Elsevier

Gynecologic Oncology

Volume 122, Issue 1, July 2011, Pages 100-106
Gynecologic Oncology

Trends in treatment of advanced epithelial ovarian cancer in the Medicare population

https://doi.org/10.1016/j.ygyno.2011.03.022Get rights and content

Abstract

Objective

Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy.

Methods

Using the Surveillance, Epidemiology and End-Results data we identified a cohort of 8211 women aged 65 and above with stage III/IV epithelial ovarian cancer diagnosed between 1995 and 2005. Receipt of chemotherapy or surgery was identified using Medicare claims. Logistic regression was used to evaluate factors associated with sequencing of treatment and the receipt of surgery.

Results

3241 (39.1%) had surgery and at least 6 cycles of chemotherapy in either order. Surgery was performed initially in 4827 (58.8%) women and 3658/4827 (75.8%) had subsequent chemotherapy. 2017 (24.6%) had primary chemotherapy and 649/2017 (32.2%) of these women had subsequent surgery. Advanced age, African American race, stage IV disease, non-married status and increasing medical comorbidity were all associated with the failure to receive both surgery and at least 6 cycles of chemotherapy (all p < 0.01).

Conclusions

The majority of women with advanced ovarian cancer in the Medicare population do not receive both combination therapy with surgery and at least 6 cycles of chemotherapy. A large proportion of women are receiving chemotherapy as primary treatment for advanced ovarian cancer, and the majority of these patients do not have cancer-directed surgery.

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

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    Presented at the Forty Second Annual Meeting of the Society of Gynecologic Oncologists, Orlando, Florida, March 6–9, 2011.

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