When and Who Should Perform Epithelial Ovarian Cancer Surgery?

Clinical impact of CA-125 ELIMination rate constant K (KELIM) on surgical strategy in advanced serous ovarian cancer patients

OBJECTIVES

The modeled CA-125 elimination constant K (KELIM) is a pragmatic early marker of tumor chemosensitivity in ovarian cancer patients treated with neoadjuvant chemotherapy before interval surgery. The primary objective of this study was to assess the prognostic value of KELIM regarding the feasibility of complete surgery, and secondary objectives were to assess the prognostic value of KELIM for the risk of a platinum resistant relapse, progression free survival, and overall survival.

METHODS

The study was based on a retrospective cohort of 284 patients treated for an advanced serous high grade ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) stages III-IV, with neoadjuvant chemotherapy, followed by interval surgery, in a comprehensive cancer center. CA-125 concentrations at baseline and during neoadjuvant chemotherapy were collected. The KELIM predictive value regarding the tumor radiological response rate, likelihood of complete surgery, risk of subsequent platinum resistant relapse, progression free survival, and overall survival were assessed with univariate and multivariate tests.

RESULTS

In 232 patients, KELIM was an independent and major predictor of the probability of complete surgery and survival. The final logistic regression model, including KELIM (odds ratio (OR) 0.36, 95% confidence interval (CI)0.16 to 0.73, p=0.006) and complete surgery (no vs yes, OR 0.29, 95% CI 0.15 to 0.53, p<0.001), highlighted the complementary impact of chemosensitivity and surgical outcome relative to the complete surgery. In the multivariate analysis, KELIM and complete surgery were significantly associated with a lower risk of early relapse. In the case of an unfavorable KELIM, when surgical efforts allowed complete cytoreduction, median overall survival was similar to that reported in the case of a favorable KELIM (46.3 months (range 34.6-60.3) vs 46.5 months (range 40.6-68.7), respectively).

CONCLUSION

Primary tumor chemosensitivity, assessed by the modeled CA-125 KELIM, calculated during neoadjuvant chemotherapy, is a major parameter to consider for decision making regarding interval surgery. Complementary to the RECIST score and laparoscopy, this non-invasive tool, available online, helps tailor the interval surgery strategy according to patient tumor chemosensitivity.

Gynecologic oncologist impact on adjuvant chemotherapy care for stage II-IV ovarian cancer patients

OBJECTIVE

We aim to evaluate the impact gynecologic oncologists have on ovarian cancer adjuvant chemotherapy care from their role as surgeons recommending adjuvant chemotherapy care and their role as adjuvant chemotherapy providers while considering rural-urban differences.

METHODS

Multivariable adjusted logistic regressions and Cox proportional hazards models were developed using a population-based, retrospective cohort of stage II-IV and unknown stage ovarian cancer patients diagnosed in Iowa, Kansas, and Missouri in 2010-2012 whose medical records were abstracted in 2017-2018.

RESULTS

Gynecologic oncologist surgeons (versus other type of surgeon) were associated with increased odds of adjuvant chemotherapy initiation (adjusted odds ratio (OR) 2.18; 95% confidence interval (CI) 1.10-4.33) and having a gynecologic oncologist adjuvant chemotherapy provider (OR 10.0; 95% CI 4.58-21.8). Independent of type of surgeon, rural patients were less likely to have a gynecologic oncologist chemotherapy provider (OR 0.52; 95% CI 0.30-0.91). Gynecologic oncologist adjuvant chemotherapy providers (versus other providers) were associated with decreased surgery-to-chemotherapy time (rural: 6 days; urban: 8 days) and increased distance to chemotherapy (rural: 22 miles; urban: 11 miles). Rural women (versus urban) traveled 38 miles farther when their chemotherapy provider was a gynecologic oncologist and 27 miles farther when it was not.

CONCLUSION

Gynecologic oncologist surgeons may impact adjuvant chemotherapy initiation. Gynecologic oncologists serving as adjuvant chemotherapy providers were associated with some care benefits, such as reduced time from surgery-to-chemotherapy, and some care barriers, such as travel distance. The barriers and benefits of having a gynecologic oncologist involved in adjuvant chemotherapy care, including rural-urban differences, warrant further research in other populations.

