek JS. Current management of vulvar cancer. Hematol Oncol Clin North Am 2012;26: Schonberg MA, Marcantonio ER, Li D, Silliman RA, Ngo L, McCarthy EP. Breast cancer among the oldest old: tumour characteristics, treatment choices, and survival. J Clin Oncol 2010;28: Cykert S, Dilworth-Anderson P, Monroe MH, Walker P, McGuire FR, Corbie-Smith G, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA 2010;303: Sharma C, Deutsch I, Horowitz DP, Hershman DL, Lewin SN, Lu YS, et al. Patterns of care and treatment outcomes for elderly women with cervical cancer. 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8 Rauh-Hain et al. 11 Hacker NF. Revised FIGO staging for carcinoma of the vulva. Int J Gynaecol Obstet 2009;105: US Census Bureau. US interim projections by age, sex, race, and Hispanic origin, 2004 [ proj/natprojtab 02a.pdf]. Accessed 15 September Yancik R. Population aging and cancer: a cross-national concern. Cancer J 2005;11: Spencer RJ, Young RH, Goodman A. The risk of squamous cell carcinoma in persistent vulvar ulcers. Menopause 2011;18: Chang GJ, Skibber JM, Feig BW, Rodriguez-Bigas M. Are we undertreating rectal cancer in the elderly? An epidemiologic study Ann Surg 2007;246: Kircher T, Nelson J, Burdo H. The autopsy as a measure of accuracy of the death certificate. N Engl J Med 1985;313: Percy C, Stanek E III, Gloeckler L. Accuracy of cancer death certificates and its effect on cancer mortality statistics. Am J Public Health 1981;71: Percy CL, Miller BA, Gloeckler Ries LA. Effect of changes in cancer classification and the certificates on trends in cancer mortality. Ann N Y Acad Sci 1990;609: Brinkley D, Haybittle JL, Alderson MR. Death certification in cancer of the breast. BMJ 1984;289: Cornelison TL, Trimble EL, Kosary CL. SEER data, corpus uteri cancer: treatment trends versus survival for FIGO stage II, Gynecol Oncol 1999;74: Stroup AM, Harlan LC, Trimble EL. Demographic, clinical, and treatment trends among women diagnosed with vulvar cancer in the United States. Gynecol Oncol 2008;108: Bennett CL, Greenfield S, Aronow H, Ganz P, Vogelzang NJ, Elashoff RM. Patterns of care related to age of men with prostate cancer. Cancer 1991;6: Greenfield S, Blanco DM, Elashoff RM, Ganz PA. Patterns of care related to age of breast cancer patients. JAMA 1987;257: Hamel MB, Teno JM, Goldman L, Lynn J, Davis RB, Galanos AN, et al. Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med 1999;130: Muss HB, Cohen HJ, Lichtman SM. Clinical research in the older cancer patient. Hematol Oncol Clin North Am 2000;14: Canavan TP, Cohen D. Vulvar cancer. Am Fam Physician 2002;66: , Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012;137: Moyer VA. Test article sample title placed here. Ann Intern Med 2012;156: Crum CP. Carcinoma of the vulva: epidemiology and pathogenesis. Obstet Gynecol 1992;79: Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27:

9 Outcomes for elderly women with vulvar cancer We should be able to provide better vulva cancer treatment to older women WR Brewster Obstetrics Gynecology, University of North Carolina, Chapel Hill, NC, USA Mini commentary on Management and outcomes for elderly women with vulvar cancer over time In the USA, vulvar cancer is diagnosed in fewer than 4500 women annually. The findings presented by Rauh-Hain confirm, vulvar cancer typically affects women over the age of 50 years. The majority of women analysed in this study (79%) were older than 65 years and almost 25% were older than 80 years. Furthermore, Rauh-Hain et al. show that 30% of vulvar cancers in women over 80 years of age are advanced at the time of presentation (stage III or IV). This may reflect the lack of established screening or early detection programmes. Gynaecologic cancer screening guidelines that reduce the possibility of pelvic examination after age 65 limit the opportunity for visual identification of small vulvar cancers in the elderly, and increase the likelihood that vulvar cancer will only be identified following the onset of symptoms or when of sufficient size to be noticed by a caregiver. The data presented in this paper show that women over the age 80 are far less likely to receive surgical treatment to the vulva or groin compared with younger women, irrespective of their stage of presentation. Furthermore, the risk of death from vulvar cancer increases with advancing age even after controlling for multiple demographic and treatment variables, including stage of presentation. The use of the SEER database limits our ability to interpret these findings. The SEER database does not identify the women with advanced disease who received treatment with only a palliative intent. Nor does it provide data about the adjuvant use of chemotherapy, although one could expect a similar disparity. Nonetheless, this study raises the possibility that elderly women in the USA are routinely receiving inadequate treatment for vulvar cancer with inevitable consequences for their prognosis. Competing co-morbidities can affect our ability to deliver optimum care. Clinicians are frequently tasked with modifying standard of care to deliver treatment safely under challenging circumstances. Several reports from other disease sites have demonstrated the less rigorous application of treatment guidelines in the care of the elderly (Townsley C, et al. J Clin Oncol 2005;23: and Freedman RA, et al. J Clin Oncol 2009;27:713 9). The fastest growing sector of the population in the USA consists of elderly women who are vulnerable to vulvar cancer and have the greatest likelihood of dying of this disease. Improved treatment of the elderly mandates an improved understanding of risk perception among older patients, well designed clinical trials that include sufficient numbers of elderly women, and better understanding of the tolerance of various treatments by this age group. Surely we can do better than this? Disclosure of interests The author has no conflicts of interest to declare. 727