Deviation From Clinical Guidelines Takes Toll on Ovarian Cancer Survival

TON - April 2013, Vol 6, No 3 published on April 16, 2013 in Gynecologic Cancers
Charles Bankhead

According to a retrospective review of more than 13,000 cases, most women with ovarian cancer received substandard care that significantly reduced their survival odds.

The analysis showed that 37% of the patients were treated in accordance with guidelines established by the National Comprehensive Cancer Network (NCCN). Treatment at high-volume centers (≥20 cases/year) and by high-volume surgeons (≥10 cases/year) improved the chances that a woman would receive recommended therapy, but even then, the care fell short of NCCN standards half the time.

Treatment that diverged from current guidelines increased the 5-year survival hazard by a third, as compared with patients who received recommended care, Robert Bristow, MD, reported at the Society of Gynecologic Oncology 44th Annual Meeting on Women’s Cancer in Los Angeles, California.

“Adherence to NCCN guidelines for ovarian cancer is associated with overall survival and may be a useful measure of quality cancer care,” said Bristow, director of gynecologic oncology at the University of California Irvine. “High-volume providers are significantly more likely to provide NCCN guideline-adherent care, which is associated with improved survival.”

Noting that fewer than 20% of patients received care from high-volume providers, 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 for research to identify traits that distinguish the best-performing providers from the others, and then to use that information to establish best practices and enforce guidelines to improve care, he added.

The findings came from a retrospective review of the California Cancer Registry to identify women with newly diagnosed epithelial ovarian cancer from 1999 through 2006. All patients underwent a minimum surgical procedure of oophorectomy.

The primary objectives were to identify structural healthcare characteristics that could predict adherence to NCCN guidelines and to validate guideline adherence as a quality process measure associated with improved survival. Investigators defined adherence as use of stage-appropriate surgical procedures and chemotherapy as 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 high-volume surgeons cared for 38% of the patients. However, the surgeon was not identified in 22% of the cases, meaning that treatment by a high-volume surgeon could be verified in only 16.4% of cases, said Bristow.

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

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

A multivariate analysis of survival showed that nonadherence to NCCN guidelines had a significant association 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 (HR, 1.08 and 1.18, respectively).

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

“If a surgeon performs only 2 ovarian cancer surgeries a year, you don’t want to be 1 of those 2,” he said.

Reference
Bristow R, Chang J, Ziogas A, et al. NCCN treatment guidelines for ovarian cancer: a population-based validation study of structural and process quality measures. Presented at: 44th Annual Meeting on Women’s Cancer; March 9-12, 2013; Los Angeles, CA. Abstract 45. https://www.sgo.org/wp-content/uploads/2013/03/SGO_Abstract_v3.pdf. Accessed March 22, 2013.

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Last modified: May 21, 2015