Diagnostic performance of dynamic contrast-enhanced magnetic resonance imaging for malignant ovarian tumors: a systematic review and meta-analysis

BACKGROUND

Accurate preoperative diagnosis of malignant ovarian tumors (MOTs) is particularly important for selecting the optimal treatment strategy and avoiding overtreatment.

PURPOSE

To evaluate the diagnostic efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for MOTs.

MATERIAL AND METHODS

A systematic search was performed in PubMed, Embase, the Cochrane Library, and Web of Science databases to find relevant original articles up to October 2019. The included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Studies on the diagnosis of MOTs with quantitative or semi-quantitative DCE-MRI were analyzed separately. The bivariate random-effects model was used to assess the diagnostic authenticity. Meta-regression analyses were performed to analyze the potential heterogeneity.

RESULTS

For semi-quantitative DCE-MRI, the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic curves (AUC) were 85% (95% confidence interval [CI] 0.75-0.92), 85% (95% CI 0.77-0.91), 5.8 (95% CI 3.8-8.8), 0.17 (95% CI 0.10-0.30), 33 (95% CI 18-61), and 0.92 (95% CI 0.89-0.94), respectively. For quantitative DCE-MRI, the pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 88% (95% CI 0.65-0.96), 93% (95% CI 0.78-0.98), 12.3 (95% CI 3.4-43.9), 0.13 (95% CI 0.04-0.45), 91 (95% CI 10-857), and 0.96 (95% CI 0.94-0.98), respectively.

CONCLUSION

DCE-MRI has great diagnostic value for MOTs. Semi-quantitative DCE-MRI may be a relatively mature approach; however, quantitative DCE-MRI appears to be more promising than semi-quantitative DCE-MRI.

The impact of expanding gynecologic oncology care to ovarian cancer patients in small cities and rural communities

OBJECTIVE

Patients with ovarian cancer from smaller cities and rural communities face unique challenges in accessing comprehensive care. This study compares management strategies, outcomes, and access to care for patients in a small city and surrounding rural communities before and after establishing a full-time gynecologic oncology (GO) office.

METHODS

A local tumor registry was used to identify patients diagnosed with ovarian cancer before and after a full-time GO office was established. Quantitative analyses were used to compare disease characteristics, management strategies, overall survival, and distance traveled for care between cohorts.

RESULTS

Out of 381 patients, 171 women were diagnosed prior to establishing a full-time GO office (pre-GO) and 210 after (post-GO). Post-GO patients were more likely to undergo surgery by a GO specialist (97.1% versus 53.2%, p < 0.01), receive surgery locally (79.0% versus 43.3%, p < 0.01), and undergo complete lymph node dissection (63.3% versus 38.6%, p < 0.01). Patients treated with chemotherapy by GO increased from 10.3% pre-GO to 76.9% post-GO. 5-year survival rates were 33.8% versus 49.5% in the pre-GO and post-GO groups, respectively (p < 0.01). Median survival time increased from 30.8 months to 52.5 months from pre-GO to post-GO time periods. Distance patients traveled for surgery decreased from a mean of 47.9 miles pre-GO to 26.8 miles post-GO.

CONCLUSION

After establishing a full-time GO office within a small city, local patients had significantly improved overall survival and access to care. These results highlight the benefit of expanding GO care into small cities with surrounding rural communities and may be used to address public health discrepancies for women across the country.

Circular RNA circ_ABCB10 in cancer

Circular RNA (circRNA), a newly discovered type of endogenous noncoding RNA, has become a focus and hotspot in biological research in recent years. It exists widely and possesses a stable structure, is highly conserved and has cell-specific expression. circRNA is associated with disease occurence in general and cancer specifically due to its role in cell differentiation, proliferation, invasion and metastasis. Recently, circ_ABCB10, an increasingly studied member of the annular RNA family, has attracted considerable attention due to the fact that its expression is upregulated in various tumors, ie, esophageal cancer, breast cancer, lung cancer, and glioma, and may be of prognostic value. Molecular regulation and mechanism of circ_ABCB10 action in cancer are reviewed and its potential as a molecular marker and novel target for diagnosis and treatment are explored..

Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patients

OBJECTIVE

Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care.

METHODS

We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality.

RESULTS

Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm.

