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Most ovarian cancer patients not receiving recommended treatment

Teresa Tanoos's picture
Ovarian cancer patients not getting adequate care

Most women with ovarian cancer fail to receive adequate care and miss out on treatments that could add a year or more to their lives, a new study shows. Indeed, only 37 percent of ovarian cancer patients receive such care, which improves their chances of survival.

Results from the study were presented Monday at a meeting of the Society of Gynecologic Oncology in Los Angeles.

"We have a lot of room to improve," said the study’s lead author Robert E. Bristow, MD, who is director of the division of gynecologic oncology at the University of California, Irvine Medical Center. “If we could just make sure that women get to the people who are trained to take care of them, the impact would be much greater than that of any new chemotherapy drug or biological agent,” he added.

For the study, Dr. Bristow and his colleagues analyzed the medical records of 13,321 women with ovarian cancer who were diagnosed and treated from 1999 to 2006. All the patients had the most common type, called epithelial ovarian cancer.

Only 37 percent of these patients were treated according to guidelines set by the National Comprehensive Cancer Network (NCCN), with such care defined by stage-appropriate surgical procedures and recommended chemotherapy, explained researchers.

This is the first large-scale population-based analysis to validate that the NCCN treatment recommendations correlate with improved clinical outcomes, Dr. Bristow said.

Such analysis found that surgeons who operated on 10 or more women a year for ovarian cancer – and hospitals that treated 20 or more a year – were more likely to stick to the guidelines. As a result, their patients lived longer.

Of the women who had advanced disease – the stage when ovarian cancer is usually first found – 35 percent survived at least five years if their care met the guidelines, compared to 25 percent of those whose care did not meet the guidelines.

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However, researchers said that more than 80 percent of the women in the study were treated by what they called “low-volume” providers – surgeons who had 10 or less cases a year, and hospitals with 20 or fewer.

Accordingly, Dr. Bristow advises women to ask surgeons how often they operate on women with ovarian cancer and how often they achieve complete debulking, which is when the residual tumor remaining after surgery is very small. However, he acknowledged that many patients hesitate to ask such questions for fear of offending the doctor who may operate on them, which may be one reason why so many women do not receive adequate treatment for ovarian cancer.

"There may be a number of reasons women do not receive guideline-adherent care. [For instance] low-volume hospitals may not have access to gynecologic oncologists who specialize in this care," Dr. Bristow said in a statement. "Patients need to be their own advocates and ask the provider and hospital how many ovarian cancer patients they treat, how many ovarian cancer surgeries they perform, and the survival rate of their ovarian cancer patients. If a surgeon only performs 2 ovarian cancer surgeries a year, you don't want to be 1 of those 2," he added.

Dr. Bristow further stated that, in many cases, physicians provided some of the recommended care, such as the appropriate chemotherapy or surgery, but not both. He also pointed out that not all patients should necessarily receive guideline-recommended care. For example, he noted, aggressive guideline-directed care might be more harmful than helpful to an elderly frail woman.

"One option might be to concentrate care in high-volume hospitals, but there are obviously other factors at work," he said. To improve outcomes, "we need to...determine what the best-performing physicians are doing that is different from everyone else, establish best practices, and then enforce them," he explained.

David O'Malley MD, assistant professor of obstetrics/genecology at Ohio State University in Columbus, told Medscape Medical News that adherence to the guidelines appears to depend on treatment being carried out by a gynecologic oncologist. "We don't know that from this study, but we suspect that this is the case," he said.

"We know that proper surgery with maximum cytoreduction by a gynecologic oncologist can improve outcomes," he added. In this study, "we suspect that a contributing factor is that high-volume hospitals have physicians with more experience," whereas low-volume hospitals might not have a trained gynecologic oncologist on board, and the treatment might be carried out by a general surgeon, a general gynecologist, or a general medical oncologist without any specialist gynecologic training, Dr. O'Malley explained.

According to the current NCCN guidelines, both routes of chemotherapy administration are acceptable, although Dr. O’Malley noted this may change in the future, adding that evidence for the superiority of intraperitoneal administration is growing, although there are still several large trials awaiting publication.

Society of Gynecologic Oncology (SOG) 44th Annual Meeting on Women's Cancer (Abstract 46. Presented March 11, 2013)
National Comprehensive Cancer Network (NCCN)