Neoadjuvant chemotherapy in the Medicare cohort with advanced ovarian cancer.

OBJECTIVE: The value of neoadjuvant chemotherapy (NAC) for the treatment of advanced ovarian cancer has yet to be determined. While NAC may facilitate and simplify complete cytoreduction and reduce the risk of surgery, the delay of surgery related to NAC needs to be balanced against any potential benefit. METHODS: Surveillance, Epidemiology and End-Results (SEER) data linked to Medicare claims were used to identify 6844 women with treated stage III/IV epithelial ovarian cancer (1995-2005). Patients were classified by primary treatment (surgery (PDS) or chemotherapy), and the primary chemotherapy group was characterized as having NAC or palliative chemotherapy (PC) based on whether there was documentation that surgery was recommended. We compared surgical complications and survival between the groups. RESULTS: 4827 (71%) of women were treated with PDS, 958 received NAC (14%) and 1059 (15%) had PC. Only 577 (60%) of women with NAC underwent surgery and they had fewer ostomies (8.5% vs. 19.2%, p<0.001) and fewer infections, gastrointestinal and pulmonary complications than PDS (all p<0.01). Comparing NAC to PDS there was a 16% increase in the risk of death at 2years (RR 1.16, 95%CI 1.01-1.34) for women with stage III disease and a 15% reduction in the risk for women with stage IV disease (RR 0.85, 95%CI 0.73-0.99). CONCLUSIONS: NAC followed by surgery was associated with fewer surgical complications than PDS. The direction and magnitude of the difference in survival between women receiving NAC and those receiving PDS differed according to the stage of disease and follow up time.

Thirty-day mortality after primary cytoreductive surgery for advanced ovarian cancer in the elderly.

OBJECTIVE: To identify factors associated with increased 30-day mortality after advanced ovarian cancer debulking among elderly women. METHODS: A database linking Medicare records with the Surveillance, Epidemiology, and End Results (SEER) data was used to identify a cohort of 5,475 women aged 65 and older who had primary debulking surgery for stage III or IV epithelial ovarian cancer (diagnosed 1995-2005). Women were stratified by acuity of hospital admission. Multivariable analysis was performed to identify patient-related and treatment-related variables associated with 30-day mortality. RESULTS: Five thousand four hundred seventy-five women had surgery for advanced ovarian cancer, and the overall 30-day mortality was 8.2%. Women admitted electively had a 30-day mortality of 5.6% (251 of 4,517), and those admitted emergently had a 30-day mortality of 20.1% (168 of 835). Advancing age, increasing stage, and increasing comorbidity score were all associated with an increase in 30-day mortality (all P<.05) among elective admissions. A group of women at high risk admitted electively included those aged 75 or older with stage IV disease and women aged 75 or older with stage III disease and a comorbidity score of 1 or more. This group had an observed 30-day mortality of 12.7% (95% confidence interval 10.7%-14.9%). CONCLUSION: Age, cancer stage, and comorbidity scores may be helpful to stratify electively admitted patients based on predicted postoperative mortality. If validated in a prospective cohort, then these factors may help identify women who may benefit from alternative treatment strategies. LEVEL OF EVIDENCE: II.

Patterns of spread and recurrence of sex cord-stromal tumors of the ovary.

OBJECTIVE: Sex cord-stromal tumors are an uncommon type of ovarian neoplasm and limited data are available in the literature to guide clinical management. Recent published series suggested a lack of lymph node involvement and recommended abandonment of the lymph node dissection as part of the primary surgical staging of these tumors. To confirm these findings, we evaluated pathologic findings in women undergoing surgical management of sex cord-stromal tumors in the Seattle metropolitan area. METHODS: A retrospective multi-institutional review of all patients treated with sex cord-stromal tumors at University of Washington Medical Center and Swedish Medical Center in Seattle was conducted. Information was collected on the pathology, evaluation, and treatment of these patients. RESULTS: A total of 87 patients were available for analysis, the majority of whom had adult granulosa cell tumors (82%) and Sertoli-Leydig cell tumors (13%). Of these patients, 68% had complete or partial surgical staging procedures, and 47 patients had some nodal tissue examined as part of the initial or restaging procedure. All nodes examined were negative. Tumor size was significantly associated with risk of recurrent disease, with a 20% increase in the hazard of recurrence for each increase of tumor size of 1cm (HR, 1.20; 95% CI, 1.11-1.07). CONCLUSIONS: This study confirms the finding that lymph node metastasis are rare in sex-cord stromal tumors. These findings support the hypothesis that routine lymphadenectomy provides limited additional information in the management of these patients and can be omitted from the primary surgical staging procedure or secondary restaging procedures.

