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Most patients with ovarian cancer fail to receive recommended treatment
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Adherence to National Comprehensive Cancer Network guidelines is associated with significantly longer OS among patients with ovarian cancer, yet nearly two-thirds of patients do not receive guideline-recommended treatment, according to study results presented at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer.
Treatment at high-volume hospitals, defined as those that treat 20 or more patients with ovarian cancer each year, and treatment by high-volume surgeons — defined as those who treat at least 10 such patients annually — were more likely to adhere to NCCN guidelines.
Low-volume hospitals may not have access to gynecologic oncologists who specialize in this type of care, the researchers wrote.
Robert E. Bristow
“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 their ovarian cancer patients’ rates of survival,” Robert E. Bristow, MD, MBA, FACS, director of gynecologic oncology services at UC Irvine Healthcare, said in a press release. “If a surgeon only performs two ovarian cancer surgeries a year, you don’t want to be one of those two.”
Ovarian cancer is the fifth leading cause of death among American women. An estimated 22,240 new cases will be diagnosed in the United States this year, and 15,500 women will die from the disease, according to the American Cancer Society.
Bristow and colleagues used data from the California Cancer Registry to validate NCCN guideline adherence as a quality process measure associated with improved survival among patients with ovarian cancer. They also aimed to identify structural health care characteristics that were predictive of guideline-recommended care.
They defined adherence to NCCN guideline care by stage-appropriate surgical procedures and recommended chemotherapy. They also used multivariate logistic regression models to identify treatment-, patient- and disease-related characteristics that were independently predictive of OS and adherence to NCCN guidelines.
The researchers identified 13,321 consecutive patients diagnosed with epithelial ovarian cancer from 1999 to 2006 who underwent a minimum surgical procedure of oophorectomy.
Of them, 37.2% received care that adhered to NCCN guidelines — 18.8% were treated at high-volume hospitals and 16.4% underwent surgeries performed by high-volume surgeons.
High-volume hospitals were significantly more likely than low-volume hospitals to deliver care that adhered to NCCN guidelines (50.8% vs. 34.1%; P<.001), study results showed. High-volume surgeons were significantly more likely than low-volume surgeons to adhere to guidelines (47.6% vs. 34.5%; P<.001), the researchers found.
When Bristow and colleagues controlled for other factors, they determined low-volume hospitals (OR=1.83; 95% CI, 1.66-2.01) and low-volume surgeons (OR=1.19; 95% CI, 1.07-1.32) were independently associated with deviation from NCCN guidelines.
Multivariate analysis demonstrated nonadherence to the guidelines was independently associated with shorter OS (HR=1.34; 95% CI, 1.26-1.42).
When researchers adjusted for NCCN guideline adherence, they determined low-volume surgeons (HR=1.18; 95% CI, 1.09-1.28) and low-volume hospitals (HR=1.08; 95% CI, 1.01-1.16) were independently associated with inferior OS.
“We have a lot of room to improve,” Bristow said. “One option might be to concentrate care in high-volume hospitals, but there are obviously other factors at work. We need to become more sophisticated and to determine what the best-performing physicians are doing different from everyone else, establish best practices and then enforce them to improve outcomes.”
For more information:
Bristow RE. Abstract #45. Presented at: Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer; March 9-12, 2013; Los Angeles.
Perspective
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David O’Malley, MD
Clearly, we all need to do better adhering to and performing evidence-based medicine, and NCCN guidelines are evidenced-based medicine.
We have a large amount of data that suggest patients do better when they are seen by GYN oncologists, who have specialty training in ovarian cancer in both surgery and chemotherapy administration. This paper showed centers that handle a high volume of cases, as well as surgeons who treat a high volume of patients, did significantly better adhering to NCCN guidelines.
Patients with ovarian cancer should make every effort to be seen at an institution — and by a physician — that treats a large number of patients. This is one of those diseases in which being seen by an expert adds years to survival. However, there still is tremendous room for improvement.
The researchers in this study were not able to do risk stratification. There may have been risks, comorbidities or other reasons why the algorithms were not applied, but that still does not explain a 50% nonadherence rate at high-volume centers or by high-volume surgeons.
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