Many Ovarian Cancer Patients Not Receiving Recommended Treatment

Zosia Chustecka

March 11, 2013

Although guideline-recommended treatment for ovarian cancer improves survival, only 37% of women receive such treatment, a new study shows.

This finding was presented at the Society of Gynecologic Oncology (SOG) 44th Annual Meeting on Women's Cancer, being held in Los Angeles, California.

"We have a lot of room to improve," said lead author Robert E. Bristow, MD, director of the division of gynecologic oncology at the University of California, Irvine Medical Center.

Dr. Bristow and colleagues analyzed data from the California Cancer Registry on 13,321 consecutive patients with epithelial ovarian cancer treated from 1999 to 2006.

Only 37.2% of these patients were treated according to National Comprehensive Cancer Network (NCCN) guidelines. Adherence to care was defined by stage-appropriate surgical procedures and recommended chemotherapy, the researchers explain.

Multivariate analysis controlling for factors related to the patient, disease, and healthcare system showed that nonadherence to NCCN guidelines was independently associated with inferior overall survival (hazard ratio, 1.34).

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

"This is an interesting analysis....[but] caution is advised in the interpretation of these population-based data," said Maurie Markman, MD, national director for medical oncology at the Cancer Treatment Centers of America, clinical professor at Drexel University College of Medicine in Philadelphia, and Medscape video blogger for Markman on Oncology.

"It is critical to recognize that the database does not permit these investigators to know why a particular management option was selected or rejected, and such decisions might include both existing comorbidity and patient choice. Further, it is appropriate to inquire if the existing database actually permits a rigorous analysis of whether or not individual physicians followed particular guidelines," Dr. Markman told Medscape Medical News.

Volume Matters

The data showed that the factor most predictive of NCCN guideline adherence was the annual volume of ovarian cancer cases. High-volume hospitals (>20 cases annually) were significantly more likely to deliver guideline-adherent care than low-volume hospitals (50.8% vs 34.1%; P < .001). In addition, high-volume surgeons (>10 cases annually) were significantly more likely to deliver guideline-adherent care than low-volume surgeons (47.6% vs 34.5%; P < .001).

"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 noted.

Majority Treated in Low-Volume Settings

The majority of patients were treated at low-volume hospitals (81%) and by low-volume surgeons (62%). However, only 51% of patients treated in high-volume hospitals received guideline-adherent therapy, and only 48% of patients treated by high-volume surgeons did.

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

"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, acting as an official spokesperson for the SGO, said 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 told Medscape Medical News.

"We know that proper surgery with maximum cytoreduction by a gynecologic oncologist can improve outcomes," he said. 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.

In addition, physicians with specialist training might be more comfortable with the intraperitoneal administration of chemotherapy. Another study presented at the SOG annual meeting showed better survival with intraperitoneal administration than with intravenous administration.

The current NCCN guidelines state that both routes of chemotherapy administration are acceptable. This may change in the future, Dr. O'Malley noted. Evidence for the superiority of intraperitoneal administration is growing, although there are still several large trials awaiting publication, he said.

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