Objective We aimed to analyze management and survival outcomes of older people (≥75 years) with stage II+ epithelial ovarian cancer (EOC) across six gynaecological cancer centers in the United Kingdom.

Methods Retrospective cohort study performed using the IMPRESS project dataset. Clinical information for patients diagnosed with EOC from six sites of varying size and population demographics, was collated between 1/1/2018 and 31/12/2019. We compared treatment of patients aged ≥75 years with those <75, within and between centers, using multi-variate analysis, to understand effects on outcomes.

Results After exclusions, we assessed 721 people for overall survival (OS) and 702 for progression-free survival (PFS). The ≥75s had poorer performance status, more comorbidities and were less likely to receive combination treatment with surgery and chemotherapy (in either order) (overall = 392/721 (54.4%) overall; <75 cohort = 320/495 (64.6%); ≥75 cohort = 72/226 (31.9%). Treatment proportions varied between sites, with some having no active treatment rates of nearly 50% for ≥75s. Those ≥75 years had twice the relative risk of death compared to those <75 (Relative Risk (RR) = 1.98, 95% confidence intervals (CI) 1.63 to 2.39, P<0.001). Adjustment for confounders individually caused only a relatively modest reduction in magnitude and strength of association. Adjustment for treatment led to this association essentially disappearing (RR = 1.10, 95% CI 0.88 to 1.38; 99% reduction in Chi2), though with significant variation in association between age and OS between treatment groups (p-heterogeneity: 0.0004).

Conclusion Older women may do as well as younger women in terms of survival, if treated similarly, although this varies depending on treatment groups. Treatments varied between and within sites, with some sites treating older women more differently than others. Some differences may be appropriate, but significant differences in rates of no active treatment between sites suggests that not all variation may be appropriate.

Key messages What is already known on this topic?

Older patients with ovarian cancer are under-represented in clinical trials.

Optimal management of advanced ovarian cancer requires a combination of surgery and chemotherapy.

Management of older patients remains a challenging area due to the lack of consensus regarding optimal treatment strategies tailored to this population.

Evidence suggests that older patients often receive less aggressive treatment than younger counterparts, partly due to concerns about comorbidities and treatment tolerance, despite similar attitudes to treatment.

What this study adds?

Treatment of older patients varied between and within centers.

A greater percentage of older patients died within 30 or 90 days of diagnosis.

Older patients were less likely to have combination treatment with surgery and chemotherapy, especially in some centers.

Older patients who had combination treatment had similar outcomes to the younger cohort.

How this study might affect research, practice or policy?

Further work is needed to understand which older patients will do better if treated with surgery and/or chemotherapy and in which order, and to improve shared decision-making with our patients.

This study suggests that age alone should not be a barrier to enrolment in clinical studies and active recruitment of older people should be encouraged.

CF has received honoraria received for advisory boards from: Ethicon, Roche, AstraZeneca/MSD, Oncoinvent, GSK. RJE has received institutional grant funding from Ovarian Cancer Action for the IMPRESS study and honoraria from GSK and AstraZeneca. None of the other authors declared a conflict of interest.

The IMPRESS study was funded by a grant from Ovarian Cancer Action (RE). No specific funding was received for this sub-study. KG was partly supported by the CRUK Oxford Centre (grant no. CTRQQR-2021\100002). JM and VC were partly supported by a Medical Research Council/National Institute for Health and Care Research Clinical Academic Research Partnership grant MR/X030776/1.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethical approval was granted from the Health Research Authority (HRA) and Health and Care Research Wales for data collection and storage (ref 22/HRA/3264)

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Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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we will provide our data for independent analysis by a selected team for the purposes of additional data analysis or for the reproducibility of this study in other centers, if such is requested, if in accordance with the ethical approval requirements.