A retrospective analysis of Medicare claims for women with advanced epithelial ovarian cancer (EOC) found that only 39% of patients received optimal therapy as outlined by national treatment guidelines. Data were presented at a plenary session at the annual meeting of the Society of Gynecologic Oncology, taking place in Orlando this week. Discussant Michael Carney, MD, University of Hawaii, Honolulu, described the report as "disappointing, shocking, and sad."
For primary treatment of stage III-IV EOC, guidelines from the National Cancer Institute and the National Comprehensive Cancer Network call for cytoreductive surgery if possible and 6 to 8 cycles of adjuvant chemotherapy, generally with a taxane and a platinum. Strong consensus exists for this therapeutic regimen, which represents the standard of care at most comprehensive cancer centers.
Of the 8211 women included in the study, 59% (4827) underwent primary surgery; of these women, 75.8% went on to receive adjuvant chemotherapy but barely more than half (55%) completed 6 cycles. Among patients overall, another 24% received chemotherapy as their initial treatment, and only 32.2% of these women subsequently underwent surgery. Melissa Thrall, MD, University of Washington Medical Center, Seattle, who presented the research, said she and her colleagues could find no evidence of treatment for 17% of the patients in the first year after diagnosis.
Women who were wealthier, better educated, and lived in the Southern or Western regions of the United States were more likely to get optimal care. Black women, older women, those with a stage IV diagnosis or with comorbid conditions, and women living in the Midwest were among those least likely to receive optimal care. Thrall said this group probably included some women who were not good surgical candidates.
Among other findings, Thrall said black women were more likely than white women to receive chemotherapy instead of surgery as initial treatment; unmarried women were less likely to complete all 6 cycles of chemotherapy; and the rate of surgical debulking declined from 1995 to 2005, despite a growing push for providers to follow treatment guidelines. Thrall said some of these conclusions suggest that “modifiable factors” are also at work in determining who receives optimal treatment.
The study was limited by its retrospective nature and exclusive reliance on billing data, which did not provide a rationale for the therapy administered. Thrall identified the age of the participants as another limitation, because all were aged 65 years and older while the median age of ovarian cancer diagnosis is 64 years. She recommended additional studies on this issue that incorporate variables such as performance status and look at barriers to treatment.
Carney described the study as important and timely. He pointed out that it essentially shows that “about 50% [of women] receive no chemotherapy after initial surgery, no surgery after initial chemotherapy, or no surgery or chemotherapy at all.”