SAN DIEGO – Surgery, chemotherapy, and radiation do not prolong survival in advanced-stage but low-grade papillary serous ovarian cancer, according to a review of 1,159 low-grade cases in the National Cancer Data Base.
Dr. Allison Gockley
“All you are doing is exposing patients to the toxicity without any benefit. You [should] think really hard about whether or not to give [low-grade] patients radiation or chemotherapy, instead of just following them,” said investigator Dr. Allison Gockley, an ob.gyn. at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.
Seventy-four percent of the women received platinum-based chemotherapy, but it made no difference in survival (hazard ratio, 0.94; 95% CI, 0.75 -1.19); likewise, radiation made no difference in the seven women (0.6%) who received it.
Lymphadenectomy was the only thing associated with improved survival (HR, 0.5; 95% CI, 0.4-0.7). Dr. Gockley said she suspects it was a marker for careful surgery, but even surgery didn’t improve survival in low-grade cases (HR, 0.93; 95% CI, 0.51-1.70), although most patients had an operation.
The percentages of women who had surgery, chemotherapy, and radiation were almost identical among the 24,073 advanced-stage, high-grade cases also considered in the review, except that low-grade patients were more likely to get radiation. The approaches help high-grade cases, but “it feels very unsatisfying to me to treat low-grade” patients the same way when “they obviously have” different tumor biology, Dr. Gockley said at the annual meeting of the Society of Gynecologic Oncology.
She said she’s found similar issues with early-stage uterine clear cell carcinoma. The problem is that there just aren’t much data to guide treatment in less-dangerous gynecologic cancers, so patients end up being treated like they have advanced disease. “We need to step up and focus [study] on patients with these tumors so we can have specific treatments. For a lot of these rare tumors” – advanced-stage, low-grade disease represents about 5% of ovarian cancer – “these patients would probably do better if we had supertargeted chemotherapy,” she said.
In the absence of evidence, some patients opt for aggressive treatment “because it makes them feel that they can do something to control their disease.” As for doctors, “I’ve been in rooms where it’s very highly advocated, and others where physicians are more hesitant. What happens in the end is very much about how doctors [frame] the discussion,” Dr. Gockley said.
Her institutions follow national trends; very few patients get radiation, but most get chemotherapy, sometimes three cycles instead of six, or in low dose.
She and her colleagues looked into the issue because “we’ve seen a bunch of patients on our services recently who have low-grade, advanced-stage” ovarian cancer. The investigators wanted to know how other institutions handle the situation.
Most of the low-grade patients had stage III disease, and the rest had stage IV. Their mean age at diagnosis was 54 years, 9 years earlier than for high-grade diagnoses. About half of stage III patients were alive at 10 years, vs. about 20% of stage IV patients. As expected, high-grade patients died sooner.