One Women In Three Under-Treated For Ovarian Cancer

SEATTLE, April 9 -- One in three American women with ovarian cancer may not get the recommended comprehensive surgical treatment, according to researchers here.

An analysis of hospital data from nine states shows that 66.9% of all women admitted with a diagnosis of ovarian cancer got optimal treatment, reported Barbara Goff, M.D., of the University of Washington, and colleagues, in the May 15 issue of Cancer.

Women who were 71 or older, of African-American race, or Hispanic ethnicity or covered by Medicaid were most likely to be under-treated, Dr. Goff and colleagues said.

On the other hand, the analysis showed, women cared for by surgeons with a high volume of ovarian cancer treatment -- defined as 10 or more cases a year -- were more likely to get appropriate therapy, the researcher said.

The findings bolster the argument that all women with ovarian cancer should be sent to specialist centers for their surgical care, the researchers said.

"The referral of women with suspected ovarian cancer to expert centers for primary surgery would be an effective strategy to improve overall outcomes," Dr. Goff and colleagues argued.

The Institute of Medicine concluded in 1999 that many Americans with cancer are not receiving ideal care, the researchers noted, adding that for ovarian cancer, "the key to high-quality care is appropriate surgical treatment."

If a patient has limited disease outside the pelvis, the recommended comprehensive surgical treatment is a lymph node dissection and omentectomy and cytoreduction, Dr. Goff and colleagues noted.

If there is a secondary malignancy of a specified organ or site, the recommended treatment is omentectomy and cytoreduction. Lymph node dissection is not considered essential for comprehensiveness if there is extensive disease outside the pelvis.

Using those definitions and the state inpatient databases of the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project' the researchers analyzed 10,432 admissions of women who were hospitalized for both a primary diagnosis of ovarian cancer and an oophorectomy.

The analysis covered nine states -- Colorado, South Carolina, Wisconsin, Florida, Iowa, Maine, New Jersey, New York, and Washington.

The study found that advanced disease was recorded in 61.1% of cases and that 24% of cases were considered urgent or emergent. A crude analysis of discharge data showed that 66.9% of women got recommended surgical care, the researchers said.

A more detailed regression analysis showed that:

• Women with advanced cancer were nearly five times as likely to get comprehensive care as women with early stage disease. The odds ratio was 4.78, with a 95% confidence interval from 4.26 to 5.37.
• Women treated at non-teaching hospitals by a medium- or high-volume surgeon were 35% and 57% more likely to get optimal treatment, respectively, than those cared for by a doctor treating only one case a year. The rate of optimal treatment did not vary by surgeon volume at teaching hospitals.
• Compared with Caucasian women, African-American or Hispanic women were less likely to get optimal treatment. The odds ratios were 0.66 and 0.76, respectively, with 95% confidence intervals from 0.52 to 0.83 and from 0.60 to 0.95.
• Compared with women ages 21 to 50, those 71 through 80 and those 81 and older were less likely to get optimal care. The odds ratios were 0.79 and 0.54, respectively, with 95% confidence intervals from 0.64 to 0.97 and from 0.41 to 0.72.

The study also noted some state-by-state disparities. Colorado, for instance, had the highest rate of comprehensive surgery at 74.4%, while Iowa had the lowest rate at 61.5%.

Also, the researchers found, the rate of comprehensive surgery was lowest among those insured by Medicaid, at 62.1%, and highest among women with private insurance, at 68.7%.

The hospital discharge data allowed an analysis of the pattern of care in the nine states, but it was limited because not all states reported all variables, the researchers said.