Nearly two-thirds of women with ovarian cancer do not receive guideline-adherent care

Women are 30 percent less likely to die of ovarian cancer if they have guideline-recommended treatment, yet nearly two-thirds of those with the disease do not receive it, often because they are cared for at hospitals that treat a small number of ovarian cancer patients. These are the findings of a study of more than 13,000 patients being presented at the Society of Gynecologic Oncology (SGO) Annual Meeting on Women's Cancer in Los Angeles, March 9-12.

Women with ovarian cancer treated by high-volume surgeons and at high-volume hospitals were more likely to receive therapy recommended by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, according to the study. A high-volume surgeon is one who treats 10 or more ovarian cancer patients a year; a high volume hospital treats 20 or more per year. More than 15,000 women die of ovarian cancer each year, making it the fifth leading cause of death among American women.

"There may be a number of reasons women do not receive guideline-adherent care, such as that low-volume hospitals may not have access to gynecologic oncologists who specialize in this care," said Robert E. Bristow, MD, Director of the Division of Gynecologic Oncology at the University of California, Irvine Medical Center. "Patients need to be their own advocates and ask the provider and hospital how many ovarian cancer patients they treat, how many ovarian cancer surgeries they perform and their ovarian cancer patients' rates of survival. If a surgeon only performs two ovarian cancer surgeries a year, you don't want to be one of those two."

The study was an analysis of treatment of 13,321 ovarian cancer patients reported to the California Cancer Registry from 1999 through 2006. NCCN guideline-adherent care includes a combination of surgery and chemotherapy depending on the stage of the cancer. Only 4,952 patients (37 percent) received care recommended by NCCN guidelines, researchers found. Patients who did not receive guideline-adherent care were 30 percent more likely to die of ovarian cancer during the five-year follow-up period.

The study is the first large-scale population-based analysis to validate the NCCN treatment recommendations, showing that they correlate with improved clinical outcomes, said Dr. Bristow. NCCN is a not-for-profit alliance of 21 of the world's leading cancer centers that work together to develop guidelines for most cancers.

The majority of patients were treated at low-volume hospitals and by low-volume surgeons: 81 percent of patients had surgery at low-volume hospitals and 62 percent of surgeries were performed by low-volume surgeons, although in 22 percent of cases, no surgeon was identified. However, even patients treated at high-volume hospitals and by high-volume surgeons received guideline-adherent therapy only about half the time. Appropriate care was delivered at high-volume hospitals 51 percent of the time and by high-volume surgeons 48 percent of the time. Dr. Bristow points out that in many cases these physicians provided some of the recommended care, such as the appropriate chemotherapy or surgery, but not both. He also notes that not all patients should necessarily receive guideline-recommended care. For example, aggressive guideline-directed care might be more harmful than helpful to an elderly, frail woman.

"This shows we have a lot of room to improve. One option might be to concentrate care in high-volume hospitals but there are obviously other factors at work," said Dr. Bristow. "We need to become more sophisticated and to determine what the best performing physicians are doing different from everyone else, establish best practices and then enforce them to improve outcomes."