Imagine that you have a life-limiting condition but a life-extending therapy was available to treat it. Now imagine that you’re not offered that intervention. This scenario could be the case for too many older women with ovarian cancer, reports a new University of Pennsylvania study that analyzed treatment data from the National Cancer Database.
Ovarian cancer survival rates have been incrementally improving. Women diagnosed in 2006 with an advanced-stage tumor had a 51 percent lower risk of death than women diagnosed in 1975, according to statistics published last year in the Journal of Obstetrics and Gynecology. Experts attribute this outcome in part to improved surgical techniques.
Clinical guidelines recommend surgery as a component of first-line treatment for most women with advanced epithelial ovarian cancer regardless of age. Epithelial ovarian cancer, the most common form, is typically diagnosed at an advanced stage.
The goal of surgery is to remove as much visible disease as possible. Optimal cytoreduction—removal of the tumor to less than a centimeter, ideally leaving no residual disease—is associated with improved survival. Even after removing all visible and palpable disease, microscopic disease is inevitably present, requiring chemotherapy, an integral part of therapy.
New statistics and new concerns
The University of Pennsylvania study, published in the July issue of Gynecologic Oncology, reported that one in five women with ovarian cancer in all age groups didn’t undergo surgery for the disease. Women with early or advanced cancer who underwent surgery had a survival rate of an average 57 months, compared with women who received nonsurgical care, such as radiation or chemotherapy, whose survival rate was less than 12 months.
A top concern was the lack of surgical intervention in women 75 years and older with advanced ovarian cancer. Approximately 45 percent of these women didn’t undergo surgery. This includes about 22 percent who received only systemic treatment such as chemotherapy, and nearly 23 percent who weren’t treated at all.
The older women treated surgically had an average survival rate of 21.5 months. Women in this age group who underwent only systemic therapy survived an average of 10.4 months, and those who received no treatment survived just 1.2 months.
“There may be legitimate factors at play that preclude recommending surgery for some older women,” says Robert L. Giuntoli II, M.D., one of the study’s authors and an associate professor of obstetrics and gynecology at the University of Pennsylvania’s Perelman School of Medicine.
These factors may have to do with an inoperable tumor or preexisting conditions, which could make surgery too risky. Some patients may refuse invasive treatment. The researchers couldn’t determine in 80 percent of the cases why surgery wasn’t performed but suspect some doctors might be reluctant to take older patients to surgery simply because of their age—an approach that stands in contrast to standard clinical practice guidelines.
“When you see numbers like these, however,” Giuntoli says, “you have to ask whether some older patients are being unnecessarily undertreated. These patients may represent sentinel cases of failure to access or deliver appropriate cancer care.”
In addition to tumor cytoreduction—also called debulking—standard surgery includes staging, which determines whether the cancer has spread from the ovaries. Surgeons typically remove both ovaries and the fallopian tubes, the uterus, the layer of fatty tissue that covers the abdomen called the omentum, and any nearby lymph nodes that look suspicious.
If the cancer has spread beyond the pelvic area, surgeons remove all or part of the affected organs, which can include the colon, bladder, spleen, gallbladder, stomach, liver, and pancreas.
Because of ovarian surgery’s complexity, Giuntoli says, “having a fellowship-trained gynecologic oncologist perform the procedure can mean the difference between a successful surgery and suboptimal debulking, which leaves behind larger tumors and is associated with a poorer prognosis.”
“This study raises many questions about whether all older women are receiving proper care and why a doctor might deviate from established guidelines for ovarian cancer treatment,” Giuntoli says. “Obviously, additional research is needed to ensure that forgoing surgery is clinically appropriate in these cases, and that these patients weren’t denied intervention just because they are deemed ‘too old’ or they lack access to specialized oncology care.”
If you’ve been told that surgery for ovarian cancer isn’t an option, consider getting a second opinion. You can find a local board-certified gynecological oncologist at the Society of Gynecologic Oncology.