Sub Specialist Care Does Not Necessarily Improve Outcomes In Ovarian Cancer

Main Category: Ovarian Cancer
Also Included In: Cancer / Oncology
Article Date: 13 Oct 2007 - 0:00 PDT

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Referral to a gynaecological oncologist does not necessarily improve the chances of survival for women with ovarian cancer, although these specialists are more likely to recommend life-extending surgical and chemotherapy treatments which result in better outcomes, according to the results of a retrospective study published in Obstetrics and Gynecology.

Whether or not referral to a specialist in gynaecological cancer is necessary for achieving the best outcomes for patients with ovarian cancer has been debated for some time. Some studies have shown a survival benefit associated with sub-specialty care and others suggest that women who see a gynaecological oncologist are more likely to receive appropriate staging, surgery (with the purpose of reducing the size of the tumour because complete removal is usually not feasible), and adjuvant chemotherapy than those who are seen by other specialists. Overall, however, the results are mixed.

To identify whether any benefits observed in women referred to sub-specialists derive specifically from the involvement of an expert in gynaecological cancer, or if they are instead attributable to the treatments these specialists use, John Chan and colleagues from the University of California examined cancer-database records for 1491 women with invasive ovarian cancer and used medical records to follow their disease and treatment course. They then applied a series of statistical tests to identify associations between variables related to the treatment, disease, or socioeconomic status of patients and outcomes.

The women who made up the study population were identified through the Northern California cancer registry and had been diagnosed with cancer between January 1, 1994, and December 31, 1996. Socioeconomic information for the women was extrapolated from residential addresses linked to census information. For the purpose of analysis, the patients were split into two groups: those who had seen a gynaecological oncologist---defined as any of her physicians who was a member of the Society of Gynecologic Oncology--- and those who had not.

Of the total patient population, only 34.1% received care by gynecologic oncologists while 65.9% were treated by others. Women who were seen by sub-specialists were found to live in more affluent and urban areas and to be more educated. These patients were also more likely to have undergone primary surgery, to have more advanced cancers, and to have received chemotherapy. But which of these factors influenced survival?

Primary surgery and chemotherapy were associated with improved survival in all patients, regardless of whether or not their physicians were specialists in gynaecological cancers. However, the survival of patients who were seen by a gynaecological oncologist was higher than those who did not: 38.6% compared with 30.3%, respectively. This advantage was most notable in more advanced cancers. Combining these two factors, the difference was even greater: patients who received multimodality treatment under the care of gynecologic oncologists had a 5-year disease-specific survival of 41% compared with only 7.1% for patients who did not undergo primary surgery by a gynecologist. However, although treatment by a gynaecological oncologist was significantly associated with patients receiving chemotherapy and undergoing surgery, after the researchers adjusted for the beneficial effects of these treatments, the improvement in survival associated with care by gynecological oncologists was non-significant.

"After accounting for st and ard treatments, there was no improvement in survival associated with subspecialist care," admit the researchers. However, they add, "our study showed that the combination of primary surgery and chemotherapy positively influences survival in patients with ovarian cancer. Moreover, gynecologic oncologists are more likely to provide this care." Put simply, the researchers found that the main reason referral to gynaecological oncologists improves the outcomes of patients with ovarian cancer is because they used aggressive treatments including debulking surgery and adjuvant chemotherapy.

"Given that a large number of patients with high risk disease treated by non-gynecologic oncologists did not receive chemotherapy, our data suggests that some physicians without subspecialty training in ovarian cancer may not appreciate the risk of recurrence and failure in this aggressive cancer," warn the authors. They recommend that "thorough underst and ing of the natural progression of this aggressive cancer by a subspecialty trained physician may ultimately impact the outcome of these patients."

Influence of the gynecologic oncologist on the survival of ovarian cancer patients. Chan JK, Kapp DS, Shin JY, Husain A, Teng NN, Berek JS, Osann K, Leiserowitz GS, Cress RD, O'Malley C. Obstet Gynecol 2007; 109: 1342-50.

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