Does aggressive therapy improve survival in suboptimal stage IIIc/IV ovarian cancer? A Canadian-American comparative study

End-of-life care for lung cancer patients in the United States and Ontario

BACKGROUND

Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.

METHODS

We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.

RESULTS

Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).

CONCLUSIONS

NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.

Indicators of survival duration in ovarian cancer and implications for aggressiveness of care

BACKGROUND

Ovarian cancer patients frequently receive chemotherapy near the end of life. The purpose of the current study was to develop indicators that characterize those ovarian cancer patients who have a short life span.

METHODS

The medical charts of deceased epithelial ovarian cancer patients were retrospectively reviewed from 2000 through 2006. All patients received primary debulking surgery and adjuvant chemotherapy. Aggressiveness of cancer care within the last month of life was measured by chemotherapy regimens, emergency room visits, and hospitalizations. Significant clinical events (SCE) were defined as ascites, bowel obstruction, and pleural effusion. Survival quartiles were compared using chi-square and Student t test statistics. Multiple regression analysis was performed using survival duration as a dependent variable.

RESULTS

In all, 113 patients with epithelial ovarian cancer were reviewed. Patients had increased hospitalizations (P < .001) and SCE (P < .001) as they approached the end of life. There was no difference in the pattern of hospitalizations and SCE between the top and bottom survival quartiles. Patients with a shorter survival time had a trend toward increased chemotherapy during their last 3 months of life (P = .057) and had increased overall aggressiveness of care (P = .013). In patients with a disease remission, the length of initial remission time was found to be significant in predicting survival (P < .01). Time to second disease recurrence was also significant in predicting survival time (P < 0.01).

CONCLUSIONS

Patients who received aggressive care did not have improvement in survival. Short disease remissions and increasing hospitalizations with SCE should be indicators of the appropriateness of reducing cure-oriented therapies and increasing palliative interventions.

Predictive factors for irresectability in advanced ovarian cancer

Despite advances in surgical modalities and chemotherapeutic agents, the 5-year survival for patients with advanced ovarian cancer is barely 40-50%. At the moment, optimally cytoreductive primary surgery is the best option for patients with advanced ovarian cancer. Predictive factors of primary optimum reduction surgery have been described based on imaging studies and tumor markers and based on the premise to know a priori the weight and tumor volume, with promising results. A retrospective study was conducted based on the hypothesis that it is feasible to identify those patients not susceptible of undergoing optimum primary cytoreductive surgery. The variables associated with a lesser probability of success in this study are the presence of palpable abdominal tumor on physical examination, the presence of tumor in Douglas' cul-de-sac on vaginal exploration, the presence of ascites in any quantity, elevation of CA-125 above 1000 U/l, and the presence of pulmonary and liver metastases. The success rate for cytoreduction was 62% when none or one of these variables was present and 32% when two or more variables were present.

Prediction of optimal versus suboptimal cytoreduction of advanced-stage serous ovarian cancer with the use of microarrays

OBJECTIVE

The purpose of this study was to define gene expression patterns that are associated with the optimal versus suboptimal debulking of advanced-stage serous ovarian cancers.

STUDY DESIGN

RNA from 44 advanced serous ovarian cancers (19 optimal, 25 suboptimal) was evaluated with microarrays that contain >22,000 genes. Genes were screened on the basis of their association with debulking status to obtain the top 120 differentially expressed genes. These genes were then used to develop a predictive model for debulking status, which was subjected to out-of-sample cross validation.

RESULTS

We found that patterns of expression of 32 genes can distinguish between optimal and suboptimal debulking with 72.7% predictive accuracy. An analysis of the data that were based on clusters of co-ordinately expressed genes resulted in only a marginal improvement in predictive accuracy (75%).

CONCLUSION

These data support the hypothesis that favorable survival that is associated with optimal debulking of advanced ovarian cancers is due to, at least in part, the underlying biologic characteristics of these cancers.

The potential role of neoadjuvant chemotherapy in advanced ovarian cancer

There is a multitude of evidence from retrospective analyses and meta-analyses showing that the amount of residual tumor after debulking surgery and before chemotherapy is one of the most powerful prognostic determinants in advanced ovarian cancer. This supports the important role of maximum cytoreductive surgery as one of the cornerstones in the treatment of this disease. These same analyses, however, do not suggest that patients whose tumors cannot be debulked optimally derive a significant survival benefit from upfront surgery. For these patients and those who have a poor performance status or other morbidity, making comprehensive upfront surgery contraindicated, different therapeutic approaches have to be explored. One possible way to go is to change the timing of the different therapeutic modalities: upfront chemical cytoreduction, followed by a maximal surgical effort, in turn followed by the remainder of the first-line chemotherapy or neoadjuvant chemotherapy and interval or delayed debulking surgery. The potential role of this approach and the experience with it thus far are discussed.

Clinical disease course during the last year in ovarian cancer

OBJECTIVE(S)

The objective was to determine whether there were changes in the pattern and nature of hospitalizations during the last year that could be used in the assessment of whether chemotherapy should be continued.