CONCLUSION

There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

Patient and Provider Perspectives on Barriers to Accessing Gynecologic Oncologists for Ovarian Cancer Surgical Care

Objective

National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with ovarian cancer receive surgical care from a gynecologic oncologist. However, 15%-30% of patients with ovarian cancer do not receive surgical care from this specialist. The reasons for this remain unknown. We aim at assessing the barriers and attitudes perceived by patients with ovarian cancer who did not receive their primary surgery from a gynecologic oncologist and by diagnosing providers in an exploratory qualitative study.

Materials and Methods

Patients and providers were sampled through the Iowa Cancer Registry. Participants were interviewed by telephone about barriers that patients face receiving surgical care from a specialist. Interviews were transcribed verbatim, and thematic analysis was completed by two team members.

Findings

Providers (n = 10, 13% participation rate) identified many system-level barriers, including poor provider-to-provider communication, long time-to-surgery wait times, and a limited number of gynecologic oncologists working in their referral range. Patients (n = 16, 38% participation rate) denied system-level barriers; however, no patients reported receiving a referral to a gynecologic oncologist. This, in and of itself, constitutes a system-level barrier. Providers identified many barriers that their patients face, whereas patients failed to identify these barriers and denied facing them. Patients described the shock that they experienced after diagnosis and its limitations on their decision-making process. Both providers and patients agreed that the providers were influential in determining care decisions.

Discussion

There is a divergence in the perceptions of barriers to care between providers and patients. Open discussions are needed about options and clinical guidelines for surgical ovarian cancer care. Further research is needed to develop and evaluate mechanisms to improve provider-to-patient discussions about surgical recommendations.

Development of a nomogram to predict prognosis in ovarian cancer: a SEER-based study

Background

Ovarian cancer remains the most lethal gynecologic malignancy. In this study, we aimed to identify the specific risk factors affecting overall survival (OS) and develop a nomogram for prognostic prediction of ovarian cancer patients based on data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Information from the SEER database on ovarian cancer between 2004 and 2016 was screened and retrieved. Cases were randomly divided into the training cohort hand the validation cohort at a 7:3 ratio. The prognostic effects of individual variables on survival were evaluated via Kaplan-Meier method and Cox proportional hazards regression model using data from the training cohort. A nomogram was formulated to predict the 3- and 5-year OS rates of patients with ovarian cancer, and then validated both in the training cohort and the validation cohort.

Results

A total of 28,375 patients were selected from 75,921 samples (19,862 in training cohort and 8,513 in validation cohort). Cox regression analysis identified race, age laterality, histology, stage, grade, surgery, chemotherapy, radiotherapy, and marital status as independent risk factors for ovarian cancer prognosis. A nomogram was developed based on the results of multivariate analysis and validated using an internal bootstrap resampling approach, which demonstrated a sufficient level of discrimination according to the C-index (0.752, 95% CI: 0.746–0.758 in the training cohort, 0.755, 95% CI: 0.746–0.764).

Conclusions

We developed a nomogram valuable for accurate prediction of 3- and 5-year OS rates of ovarian cancer patients based on individual characteristics.

Interval Debulking Surgery for Advanced Ovarian Cancer in Elderly Patients (≥70 y): Does the Age Matter?

BACKGROUND

Elderly ovarian cancer (OC) patients are more likely to be managed suboptimally, with worse clinical outcomes as a result. Strategies to decrease morbidity are lacking.Methodology: Consecutive patients with advanced stage OC (IIIC-IV) who were managed in our center between January 2016 and July 2018 were retrospectively analyzed. All patients underwent neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) according to our institution protocol. We divided patients into two groups: Group 1 (age ≥ 70 years) and Group 2 (age < 70 years). The primary outcome of the study was assessment of peri-operative morbidity amongst two groups.

RESULTS

A total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS compared to younger patients (39% vs. 19%, p = 0.03). Elderly patients were more frequently subjected to Cardiopulmonary Exercise Testing (CPET) as pre-operative assessment (63% vs. 27%, p = 0.002). Optimal/complete resection was achieved in all patients in Group 1 (100%) and in 97% of patients in Group 2. With the exception of higher postoperative cardiac arrhythmias in Group 1 (11% vs. 1%, p = 0.04), no significant differences in 30-day morbidity were observed. No 90-day death in both groups was registered.

CONCLUSION

Older age should not preclude clinicians from offering ultra-radical resection to patients with advanced OC after NACT. In our series, elderly patients received the same treatment with similar outcomes to the younger group. Clinicians should be encouraged to use CPET for patients' selection following NACT.