Many Ovarian Cancers Not Being Treated by Gynecologic Oncologists

Roxanne Nelson

March 10, 2011

March 10, 2011 — Surgical outcomes and overall survival can be improved in ovarian cancer when gynecologic oncologists are involved in the care. However, these specialists are not seeing many ovarian cancer patients.

A study investigating the reasons why was presented this week at the Society of Gynecologic Oncologist's Annual Meeting on Women's Cancer, in Orlando, Florida.

Most primary care physicians are not referring patients with a suspicious ovarian mass to gynecologic oncologists, but to obstetrician gynecologists, explained study author Barbara A. Goff, MD. However, "when we look at obstetrician gynecologists, two thirds say that they would refer a patient with a suspicious mass to a gynecologic oncologist, and most say that if there was cancer or if they were concerned that there was cancer they would get an gynecologic oncologist involved."

"But from what we've seen in large population-based studies, women are not getting referred to a subspecialist," said Dr. Goff, director of the division of gynecologic oncology at the University of Washington School of Medicine in Seattle. "So somewhere along the line there is a breakdown."

Response to Hypothetical Patient Different From Reality

Dr. Barbara Goff

In their study, Dr. Goff and colleagues surveyed 3200 randomly sampled physicians from the American Medical Association Physician Masterfile — there were equal numbers of family physicians, general internists, and obstetrician gynecologists. Their goal was to identify the factors associated with inclusion of a gynecologic oncologist in the management of women with suspected ovarian cancer.

The physicians were presented with a hypothetical patient: a 57-year-old woman with pain, bloating, and a right adnexal mass. Her ultrasound findings revealed a 10 cm complex mass with increased vascularity and ascites.

Among the obstetrician gynecologists who responded to the survey, 33.7% indicated they would perform surgery themselves and 66.3% recommended consultation or referral to another physician, primarily a gynecologic oncologist. In addition, 84% said they would ask a gynecologic oncologist to consult on the surgery.

Only 39.3% of family physicians would refer the hypothetical patient directly to a gynecologic oncologist, and just over 50% of internists would.

"In reality, if you look at what they are saying in terms of how they would respond to a hypothetical patient, they are taking the correct steps," Dr. Goff told Medscape Medical News. "So there is not a lack of knowledge."

"But we know from large population-based studies that the majority of women do not get operated on by gynecologic oncologists," she continued. "When you look at Medicare SEER [Surveillance, Epidemiology and End Results] databases or hospital discharge databases, that's not what is happening to patients at all. Somewhere there is a breakdown, and it's not from a lack of knowledge."

Family practice physicians and internists should be directly referring these women to gynecologic oncologists, rather than to obstetrician gynecologists, explained Dr. Goff. The American Congress of Obstetricians and Gynecologists have criteria for direct referral.

These criteria are based on ultrasound data, and are targeted toward obstetrician gynecologists, she said. "If the woman meets these criteria, they should be referred."

Variable Factors Involved

It is not clear at this time why patients are not getting referred to subspecialists. The authors did find, however, that physicians who were more likely to refer a patient directly to a gynecologic oncologist included female internists, those who were board certified, those who were part of a group practice, and those practicing in urban areas. Other variables were fewer years in practice, lighter weekly patient loads, and experience in clinical teaching.

Conversely, clinicians who were less likely to refer a patient directly to a gynecologic oncologist included male physicians, family physicians, solo practitioners, practitioners in rural locations, and practitioners with higher weekly patient loads.

Geography also appears to play a role. Gynecologists who reported that they would operate on the patient themselves were primarily located in small and remote rural practices. Those residing in the Mid Atlantic, East North Central, West South Central, and Pacific census regions were also more likely to perform surgery themselves.

Among internists and family practitioners, the only patient factor associated with lower referral rates was Medicaid insurance.

The authors note that previous studies have shown that direct referral to gynecologic oncologists for initial surgery correlates with fewer complications and improved survival.

Society of Gynecologic Oncologist's Annual Meeting on Women's Cancer. Presented March 6, 2011.

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