By Mike Bassett
— Programs frequently using this treatment achieved these declines without compromising OS
Cancer programs that were more likely to use neoadjuvant chemotherapy to treat advanced ovarian cancer saw larger declines in short-term mortality versus programs with less frequent use of this treatment, according to a comparative effectiveness analysis.
From 2004-2009 to 2010-2015, the 1-year mortality rate declined from 25.6% to 19.3% with high use of neoadjuvant chemotherapy, and from 24.9% to 21.8% with low use, for a difference-in-differences of -2.1% (95% CI -3.7 to -0.5), reported Alexander Melamed, MD, MPH, of Columbia University Vagelos College of Physicians and Surgeons in New York City, and colleagues.
High-use programs were able to achieve these declines without compromising overall survival. In low-use programs, the standardized median overall survival time improved from 31.4 months in the 2004-2009 period to 36.8 months in 2010-2015 — an absolute difference of 5.4 months. This improvement was similar in the high-use programs: 31.6 months to 37.9 months over this same time period, for an absolute difference of 6.3 months (difference-in-differences of 0.9 months, 95% CI -1.9 to 3.7).
“The study findings suggest that receiving care in a program with high use of neoadjuvant chemotherapy was associated with a reduction in the risk of early mortality without a decrease in median overall survival,” the authors wrote in JAMA Oncology.
“This is a comparative effectiveness study using real-world data from the National Cancer Database, which confirms what has been shown in multiple randomized trials, and which should provide reassurance that people being treated at centers that utilize neoadjuvant chemotherapy more frequently do as well as those in institutions that do not utilize it,” commented Don Dizon, MD, of Lifespan Cancer Institute and Rhode Island Hospital in Providence.
“In addition, lower all-cause mortality in the short term tracks with those institutions that utilized neoadjuvant chemotherapy more,” he told MedPage Today. “In total, I think it does more than suggest the appropriateness of neoadjuvant chemotherapy, it confirms it.”
A randomized trial in 2010 demonstrated the noninferiority of neoadjuvant chemotherapy compared with primary debulking surgery in treating advanced ovarian cancer, after which its use became more frequent.
The results of this study “mirror those of 4 randomized clinical trials that compared neoadjuvant chemotherapy with primary surgery for advanced ovarian cancer. Each trial found that neoadjuvant chemotherapy reduced the risk of surgical morbidity and mortality without compromising long-term overall survival,” noted Melamed and team.
Melamed and colleagues used the 2010 study as a benchmark to define the pre-publication period from 2004 to 2009 as a low-use period preceding the widespread use of neoadjuvant chemotherapy, and the post-publication period of 2010 to 2015 as a period in which its use was more frequent.
Using the National Cancer Database, the authors identified women with stage IIIC or IV epithelial ovarian cancer who were treated at Commission on Cancer-accredited programs in the U.S. from 2004 to 2015, including 19,562 patients (mean age 63.9, 82.5% white) who were treated at 332 cancer programs that increased their use of neoadjuvant chemotherapy from 21.7% in 2004-2009 to 42.2% in 2010-2015, and 19,737 patients (mean age 63.5, 81.8% white) in 332 programs that marginally increased their use, from 20.1% to 22.5%, over these time periods.
In addition to the 1-year mortality rate differences, the standardized 6-month mortality rate declined from 16.4% to 12.0% in high-use programs, and from 16.1% to 14.4% in low-use programs (difference-in-differences -2.3%, 95% CI -3.2% to -1.3%).
Melamed and colleagues acknowledged that their study had several limitations. They pointed out that its “design depends on the assumption that, if the programs included in the high-use and low-use groups had not developed differential use of neoadjuvant chemotherapy, improvements in survival would have been the same in these cancer programs.”
“It is possible that unmeasured patient-level or clinician-level factors affected the survival of the patients treated in these programs differentially,” they wrote.
This article was published by Med Page Today.