Abstract & Commentary
Synopsis: Despite guidelines presented by several organizations, significant numbers of women with ovarian cancer are not being provided with appropriate care.Source:Harlan LC, et al.J Clin Oncol. 2003;21:3488-3494.
Harlan and colleagues sampled patient cases from within the Surveillance, Epidemiology, and End Results (SEER) program to examine trends in care of women with ovarian cancer. They abstracted medical records of 601 patients with ovarian cancer diagnosed in 1991 and 566 women with ovarian cancer diagnosed in 1996 to compare findings. In addition, they verified treatment data with the attending physicians. Across these 2 time periods, the percentage of women with presumptive stage I, II, and IV disease who received lymph node dissection increased. However, a significant number still were not precisely staged. More than 65% of women with ovarian cancer were given cyclophosphamide in 1991 compared with about 14% in 1996. Paclitaxel use increased from 1% to 62% during that time. After adjusting for age, race or ethnicity, registry, income, insurance status, Charlson score, residency training program, and marital status, women with early stage disease were significantly more often given National Institutes of Health Consensus Development Conference guideline therapy in 1996 than in 1991. However, for women with stage III and IV disease, the use of guideline therapy did not significantly increase. Older women and minorities consistently received less guideline therapy, and lack of private insurance was an impediment for both Hispanic and non-Hispanic black women.
Harlan et al concluded that, despite guidelines presented by several organizations, significant numbers of women with ovarian cancer are not being provided with appropriate care. This was particularly true for older and minority women, especially those without private insurance. They recommended that educational strategies be devised to increase the number of women receiving guideline therapy and decrease disparities across population groups.
Comment by David M. Gershenson, MD
Ovarian cancer remains the most challenging of the gynecologic malignancies, with the highest death rate. Patients treated in a hospital with a residency program were more likely to having appropriate treatment compared with patients treated in a hospital without a residency program. For stage I and II patients, this was principally related to have lymph node sampling as part of surgical staging. Furthermore, non-Hispanic white women were more likely to receive appropriate therapy than non-Hispanic black women. In a multivariate analysis, women treated for apparent stage I and II disease received appropriate therapy significantly more often in 1996 than in 1991. For women with stage III and IV disease, approximately 40% did not receive appropriate therapy. This latter observation was essentially unchanged from 1991 to 1996. Age did, however, influence treatment. For women with advanced-stage disease, only 53% of women 65 years and older received guideline therapy compared with 73% of women younger than 65 years of age. The lack of private insurance also negatively influenced a woman’s ability to receive guideline therapy. These findings are encouraging, in that some progress occurred in the period between 1991 and 1996. But it is not enough. American women in general are not receiving the level of excellence in ovarian cancer care that they deserve, and the elderly, minorities, and those without private insurance are being shortchanged the most. Oncologists and advocacy groups cannot relax their resolve to continue the fight for state-of-the-art care for all women with ovarian cancer.
Dr. Gershenson is Professor and Chairman Department of Gynecology M.D. Anderson Cancer Center, Houston.