Deviation from Clinical Guidelines Takes Toll on Ovarian Cancer Survival

Charles Bankhead

May 2013, Vol 4, No 4 - Ovarian Cancer

Los Angeles, CA—Most women with ovarian cancer receive substandard care that significantly reduces their survival odds, based on a new retrospective review of 13,000 patients that was presented at the 2013 Society of Gynecologic Oncology annual meeting.

Treatment that diverged from the current National Comprehensive Cancer Network (NCCN) guidelines increased the 5-year survival hazard by 33% compared with patients who received the recommended care, reported Robert E. Bristow, MD, MBA, FACS, Director, Division of Gyneco­logic Oncology, Professor, Department of Obstetrics and Gynecology, and the Philip J. DiSaia Chair of Gynecologic Oncology, University of California, Irvine Medical Center.

“Adherence to NCCN guidelines for ovarian cancer is associated with overall survival and may be a useful measure of quality cancer care,” noted Dr Bristow. “High-volume providers are significantly more likely to provide NCCN guideline–adherent care, which is associated with improved survival.”

This new analysis showed that 37% of the patients were treated in accordance with guidelines established by the NCCN. Treatment at high-volume centers (≥20 ovarian cancer cases annually) and by high-volume surgeons (≥10 cases annually) improved the chances that a woman would receive the recommended therapy; even then, the care fell short of NCCN standards 50% of the time.

Noting that fewer than 20% of patients with ovarian cancer received care from high-volume providers, Dr Bristow said, “We have a lot of work to do. In particular, we have to increase our efforts to ensure that ovarian cancer patients receive the best care possible, and that means getting them to high-volume surgeons and centers.”

A critical need exists to establish best practices, and then to enforce guidelines to improve care, he added.

The Study Findings
This retrospective review of the California Cancer Registry of women with newly diagnosed ovarian cancer between 1999 and 2006 assessed adherence to the NCCN guidelines and the link to survival. All patients underwent a minimum surgical procedure of oophorectomy.

Adherence was defined as the use of stage-appropriate surgical procedures, and the use of chemotherapy adopted by the NCCN. The analysis included 13,321 patients. Overall, 37.2% of patients received guideline-adherent care. High-volume centers accounted for 18.8% of cases, and approximately 16.4% of surgeries were done by high-volume surgeons.

Patients had a significantly better chance of receiving guideline-consistent care at high-volume centers (50.8%) compared with at low-volume centers (34.1%; P <.001). High-volume surgeons treated patients in accordance with the NCCN guidelines significantly more often than low-volume surgeons (47.6% vs 34.5%, respectively; P <.001).

An adjusted analysis showed that low-volume centers and low-volume surgeons were significantly associated with deviation from the NCCN guidelines (odds ratios, 1.83 and 1.19, respectively).

The 5-year survival rate in the study population was 45%. A multivariable analysis of survival showed that nonadherence to the NCCN guidelines was significantly associated with worse 5-year survival (hazard ratio [HR], 1.34). After adjustment for guideline adherence, low-volume hospitals and low-volume surgeons remained independent predictors of worse survival (HRs, 1.08 and 1.18, respectively).

While exhorting his gynecologic oncology colleagues to advocate aggressively for better ovarian cancer care, Dr Bristow also encouraged patients to be their own advocates and to insist on treatment by high-volume providers.

“If a surgeon performs only 2 ovarian cancer surgeries a year, you don’t want to be one of those 2,” he said.