Ovarian cancer clinical practice guidelines

Spatial analysis of advanced-stage ovarian cancer mortality in California

OBJECTIVE

We sought to determine the impact of geographic location on advanced-stage ovarian cancer mortality in relation to adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and hospital case volume.

STUDY DESIGN

This was a retrospective observational cohort study of patients diagnosed with stage IIIC/IV epithelial ovarian cancer (Jan. 1, 1996, through Dec. 31, 2006) identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, demographic characteristics, disease-related variables, adherence to NCCN guidelines, and hospital case volume, with simultaneous smoothing of geographic location and adjustment for confounding variables.

RESULTS

A total of 11,765 patients were identified. Twelve of the 378 hospitals (3.2%) were high-volume hospitals (HVH) (≥20 cases/y) and cared for 2112 patients (17.9%). For all patients, the median distance to an HVH was 22.7 km/14.1 miles and 80% were located within 79.6 km/49.5 miles of an HVH. Overall, 45.4% of patients were treated according to NCCN guidelines. The global test for location revealed that geographic position within the state was significantly correlated with ovarian cancer mortality after adjusting for other variables (P < .001). Distance to receive care ≥32 km/20 miles was protective against mortality (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.79-0.93), while distance from an HVH ≥80 km/50 miles was associated with an increased risk of death (HR, 1.13; 95% CI, 1.03-1.23). The effects of geographic predictors were attenuated when nonadherence to NCCN guidelines (HR, 1.25; 95% CI, 1.18-1.32) and care at an HVH (HR, 0.87; 95% CI, 0.81-0.93) were introduced into the model.

CONCLUSION

Geographic location is a significant predictor of advanced-stage ovarian cancer mortality and the effect is primarily related to the likelihood of receiving NCCN guideline adherent care and treatment at an HVH.

Reasons for failure to deliver National Comprehensive Cancer Network (NCCN)-adherent care in the treatment of epithelial ovarian cancer at an NCCN cancer center

OBJECTIVE

The National Comprehensive Cancer Network (NCCN) has established guidelines for treating epithelial ovarian cancer (EOC) which includes cytoreductive surgery and platinum and taxane-based chemotherapy (CT). The objective of this study was to determine the reasons for failure to deliver NCCN-adherent care at an NCCN cancer center serving a diverse racial and socioeconomic population.

METHODS

Medical records of women with EOC diagnosed between 2004 and 2009 were reviewed for demographic, clinical, tumor, treatment, and survival data. Independent reviewers determined if their treatment met criteria for being NCCN-adherent. Progression-free survival (PFS) and overall survival (OS) were calculated with Kaplan-Meier estimates and compared with the log-rank test.

RESULTS

367 patients were identified. 79 (21.5%) did not receive NCCN-adherent care. Non-adherent CT in 75 patients was the most common reason for failure to receive NCCN-adherent care. 39 patients did not complete CT due to treatment toxicities or disease progression. 12 patients received single agent CT only and 4 received no CT due to comorbidities. 2 patients declined CT. 18 patients died in the postoperative period without receiving CT. 8 patients did not undergo cytoreduction due to disease progression or comorbidities. PFS and OS were improved in the NCCN-adherent cohort (PFS: 5.7 vs. 18.3 months, p<.005) (OS: 11.4 vs. 49.5 months, p<.005).

CONCLUSIONS

The vast majority of patients at an NCCN cancer center received NCCN-adherent treatment. Reasons for failure to receive NCCN-adherent care were variable, but most did not receive chemotherapy in accordance with guidelines due to comorbidities or disease progression.

Patterns of fatigue during a course of chemotherapy: Results from a multi-centre study

Fatigue is a highly prevalent condition among patients with cancer affecting between 70% and 100% and patients describe their fatigue experiences as the most distressing of symptoms. However, the management of fatigue is complicated by our current lack of understanding of its pathophysiology. This study aimed to gain an insight into the longitudinal fatigue experiences of patients receiving chemotherapy. A convenience sample of patients receiving chemotherapy (n=249) were recruited and recorded their fatigue experiences using a paper questionnaire for 14 consecutive days following each cycle of chemotherapy. Fatigue was reported in 57% of all completed questionnaires. Patients report fatigue as a relatively constant presence following chemotherapy. Moreover, fatigue experiences increase over consecutive cycles of chemotherapy. This study supports the existing evidence illustrating fatigue as a significant problem for patients with cancer and provides new data demonstrating patterns of fatigue over the duration of a course of chemotherapy. Understanding this experience of fatigue should prompt health professionals providing care for this patient population to seek and test a range of management strategies to help patients maintain their quality of life during cancer treatment.

Bone health in men receiving androgen deprivation therapy for prostate cancer

PURPOSE

Patients with recurrent or metastatic prostate cancer generally receive androgen deprivation therapy, which can result in significant loss of bone mineral density. We explored androgen deprivation therapy related bone loss in prostate cancer, current treatments and emerging therapies.

MATERIALS AND METHODS

Literature published on the pathogenesis and management of androgen deprivation therapy related bone loss was compiled and interpreted. Recent drug therapy findings were reviewed, including treatment guidelines.

RESULTS

Men with prostate cancer often present with bone loss and the initiation of androgen deprivation therapy can trigger further rapid decreases. This results in an increased fracture risk, and greater morbidity and mortality. Early detection of osteoporosis through androgen deprivation therapy screening and prompt initiation of therapy are critical to prevent continued decreases. Lifestyle changes such as diet, supplementation and exercise can slow the rate of bone loss. Pharmacological therapy with oral and intravenous bisphosphonates has been demonstrated to prevent or decrease the bone loss associated with androgen deprivation therapy. However, important differences exist among various bisphosphonates with respect to efficacy, compliance and toxicity. Only zoledronic acid has been shown to increase bone mineral density above baseline and provide long-term benefit by decreasing the incidence of fracture and other skeletal related events in men with bone metastases.

CONCLUSIONS

Androgen deprivation therapy associated bone loss adversely affects bone health, patient quality of life and survival in men with prostate cancer. Increased awareness of this issue, identification of risk factors, lifestyle modification and initiation of bisphosphonate therapy can improve outcomes. Education of patients and physicians regarding the importance of screening, prevention and treatment is essential.

Cytoreductive surgery and intraoperative hyperthermic chemoperfusion for advanced ovarian carcinoma

BACKGROUND

Optimal cytoreductive surgery combined with intraoperative hyperthermic chemoperfusion (IHCP) is a therapy that potentially could improve survival in a select group of patients with advanced ovarian cancer. The purpose of this study was to review the results of cytoreductive surgery and IHCP for advanced ovarian cancer and to identify factors that may predict which patients maximally benefit from this aggressive treatment.

METHODS

Patients treated with cytoreduction followed by IHCP for ovarian cancer were identified from an IHCP database from 1/2001 through 3/2004. Several factors including resection status, peritoneal cancer index (PCI), and prior surgery were evaluated for their ability to predict survival in our cohort of patients.

RESULTS

Thirteen patients with ovarian cancer treated with cytoreductive surgery followed by IHCP were identified. The 3-year overall survival rate for all thirteen patients was 55%. The median disease-free survival was 15.4 months (3-year disease-free survival, 11%). Several factors including PCI score (<6), ability to resect all gross disease, and previous surgical exploration appeared to impart an overall survival advantage.

CONCLUSIONS

The use of IHCP coupled with optimal cytoreduction is a safe and effective treatment for advanced ovarian carcinoma. However, the proper selection of patients who will benefit most from the therapy is essential for the success of the treatment.