To my friend, Judith Doneson (1946-2002), Holocaust and film scholar.
In the fall, you had complained of being constantly bloated.
In February, you had already died.
I will always remember you.
From the NYTimes
Symptoms Found for Early Check on Ovary Cancer (2007)
Ovarian Cancer Screenings Are Not Effective, Panel Says (2012)
Widespread Flaws Found in Ovarian Cancer Treatment (2013)
Fewer than half of ovarian cancer patients at American hospitals receive the type of treatment that has long been known to prolong survival the most, doctors reported on Monday.
The treatment involves pumping chemotherapy directly into the abdomen. In 2006, a major study found that compared with intravenous chemotherapy alone, a combination of intravenous and abdominal treatment could add 16 months or more to women’s lives.
But nearly 10 years later, the abdominal treatment is still underused. Experts suggest a variety of reasons: It is harder to administer than intravenous therapy, and some doctors may doubt its benefits or think it is too toxic. Some may also see it as a drain on their income, because it is time-consuming and uses generic drugs on which oncologists make little money.
“It’s very unfortunate, but it’s the real world,” said Dr. Maurie Markman, the president of medicine and science at Cancer Treatment Centers of America. He added, “The word ‘tragic’ would be fair.”
He said that for now, a woman’s best option is to ask whether her doctor offers the treatment, and if the answer is no, to find a doctor who does.
This year, 21,290 new cases of ovarian cancer are expected in the United States, and 14,180 deaths.
Some experts say that the ability to offer abdominal chemotherapy for ovarian cancer should be added to the list of basic “quality measures” — such as making sure all heart attack patients receive certain drugs — that Medicare and other payers use to evaluate hospital performance.
The 16-month difference in median survival reported in 2006 was considered extraordinary in cancer treatment, and the study prompted a rare move by the National Cancer Institute. It issued a “clinical announcement” to encourage doctors to provide the abdominal treatment, known as intraperitoneal, or IP, chemotherapy. Cancer experts said that medical practice should change immediately.
Practice did change, but not enough, experts say. A study published on Monday in The Journal of Clinical Oncology looked at the use of IP treatment at six cancer hospitals from 2003 to 2012, and at patient survival rates. The six hospitals were all members of the National Comprehensive Cancer Network, an alliance of 26 cancer centers that calls itself “the arbiter of high quality cancer care” and creates widely used practice guidelines for cancer treatment.
But even at these elite centers, IP treatment did not take off as much as experts thought it should. From 2003 to 2006, as research began showing it had benefits, overall use of the treatment rose from zero to 33 percent of patients. From 2007 to 2008 — after the major, landmark study and the alert from the cancer institute — the use rose to 50 percent of eligible patients. But then it reached a plateau. Rates varied from one hospital to the next, with 4 percent to 67 percent of patients receiving IP treatment.
The hospitals are named in the journal article, but their individual rates are not disclosed.
“We suspected that even at the best centers there would be low integration of IP chemotherapy, but we were surprised to see how low it was across academic centers, and also to see how much variation there was between centers,” said Dr. Alexi A. Wright, the first author of the study and a medical oncologist at the Dana-Farber/Brigham and Women’s Cancer Center in Boston. “It’s the best data we have for improving survival among patients with this cancer.”
The study confirmed earlier findings that IP treatment helps women live longer. Among women who had IP treatment, 81 percent were still alive three years later, compared with 71 percent in women who had only intravenous chemotherapy. The findings are based on the records of about 500 women.
Another study, also published in The Journal of Clinical Oncology, in May, found that the benefits of IP therapy are long-lasting: among women followed for 10 years, the risk of death was 23 percent less in those who had IP therapy.
The disease is usually not found until it has reached Stage 3, when it has begun to spread inside the abdomen. Studies find that two factors have the greatest impact on survival: removing every visible trace of the tumor with “debulking” surgery, and finishing the recommended amount of chemotherapy.
IP treatment requires that a port be surgically implanted in the abdominal wall so that the drugs can be infused. Then, at many centers, the patients are rolled back and forth on a bed to slosh the chemotherapy around inside them. The treatment is thought to work so well because it essentially soaks any cancer cells that remain after surgery in a highly concentrated bath of cancer-killing drugs.
Dr. Wright said her study was the first to analyze outcomes from IP treatment that was given as part of regular medical practice, and not part of a clinical trial. The results are important because doctors sometimes worry that findings from clinical trials will not hold up in routine medical practice because patients in the trials are carefully selected and may be healthier, more rigorously monitored and given more help with side effects than those in real-world oncology practices.
In this case, Dr. Wright said, the survival benefit proved that women do not have to be in a clinical trial to benefit from IP treatment, and that it can be given successfully in more ordinary settings. Her study also addressed another concern that some oncologists have raised — the toxicity of IP treatment, which had led some women in the clinical trial to stop treatment without finishing it. In Dr. Wright’s study, side effects were less severe and the rates of completing treatment were similar: 89 percent of women who received IP treatment finished the planned course, compared with 91 percent who received only intravenous treatment.
Dr. Deborah K. Armstrong, a professor at Johns Hopkins Kimmel Cancer Center, and the leader of the 2006 study that proved the large survival benefit, attributed the failure of the therapy to catch on to reluctance by oncologists, especially senior ones who might influence colleagues. She said the cumulative data are so strong that oncologists have “no more excuses” for disregarding it.
But to bring about change, patients will have to speak up, she said, adding: “I think it’s going to have to be the advocate community, since they’re the ones who have the most skin in the game, and can put the money where the mouth is, and say, ‘If you can’t give me the best treatment I’ll go someplace else.’”
© New York Times 2015