ORLANDO – Only a minority of women in the Medicare population with advanced epithelial ovarian cancer receive optimal therapy with a combination of surgery and six cycles of chemotherapy, according to a large, retrospective study.
Of the 8,211 women diagnosed with stage III or IV epithelial ovarian cancer between 1995 and 2005, 3,241 or 39%, received full dual combination therapy as recommended by the National Institutes of Health consensus statement on Treatment of Advanced Ovarian Cancer.
Older age, nonwhite race, stage IV disease, and higher medical comorbidity were significantly associated with suboptimal care in the current study. In addition, unmarried women and women living in the Midwest were more likely not to complete treatment.
Physicians could focus on improving quality of medical care for these women, including greater referral to gynecologic oncologists, Dr. Melissa Thrall said at the annual meeting of the Society of Gynecologic Oncologists.
"Among U.S. women with ovarian cancer over age 65, many do not receive multimodality therapy," Dr. Thrall said. "Some of this is likely due to medical infirmity, as evidenced by the association of older age, higher stage, and comorbidity scores with failure to complete treatment. However, the associations with marital status and geographic location suggest there are other modifiable factors in this failure to complete therapy, such as lack of social support or the unavailability of gynecologic oncologists."
"It is truly disappointing, shocking, and sad to hear that merely one out of three patients in this study received the standard-of-care treatment," said study discussant Dr. Michael Carney, who is on the gynecologic oncology faculty at the University of Hawaii in Honolulu.
Women were classified according to their initial treatment: Fifty-nine percent had primary debulking surgery, and 24% had primary chemotherapy. The remaining 17% had no evidence of either treatment in their Medicare claims within 1 year of their diagnosis.
"The survival for these [untreated] women is short, and reminds us we need to keep working on increasing the awareness of the symptoms of ovarian cancer, to work toward prompt diagnosis and referral so more of these women can be offered treatment," said Dr. Thrall, a fellow in the division of gynecologic oncology at the University of Washington in Seattle.
Dr. Thrall and her colleagues identified women older than 65 diagnosed with stage III/IV epithelial ovarian cancer from 1995 to 2005 using the Surveillance, Epidemiology, and End Results (SEER) database. Treatment was identified using linked data to Medicare hospital, provider, and outpatient center claims.
A total 75.8% of the primary surgery patients had subsequent chemotherapy, and 32.2% of the primary chemotherapy group had ovarian cancer-directed surgery.
A total of 4,307 women (52.4%) had surgery and at least one cycle of chemotherapy (in either order) in the first year following diagnosis. Dr. Carney said, "Sadly, this means about 50% receive no chemotherapy after initial surgery, no surgery after initial chemotherapy, or no surgery or chemotherapy at all."
Dr. Thrall reported that a large proportion of women in the primary chemotherapy group did not have any surgery (68% of the 2,017 women). Women were significantly more likely to receive primary chemotherapy based on increasing age, increasing stage, and comorbidity score in a multivariate analysis. In addition, African American women were more likely to receive primary chemotherapy, she said. Histology also made a difference – women with serous tumors were more likely to get primary chemotherapy, compared with those with endometrioid or clear cell histology.
Dr. Carney described the paper as "important and timely for several reasons." Medicine is now focusing more on quality as an outcome measure. In addition, "in ovarian cancer we have a pretty good idea what appropriate treatment should be – surgery, chemotherapy, and specialty care, all resulting in improved survival."
It makes sense in this paper, Dr. Carney said, that if a patient has more advanced cancer, is older, or has many medical comorbidities, that patient is more likely to receive a chemotherapy or neoadjuvant chemotherapy approach. "Things that don’t make sense: Why are patients more likely to receive chemotherapy initially based on race alone, particularly African American? Why is marriage a significant variable? Why does living in the Midwest lower the rate of receiving standard-of-care treatment?"
A reliance of billing claims for treatment data and no information on why a particular treatment sequence was selected and why treatment was incomplete are among the study limitations, Dr. Thrall said. In addition, treatment information came from billing data. Also, the study was limited to women aged older than 65 years. However, Dr. Thrall said, "median age of ovarian cancer diagnosis is 64 years, so these data represent about 50% of women with ovarian cancer in the U.S."