Trends in treatment of advanced epithelial ovarian cancer in the Medicare population☆
Research highlights
► Only a minority with advanced ovarian cancer in the Medicare age are receiving guideline therapy. ► Many are receiving chemotherapy only for advanced ovarian cancer without surgery.
Introduction
Ovarian cancer is the most lethal gynecologic malignancy and the fourth leading cause of cancer death among women in the US. In 2010 an estimated 21,880 American women will be newly diagnosed with ovarian cancer and 13,850 women will die of the disease [1]. Survival in epithelial ovarian cancer is strongly related to stage of disease, and the majority of patients present with advanced stage (III/IV) disease at the time of diagnosis. Advances in the treatment of ovarian cancer in the past twenty years have been associated with an improvement in the likelihood of 5-year survival from 34.8% in 1975 to 45.6% from 1999 to 2006 [2]. This increase is thought to be largely a result of advances in ovarian cancer-directed surgery and the use of platinum based chemotherapy [3].
Current guidelines from the National Comprehensive Cancer Network (NCCN, 2010) and earlier ones issued by the National Institutes of Health (NIH, 1994) recommend that primary treatment for most patients with advanced ovarian cancer should include primary debulking surgery (PDS) with a maximal cytoreductive effort and at least 6 cycles of systemic chemotherapy [4], [5]. Despite these recommendations, previous studies have suggested that many women with ovarian cancer may not receive recommended surgical procedures [6], [7].
Administering chemotherapy as a treatment for advanced ovarian cancer prior to planned surgery is referred to as neoadjuvant chemotherapy (NAC), and the practice is controversial and generally reserved for women who are poor surgical candidates [8], [9]. The administration of chemotherapy without the intent to proceed to surgery is considered palliative chemotherapy. The proportion of patients nationwide with advanced ovarian cancer primarily treated with palliative chemotherapy has not been well described as these patients are often excluded from studies.
The primary purpose of this study is to describe the receipt and sequencing of surgery and chemotherapy in the primary treatment of advanced ovarian cancer in the US Medicare population. This analysis provides an assessment of how recommended therapies are being utilized in the general community and how this has changed over time. The secondary aims are to identify factors associated with the receipt of chemotherapy as a primary treatment for ovarian cancer and to determine the factors associated with the receipt of both ovarian cancer-directed surgery and completion of 6 cycles of chemotherapy in this population.
Section snippets
Data source
Internal Review Board approval was obtained from the Human Subjects Division of the University of Washington (IRB 37473). Data for this analysis came from a linkage between the Surveillance Epidemiology, End Results (SEER) database provided by the National Cancer Institute (NCI) and Medicare healthcare claims records provided by the Center for Medical Services (CMS) [10]. The SEER database is derived from the records of cancer registries that served approximately 14% of the US population in
Results
Of 8211 women with advanced epithelial ovarian cancer, 4827 (58.8%) were treated with primary debulking surgery (PDS), 2017 (24.6%) were treated with primary chemotherapy, and 1367 (16.6%) had no evidence of either surgery or chemotherapy. Demographic, clinical and pathological characteristics of these groups are shown in Table 1. Women treated with PDS tended to be younger than those treated with primary chemotherapy and those who did not get any treatment. Untreated women were relatively more
Discussion
Guidelines for primary treatment of advanced ovarian cancer from the National Comprehensive Cancer Network (NCCN) and National Institutes of Health (NIH) recommend primary debulking surgery (PDS) with maximal cytoreductive effort followed by at least 6 cycles of systemic platinum based chemotherapy, or alternatively neoadjuvant chemotherapy followed by interval cytoreductive surgery. Failure to receive surgery and platinum-based chemotherapy has been associated with a decrease in survival for
Conflict of interest statement
The authors have no conflicts of interest to report.
Acknowledgments
This work was supported by the Marsha Rivkin Center for Ovarian Cancer Research. Dr. Thrall is the recipient of the Scientific Scholar Award from the Rivkin Center. This work is also supported by the National Cancer Institute (NCI) at the National Institutes of Health, Dr. Thrall is the recipient of an NCI-funded postdoctoral fellowship (T32-CA009515-26). The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the
References (29)
- et al.
Conditional survival in ovarian cancer: results from the SEER dataset 1988–2001
Gynecol Oncol
(2008) - et al.
Ovarian cancer: patterns of surgical care across the United States
Gynecol Oncol
(2006) - et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases
J Clin Epidemiol
(1992) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chron Dis
(1987) - et al.
Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm
Gynecol Oncol
(2009) - et al.
Age contrasts in clinical characteristics and pattern of care in patients with epithelial ovarian cancer
Gynecol Oncol
(2002) - NCCN. Practice guidelines in Oncology v.2.2010 Ovarian Fallopian Tube and Primary Peritoneal Carcinomas. In;...
National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up
Gynecol Oncol
(1994)
The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer
N Engl J Med
The role of neoadjuvant chemotherapy in treating advanced epithelial ovarian cancer
J Surg Oncol
Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population
Med Care
Cited by (0)
- ☆
Presented at the Forty Second Annual Meeting of the Society of Gynecologic Oncologists, Orlando, Florida, March 6–9, 2011.