LOS ANGELES – Guideline-adherent treatment can make the difference between life and death in patients with ovarian cancer, and it often hinges on where and from whom patients receive care, new data suggest.
In a retrospective, population-based study of more than 13,000 patients with epithelial ovarian cancer, only about 40% of patients received treatment adhering to that recommended by the National Comprehensive Cancer Network (NCCN).
Dr. Robert Bristow
Patients were more likely to receive guideline-adherent treatment if they went to high-volume hospitals (those treating at least 20 such patients each year) and high-volume physicians (those treating at least 10 such patients each year), according to results reported at the annual meeting of the Society of Gynecologic Oncology*. Still, in absolute terms, only about half of patients treated in high-volume hospitals or by high-volume surgeons received adherent treatment.
Compared with their counterparts who received guideline-adherent treatment, patients who received nonadherent treatment had a 33% higher risk of dying from their disease in the subsequent 5 years.
"NCCN guideline adherence predicts improved survival," lead investigator Dr. Robert E. Bristow commented in an interview. "A minority of patients is getting access to guideline care, and increased efforts to direct ovarian cancer patients to high-volume providers are warranted."
From a population-based perspective, much greater gains in survival can be achieved by centralizing ovarian cancer care to gynecologic oncologists and high-volume hospitals than through new chemotherapy drugs or experimental treatments, according to Dr. Bristow, who is director of the division of gynecologic oncology at the University of California, Irvine, medical center. The success of this model "has been demonstrated in Norway, where nonaccredited providers are not paid for any ovarian cancer care they deliver."
That said, the data cannot be used to discern the reasons for the overall poor rate of guideline adherence.
"In population-based data sets, you don’t have the granularity of data to tease out the nuances that might contribute to risk, like an infirm 85-year-old woman who can’t tolerate major surgery and aggressive surgery. We were not able to control for that," Dr. Bristow noted. Yet "only about 20% of patients had access to high-volume providers, and since high-volume providers are more likely to deliver appropriate care, the lack of access to these physicians and hospitals is probably the biggest reason (for nonadherence). By ensuring that we do everything possible to get ovarian cancer patients to the physicians and centers that are best equipped to take care of them, we will maximize each patient’s chance for the best possible outcome."
Analyses were based on 13,321 patients with epithelial ovarian cancer having data in the California Cancer Registry for the years 1999 through 2006. They had a median age of 61 years; 70% had stage III or IV disease, and 42% had serous tumor histology.
Among patients having data on these measures, 81% were treated at low-volume hospitals and 79% by low-volume surgeons. In multivariate analyses, patients were significantly more likely to receive nonadherent treatment if they were treated in low-volume hospitals (odds ratio, 1.83) or by low-volume physicians (OR, 1.19).
Overall, 37% of the patients received treatment recommended by NCCN guidelines. The 5-year disease-specific survival rate was 45% for the cohort overall. In multivariate analyses, patients had significantly higher odds of ovarian cancer death if they received nonadherent treatment (hazard ratio, 1.33), and if they were treated at a low-volume hospital (HR, 1.08) or by a low-volume physician (HR, 1.18).
"We are in the infancy of defining quality care for ovarian cancer," concluded Dr. Bristow. "We need to develop risk-adjusted models for comparison, to make sure we are comparing apples to apples, so to speak. We need to become more sophisticated in our measurement and reporting. Ideally, one day, everyone’s quality performance measures will be publicly available and patients and payers can choose for themselves where to go for care."
The investigators plan future research on such models and on universal reporting requirements. "There are also critical issues of racial and socioeconomic disparities in ovarian cancer care and outcomes that we are investigating," he said.
Dr. Bristow disclosed no relevant conflicts of interest.
Correction, 3/28/2013: An earlier version of this story misstated the name of the Society of Gynecologic Oncology.