Why is an ovarian cancer treatment that saves women’s lives being underused?
Using intraperitoneal (IP) chemotherapy (infusing chemotherapy into the abdomen) along with intravenous chemotherapy (IV chemo, which is infused into veins) dramatically extends lives in women with ovarian cancer. Yet, a recent study found that only 41 percent of women treated at 6 academic centers received IP chemotherapy treatment. You may be thinking that it takes time for word about a major treatment advance like this to get out. A reasonable thought, but it turns out that information about this life-extending treatment has been available for almost a decade!
In 2006, the Gynecologic Oncology Group, a cancer research group, reported that a randomized trial called “GOG-172” demonstrated that IP chemotherapy improved median overall survival by 16 months — a huge accomplishment. So huge, in fact, that the National Cancer Institute sent physicians a Clinical Announcement, which is a rarely used communication tool to for advances so important that practice should change immediately.1 IP/IV chemotherapy use did increase from 33 percent in 2006, to nearly 50 percent in 2008 — but hasn’t increased since then.
There was already plenty of evidence that IP chemotherapy worked. Trials of IP chemotherapy began in 1986, and almost every study showed a dramatic benefit in extending life. These results have been repeated over the years. In fact, just a few weeks ago, a study was published in the Journal of Clinical Oncology that looked at whether the procedure is effective in “real-world” practice (as opposed to in clinical trials) and how often IP chemotherapy was used at six hospitals that are part of the National Comprehensive Cancer Network, an elite alliance of cancer centers.2
Among 823 women with stage III ovarian cancer who had all had optimal surgery that removed all visible signs of tumor, overall survival at three years was 81 percent for women who had IP and IV chemotherapy compared with 71 percent for women who only received IV chemotherapy. These results mirrored previous studies, and demonstrated that IP chemotherapy works in the real world setting, where physicians may use different drugs and doses of drugs.
So, why do only 41 percent of eligible ovarian cancer patients receive IP chemo in cancer centers that pride themselves on using evidence-based treatment? It’s unclear. The researchers cite causes for the low rate that include, vaguely, “local culture and clinical practice leaders’ enthusiasm for treatments and clinical trials.” The New York Times quotes Dr. Maurie Markman, the President of Medicine and Science at the Cancer Treatment Centers of America, as saying that this treatment requires no new drugs or devices, so manufacturers aren’t educating physicians about it.3
Let’s expand on that a moment. Oncologists profit personally from some of the drugs they recommend, because physicians are allowed to profit from drugs they administer in their offices. They do not profit off chemo drugs that are taken at home. So, an oncologist who writes a prescription for an oral therapy makes no money off it; but, if a treatment is administered in the physician’s office, he can charge for the procedure and profit from the drug that’s used. If the drug chosen is expensive, the oncologist makes more money. This is very bad for patients, because oncologists may push drugs that are administered in the office instead of oral drugs.
This case is a bit different, but still involves physicians’ reluctance to change practice habits when doing so affects their profits. IP chemotherapy takes time and uses older, less-expensive chemo drugs — usually cisplatin and paclitaxel. So physicians may choose to use IV chemo because it’s simpler and faster to administer than IP chemo. Because IP chemo takes less time, the physician can see more patients — and make more money. And oncologists may choose to use newer, branded drugs instead of the classic drugs used in IP chemo, because administering newer drugs is more profitable.
Depressed yet? We are. Deborah K. Armstrong, a Johns Hopkins professor who led the 2006 study that showed IP chemo’s large survival benefit says that the data are now so strong that oncologists have “no more excuses” not to use IP.4 Oh, they’ll find an excuse. There is plenty of evidence that physicians ignore evidence. Give this column to anyone you know with ovarian cancer and encourage them to seek care from providers who use the most effective treatment – and count on the National Women’s Health Network to provide you with science-based evidence you can use.
Charlea T. Massion, MD, is a NWHN Board member, family physician, and specialist in hospice and palliative care medicine. She is the Chief Medical Director of Hospice of Santa Cruz County and also teaches physicians about work-life balance and career development.
Adriane Fugh-Berman, MD, is an associate professor in the Georgetown University Medical Center; a former chair of the NWHN Board of Directors; and directorof PharmedOut, which educates prescribers about pharmaceutical marketing techniques.
1. National Cancer Institute, NCI Clinical Announcement: Intraperitoneal chemotherapy for ovarian cancer, Bethesda MD: NCI, January 6, 2006. Available online at: http://ctep.cancer.gov/highlights/docs/clin_annc_010506.pdf
2. Wright AA, Cronin A, Milne DA et al., “Use and effectiveness of intraperitoneal chemotherapy for treatment of ovarian cancer,” J Clin Onc. 2015; 33:1-12. Published online before print August 3, 2015, doi: 10.1200/JCO.2015.61.4776 Available online at: http://jco.ascopubs.org/content/early/2015/08/03/JCO.2015.61.4776
3. Grady D, “Effective Ovarian Cancer Treatment Is Underused, Study Finds,” New York Times, August 3, 2015, page A-13. Available online at: http://www.nytimes.com/2015/08/04/health/ovarian-cancer-abdominal-chemotherapy-underused.html?_r=0
4. Grady D, “Effective Ovarian Cancer Treatment Is Underused, Study Finds,” New York Times, August 3, 2015, page A-13. Available online at: http://www.nytimes.com/2015/08/04/health/ovarian-cancer-abdominal-chemotherapy-underused.html?_r=0