Trends in treatment of advanced epithelial ovarian cancer in the Medicare population.

OBJECTIVE: Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy. METHODS: Using the Surveillance, Epidemiology and End-Results data we identified a cohort of 8211 women aged 65 and above with stage III/IV epithelial ovarian cancer diagnosed between 1995 and 2005. Receipt of chemotherapy or surgery was identified using Medicare claims. Logistic regression was used to evaluate factors associated with sequencing of treatment and the receipt of surgery. RESULTS: 3241 (39.1%) had surgery and at least 6 cycles of chemotherapy in either order. Surgery was performed initially in 4827 (58.8%) women and 3658/4827 (75.8%) had subsequent chemotherapy. 2017 (24.6%) had primary chemotherapy and 649/2017 (32.2%) of these women had subsequent surgery. Advanced age, African American race, stage IV disease, non-married status and increasing medical comorbidity were all associated with the failure to receive both surgery and at least 6 cycles of chemotherapy (all p<0.01). CONCLUSIONS: The majority of women with advanced ovarian cancer in the Medicare population do not receive both combination therapy with surgery and at least 6 cycles of chemotherapy. A large proportion of women are receiving chemotherapy as primary treatment for advanced ovarian cancer, and the majority of these patients do not have cancer-directed surgery.

Clinical use of combined positron emission tomography and computed tomography (FDG-PET/CT) in recurrent ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the use of co-registered PET/CT using F-18 fluorodeoxyglucose (FDG) for surveillance and follow-up of ovarian cancer patients to detect recurrent disease. MATERIAL AND METHODS: A retrospective chart review was performed on 39 ovarian cancer patients who underwent a total of 59 FDG-PET/CT scans. The following information was obtained: clinical indication for FDG-PET/CT, the results of FDG-PET/CT particularly with regard to the additional diagnostic information, the localization of disease and subsequent clinical patient management. RESULTS: Twenty-four FDG-PET/CT were performed in 22 patients with previously negative or indeterminate CT scans but rising CA-125 levels providing a sensitivity of 90% for localizing disease. Nine FDG-PET/CT in 8 patients with clinical symptoms of recurrence but normal CA-125 levels detected all three patients who had recurrent disease confirmed within 6 months of follow-up. In addition, 4 FDG-PET/CT performed as routine follow-up with no clinical evidence of recurrent disease were true-negative in all cases. Fourteen FDG-PET/CT in 12 patients with recurrent disease already identified by conventional CT imaging were useful in guiding treatment decisions such as radiation therapy, surgery or chemotherapy by confirming the recurrence and more precisely localizing the site(s) of disease. Of note, FDG-PET/CT helped to avoid surgery in four patients who had additional disease detected in unresectable anatomic areas. A total of 51 FDG-PET/CT were performed in the patients described above with an overall sensitivity and specificity of 94.5% and 100%, respectively. Eight FDG-PET/CT scans in five patients performed for assessment of treatment response following chemotherapy or radiation were useful as the disease was not clearly visualized by conventional CT imaging at baseline. CONCLUSIONS: In our experience, FDG-PET/CT has the greatest utility in settings of suspected ovarian cancer recurrence, particularly in patients with rising CA-125 levels and negative conventional imaging. FDG-PET/CT was specifically helpful in optimizing the selection of patients for site-specific treatment, including radiation treatment planning, and aided in the selection of optimal surgical candidates. The co-registered metabolic-anatomic information from combined FDG-PET/CT holds promise in replacing the single imaging procedures.