The use of chemotherapy before surgery to remove ovarian cancer has increased dramatically in recent decades, particularly among certain patients, according to a new analysis from Fox Chase Cancer Center that will be presented at the 50th Annual Meeting of the American Society of Clinical Oncology.
Looking back at medical records from more than 58,000 women, Fox Chase's Angela Jain, MD, Medical Oncologist and co-investigator Elizabeth Handorf, PhD, member of the Biostatistics and Bioinformatics Facility, found that only 8.94 percent received chemotherapy before ovarian cancer surgery in 1998; by 2011, that figure had increased to 26.72 percent.
The standard of care, Dr. Jain explained, is to offer chemotherapy after surgery, not before – but in some cases, patients are not well enough to have surgery right away. "They may have other health problems, such as heart failure or severe lung disease, which complicate the procedure," she said. Their cancer may also be so far advanced that they need an additional treatment step.
Indeed, Drs. Jain and Handorf found that patients were more likely to receive so-called "neoadjuvant" chemotherapy if they were older than 70, and had additional illnesses.
Having government-run health insurance – Medicaid or Medicare – also increased a woman's odds of undergoing chemotherapy before surgery. In contrast, race and location did not appear to influence her likelihood of receiving neoadjuvant therapy.
Not surprisingly, patients who did not receive chemotherapy before surgery tended to live longer following surgery to remove their tumor – half were alive 41 months later, while median survival for those who had neoadjuvant chemotherapy was closer to 31 months. This is not an indication that neoadjuvant chemotherapy is not effective, Dr. Jain cautioned, since the women who received it were older and sicker to begin with. But additional analyses showed that patients with stage 4 disease who received neoadjuvant chemotherapy tended to have fewer complications after surgery and survive just as long as other stage 4 women. However, those with stage 3 disease tended to survive longer if they skipped neoadjuvant therapy.
Indeed, the current study cannot determine whether neoadjuvant chemotherapy was beneficial, said Dr. Jain, because it does not compare groups of similar women who were randomly chosen to receive the treatment or not. "This is good information," said Dr. Jain. "Women with stage 4 disease maybe can have chemotherapy before surgery, and their survival isn't limited. But we need to study this population in more depth before we can conclude whether there are some groups of women who should or should not be receiving neoadjuvant chemotherapy."
In the meantime, women with ovarian, fallopian, and primary peritoneal cancers who want to learn more about neoadjuvant chemotherapy should consult their physicians, said Dr. Jain. "Patients with these cancers need to talk to their oncologists about their treatment plan, and what is right for them. Each person is an individual, so their care has to be catered to them."
Just why the rate of neoadjuvant chemotherapy has increased so dramatically in ovarian cancer is "hard to know," she noted, because there are no set criteria for prescribing it. "It's a judgment call of the oncologist to decide if a patient is healthy enough to have surgery or not, and whether the gynecologic oncologist feels that they can remove all of the tumor during surgery" she said. "What we do know, is that patients in general are aging, and older patients are more likely to both have additional illnesses and receive neoadjuvant chemotherapy. So it's possible this factor may help explain why more women are receiving neoadjuvant chemotherapy."
To assess this trend, Drs. Jain and Handorf reviewed the records of 58,048 women with advanced stage ovarian cancer diagnosed between 1998 and 2011 using the National Cancer Database.