METHODS

Retrospective data were collected from patients who died from ovarian cancer between 1/2000 and 12/2001. Charts from four hospitals were reviewed to abstract chemotherapy, reason for hospitalization, and the incidence of three significant clinical events (bowel obstruction, pleural effusion requiring thoracentesis, and abdominal ascites requiring paracentesis). Data were analyzed in 3-month intervals.

RESULTS

Sixty-two patient charts were reviewed. Quarterly admissions increased linearly over the year (7, 18, 27, and 47, P < 0.0001). Hospitalizations for ascites, bowel obstruction, and pleural effusion began increasing around 6 months preceding death. Twenty-two patients did not receive chemotherapy during the last 3 months. Of the 40 patients receiving chemotherapy in the last 3 months, over half were not hospitalized during the period 4-6 months before death, and a further 20% were hospitalized for nonsignificant clinical events. Approximately one-quarter of the patients, however, continued to receive chemotherapy following hospitalization for a significant clinical event.

CONCLUSION(S)

There were significant changes in the pattern and nature of hospitalization during the last 6 months that included hospitalizations for bowel obstruction, pleural effusion, or ascites. The occurrence of these events suggests that further chemotherapy should be realistically evaluated with the patient, which may reduce the number of patients who receive chemotherapy during their last few months of life.

Treatment preferences in recurrent ovarian cancer

OBJECTIVES

In the case of recurrent ovarian cancer, salvage therapy represents the potential to trade off between quality and quantity of life. Patient and physician face a choice between chemotherapy directed at slowing disease progression and supportive or palliative care that focuses on symptom management. To date, no studies have investigated the effects of best supportive care on ovarian cancer patients' quality of life and length of life as compared to salvage therapy. In other cancers, both quantity and quality of life considerations have been shown to affect treatment preferences.

METHODS

Using a decision board, we assessed preferences for salvage therapy or palliative care in the case of recurrent ovarian cancer among 81 ovarian cancer patients receiving first-line chemotherapy and 75 Noncancer Controls.

RESULTS

Compared to Noncancer Controls, ovarian cancer patients overwhelmingly preferred salvage therapy; quantity of life was of primary importance. In both groups, preference was not related to age, marital status, number of children, or employment status. On average, patients indicated they would switch from salvage therapy to palliative care when the median survival associated with salvage therapy was reduced to 5 months. Noncancer Controls would switch significantly sooner, when the median increment in survival period was reduced to 8 months. Switchpoint was not associated with life satisfaction, quality of life, or psychological or spiritual well-being in either group.

CONCLUSIONS

The majority of women, independent of a cancer diagnosis, indicated a desire for continuing aggressive treatment, despite poor outcomes. Quality of life was of secondary importance, especially among ovarian cancer patients.

Secondary cytoreductive surgery in the patient with recurrent ovarian cancer is often beneficial

The majority of women with ovarian cancer will present at an advanced stage and ultimately experience a recrudescence of tumor. Recent data indicates that secondary cytoreductive surgery is feasible, well tolerated and associated with significant prolongation of survival in selected patients with recurrent ovarian cancer.

A critique of surgical cytoreduction in advanced ovarian cancer

Due in most part to the abundant retrospective evidence suggesting that surgical cytoreduction is essential to the management of advanced ovarian cancer, most clinicians do not question its application. Irrespective, there are many who still doubt its value, given its unique role in ovarian cancer, in comparison to other solid tumors. While many papers have extolled the virtues of debulking surgery, few have taken the opposing view. This paper attempts to expose the weaknesses in the current available data regarding surgical cytoreduction in advanced ovarian cancer. By reviewing the retrospective data, the theoretical benefits of surgery, cellular kinetics, the fallacies of residual disease, interval debulking surgery, and neoadjuvant chemotherapy, a critique of debulking surgery is made. Issues surrounding perioperative morbidity and its impact on quality of life have not been adequately addressed. Despite the need for randomized trials of surgery in advanced ovarian cancer, they are unlikely to occur. The window of opportunity with respect to studying the questions on the optimal timing, degree of aggressiveness, and patient selection for surgery has likely passed. Biases and ethical issues based upon the data cited in this paper have and will continue to hamper our ability to fully elaborate the benefits of surgery with respect to survival and quality of life.

Cytoreductive surgery for advanced stages of ovarian cancer

During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumor volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (i.e., 50% after five years). A well-trained surgeon in the field of gynecologic oncology can achieve an optimal tumor reduction in up to 75% of patients with advanced stage ovarian cancer. During the procedure, bowel resection, especially rectosigmoid, must be undertaken in 30% to 40% of cases, and para-aortic and pelvic lymphadenectomy should be performed after adequate tumor reduction in the abdominal cavity. The experienced surgeon can perform these surgeries with an acceptable morbidity, allowing chemotherapy to be undertaken within the month following surgery. However, very advanced cancer with massive peritoneal carcinomatosis and/or Stage IV disease requires a very aggressive surgical procedure but yields a poor prognosis and a higher risk of unacceptable complications. For these worst cases, the concept of cytoreductive surgery is moving toward the alternative strategy of chemosurgical cytoreduction, in which interval cytoreductive surgery is undertaken after three cycles of front-line chemotherapy. The goal of this experimental strategy is to achieve a complete tumor response after front-line chemosurgical therapy, and a better quality of life.