Aggressive Treatment of Ovarian Cancer Not Supported By Science

Crina Frincu-Mallos, PhD

November 19, 2009

November 19, 2009 (Philadelphia, Pennsylvania) — A survey designed to collect information on practice patterns of physicians treating women at high risk for ovarian cancer shows an increase in the aggressiveness of treatment in the past 7 years, according to research presented here at the American Public Health Association 137th Annual Meeting.

In 2001, the Cancer Genetics Network (CGN) began a screening study in women at high risk for ovarian cancer, based on rising CA125 blood levels, said Heather L. Symecko, MPH, a program manager at the Biostatistics Center at Massachusetts General Hospital in Boston.

Researchers collected longitudinal CA125 data to screen healthy women with a family history of ovarian cancer, aiming to detect elevated or changing levels of serum CA125 using a statistical algorithm — hence, the name of the study: Risk of Ovarian Cancer Algorithm (ROCA). The investigators calculated ovarian cancer risk and based their treatment recommendations accordingly: to redo the test in 3 months, to refer the patient for transvaginal ultrasound, or to refer the patient for surgery.

2001 vs 2008: Treatment Choices for Women at Risk for Ovarian Cancer

Practice patterns in 2001 were compared with those in 2008.

"In order to determine if practice patterns have changed over the past 7 years, a follow-up survey was distributed to the participating centers," Ms. Symecko told Medscape Public Health & Prevention. Physicians from 12 of the 15 clinical centers participating in CGN agreed to take part in this survey. She noted that pre- and posttrial surveys were not matched by individual physician; however, the respondents' demographics (median age, years in practice, board-certification specialty) suggested that they are the same cohort.

In addition to demographic information for the treating physicians, the questionnaire included identification of tools used to classify a patient as high risk, use of CA125 testing and transvaginal ultrasound in screening, and use of risk-reducing salpingo-oophorectomy and hormone-replacement therapy in patient management.

More Testing, More Salpingo-Oophorectomies at an Earlier Age

"We found an increase in the aggressiveness of how physicians were treating ovarian cancer; they are using CA125 [testing] more in 2008, as opposed to 2001," she said. Physicians who were board-certified in gynecology (including gynecologic oncology) reported a 30% increase in CA125 testing in premenopausal women between 2001 and 2008. Similarly, physicians who were board-certified in medicine or medical oncology reported about 10% more CA125 testing in 2008 than in 2001. There was also an increase in the frequency of testing, from every 6 months in 2001 to every 3 months in 2008.

"We also asked [physicians] about the recommended age for risk-reducing salpingo-oophorectomy, and we found that they were recommending it earlier in 2008 than they were in 2001," Ms. Symecko said.

"An increase in the percentage of women undergoing salpingo-oophorectomy — and at earlier ages — was also noted," she added. In 2001, 38% of BRCA-positive women between 35 and 40 years of age had salpingo-oophorectomies, compared with 48% in 2008.

Data presented earlier this year at the annual meeting of the American Society of Clinical Oncology showed that there is no survival benefit from early treatment based on elevated blood levels of CA125, so there was no value in the routine measurement of CA125 in the follow-up of ovarian cancer patients.

In 2008, for all women under the age of 50 without a history of breast cancer but who were BRCA mutation carriers, all physicians recommended salpingo-oophorectomy followed by hormone-replacement therapy. This was a practice that was unchanged from 2001. However, if women with the BRCA mutation had a previous diagnosis of breast cancer, an increasing number of physicians recommended short-term hormone-replacement therapy — 70% of physicians in 2008, compared with 50% in 2001.

Currently, Practice Lacks Supporting Scientific Evidence

"That's what the physicians are doing," said Ms. Symecko, who acknowledges that the results are not necessarily "generalizable across all physicians, [because] this was a group of physicians at academic universities who were recruiting for an ovarian study," in total 20 respondents in 2001 and 14 in 2008.

The next step is "to get studies like the ROCA done, to actually find out the significance, sensitivity, and specificity of CA125 testing, because the physicians are all using it, and they are using it frequently," she observed.

"Physicians are mostly interested in knowing what to do next," Paul Meissner, MSPH, director of Research Program Development at Montefiore Medical Center in the Bronx, New York, said in an interview with Medscape Public Health & Prevention. "A study like this is a reflection of what they are doing, it's an issue around communicating what is actually known [about the CA125 biomarker] and getting it into the hands of people who can do something with it," he added.

"To get the science to back-up the practice is something that really needs to be done," concluded Ms. Symecko.

Ms. Symecko and Mr. Meissner have disclosed no relevant financial relationships.

American Public Health Association (APHA) 137th Annual Meeting: Abstract 203073. Presented November 9, 2009.

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