Despite proof that specialists in gynecologic cancers have better outcomes, most women with ovarian cancer receive inadequate care from less qualified providers
If an oncologist knew that a particular treatment method would add on months to the life of a woman who has ovarian cancer, he or she should do it, right? This is the difference between getting cancer care with a gynecologic oncologist versus care with any other specialist for ovarian cancer.
So why are so many women with ovarian cancer getting care from doctors who are not gynecologic oncologists? The answer is complex.
Some women do not have access to a gynecologic oncologist in their hometown, so they have ovarian cancer surgery by a general surgeon or gynecologist. Some women are seen by a medical oncologist first who may prescribe chemotherapy without the accompanying debulking surgery they need.
Some women do not have access to a large academic center that offers advanced chemotherapy or intraperitoneal chemotherapy (IP chemotherapy) that may prolong their lives. And some hospitals do not offer the most effective treatments for ovarian cancer — probably because many providers aren’t familiar enough with the treatment, it’s more complicated to administer than other cancer treatments, or because it is time consuming and uses low-profit generic drugs.
Research clearly shows that doctors who specialize in gynecologic cancers — gynecologic oncologists — are better at treating these cancers than nonspecialized oncologists or surgeons. Yet many physicians treating women for ovarian cancer are general oncologists or even general gynecologic surgeons who just don’t handle enough ovarian cancer cases to be as effective as the specialists who do. And most women are unaware of their options to see a trained specialist in their fight against ovarian cancer.
Only a third of women are getting the best ovarian cancer care
Studies point out that most women with ovarian cancer do not receive adequate care, even at very good hospitals. Those physicians are not seeing enough cases to raise their outcomes and they’re also not using the most advanced surgical and therapy techniques. The result is that little more than a third of women with ovarian cancer get the best treatment.
For example, the National Cancer Institute in 2006 took the unusual step of making a “clinical announcement” asking doctors to adopt IP chemotherapy immediately and for patients to ask for it. The gynecologic oncology community expected a huge turnaround in use, but we have been disappointed at the lack of change in the way we treat the majority of ovarian cancer cases.
A study by Dr. Robert Bristow of University of California, Irvine showed that of 13,321 California women with epithelial ovarian cancer (the most common and deadly form), only 37 percent were treated according to guidelines established by the National Comprehensive Cancer Network (NCCN). CU Gynecologic Oncology is an NCCN-designated cancer center, and our own Dr. Guntupalli has also done research on treatments that improve survival rates for epithelial ovarian cancer.
But only 37 percent getting the best care? That’s difficult for me to take, and certainly more so for patients and their family members.
Ovarian cancer isn’t as common as other cancers, so there’s less chance for an oncologist or gynecologist to have that specific experience. For example, according to the American Cancer Society, there will be about 22,440 cases of ovarian cancer in 2017 in the United States but around 252,710 cases of breast cancer.
Can you imagine the uproar if two thirds of breast cancer patients were not receiving treatments known to improve success? The breast cancer constituency is more numerous and more active than the ovarian cancer constituency. Still, the time for ovarian cancer patients settling for second best should end.
Race and ethnicity impact treatment
The CU Gynecologic Oncology team recently looked at data from the American College of Surgeons National Surgical Quality Improvement Program on patients undergoing a hysterectomy for a gynecologic malignancy in 2014 and 2015. This treatment can be used for ovarian, uterine or cervical cancer.
The good news is that the study found that the majority of gynecologic cancer cases are performed by gynecologic oncologists. But the bad news is that the group most likely to see generalists and not a gynecologic oncologist were minority patients.
This study found that 90 percent of women with a gynecologic cancer were being treated by a gynecologic oncologist. This is much higher than past studies.
This data came from 603 institutions across the United States, including community hospitals in rural areas and urban academic medical centers, which is 11 percent of the more than 5,000 hospitals recognized by the American Hospital Association.
We can only guess why the numbers of minorities getting treated by a gynecologic oncologist are lower. It is important to focus on making sure all women, regardless of their race or ethnicity, get the best possible care.
Most effective ovarian cancer treatments left in the doctor’s bag
It’s clear that in an overall sense regarding ovarian cancer, we’re not using the best tools that we have. Probably the best tool is complex and extensive surgery done in conjunction with innovative chemotherapy, such as IP chemo. This type of surgery is done by a surgeon who specializes in ovarian cancer surgery.
As in life, experience counts: physicians who’ve completed more surgeries have patients with better outcomes. We routinely perform gynecologic cancer surgery at CU Gynecology Oncology, and so are leaders in open, minimally invasive and robotic surgeries for gynecologic cancer.
Studies and our own experience show that when ovarian cancer has spread into the abdomen, the most effective way to improve the woman’s outcome and survival is to perform debulking surgery to remove as much of the cancer as possible. This may include removal of the spleen, sections of the intestines, reproductive organs and omentum.
Debulking surgery should be done by a gynecologic oncologist. Often it’s not.
Many women rush into treatment once diagnosed and let their gynecologist or a general oncologist debulk their cancer, even though the doctor doesn’t do such operations regularly. Sometimes during a diagnostic operation or another operation, a surgeon will discover ovarian cancer and try to remove it. But the surgery isn’t done as well as it could be, potentially shortening an ovarian cancer patient’s lifespan or causing unintended complications.
CU Gynecologic Oncology is the only practice in the Rocky Mountain region that’s part of the National Comprehensive Cancer Network (NCCN). We would prefer that surgeons in our area who lack ovarian cancer expertise refer their patients to us so patients get the best treatment and live longer.
We would also like women to seek us out. But many women don’t know to look for a gynecologic oncologist, let alone what we can do better than other doctors to improve and extend ovarian cancer patients’ lives. Sometimes patients don’t think they have the time to find a specialist when they hear they have cancer. But they should take the time.
Following are a few things to keep in mind about a gynecologic oncologist’s ability to better treat a woman’s ovarian cancer.
- Surgeons who perform 10 or more ovarian cancer operations are more likely to stick to NCCN guidelines, yet about 80 percent of ovarian cancer operations are done by “low-volume” providers.
- Women with advanced disease treated using NCCN guidelines are 10 percent more likely to survive past five years than women who don’t receive NCCN-guideline care.
- Chemotherapies such as intrapertonal chemo are much more effective than regular IV (intravenous) chemotherapy, yet many general oncologists only use IV on ovarian cancer patients.
- Gynecologic oncologists are board-certified gynecologists who have undergone an additional three to four years of specialized oncology training, making them more qualified to handle gynecologic surgery to effectively remove and treat ovarian cancer.