Ovarian cancer carries a heavy morbidity and mortality burden, particularly in settings and regions of the globe that feature significant limitations in health-care resources. Given that ovarian cancer is more lethal than breast cancer, clinicians in resource-limited areas require guidance on the appropriate assessment and treatment of patients with this disease.
A recently published resource-stratified guideline from ASCO offers evidence-based recommendations on the assessment of women with ovarian masses as well as guidance on the treatment of epithelial ovarian cancer in regions that lack appropriate resources for ensuring high-level care.1
“This guideline is a lifeline for many patients in resource-constrained regions and a guiding tool for clinicians,” said Verna D. Vanderpuye, MD, of the Korle-Bu Teaching Hospital in Ghana, and Guideline Co-Chair.
Verna D. Vanderpuye, MD
Jean Rene V. Clemenceau, MD
The new recommendations represent the first guideline put forth by a multidisciplinary, multinational team of experts specifically involved in the care of patients with ovarian cancer in resource-limited settings.
“All contributors have the sensitivity and understanding of the real-world challenges clinicians face in delivering the best care possible,” said Jean Rene V. Clemenceau, MD, of the Hospital Angeles Del Pedregal in Mexico, and fellow Guideline Co-Chair. Dr. Clemenceau added he hopes the implementation of the guidelines, in addition to policies that could improve resources in certain settings, can offer continuous improvement in the management of ovarian cancer across the world.
The Need for Ovarian Cancer Guidance for Resource-Limited Areas
Dr. Vanderpuye said that resource-limited regions have a lot to grapple with in terms of delivering high-quality care. She suggested that for high-income countries, the availability and application of new technologies and systemic treatments can sometimes lead to inappropriate management, which is associated with both physical and financial toxicities. In contrast, health-care systems in lower-income countries may not even have the necessary tools that can actually improve patient care and outcomes.
“This guideline is a lifeline for many patients in resource-constrained regions and a guiding tool for clinicians.”— Verna D. Vanderpuye, MD
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“The wide spectrum of resources available is observed within health systems across high-income countries and lower middle–income countries,” Dr. Vanderpuye said. In addition, the disparities between countries makes necessary a generalizable guideline for clinicians who manage patients with early- to late-stage ovarian cancer, she added. This guidance may also serve as a document for policymakers in resource-limited settings who seek to improve the level of cancer care.
Diagnostic and Assessment Recommendations
Diagnosticand assessment strategies were discussed extensively in the resource-stratified guideline. For instance, the guideline suggests that patients who present to resource-limited centers with suspected symptoms of ovarian cancer should undergo clinical assessment and contrast-enhanced computed tomography of the abdomen and pelvis. Additionally, clinicians could consider using a combination of transabdominal, pelvic, and transvaginal ultrasound. Areas with enhanced resources may add MRI if clinicians believe it will alter treatment decisions.
The guideline also states that clinicians may use CA-125 as part of the diagnostic evaluation, if available. In terms of assessing hereditable risk, the guideline states that clinicians should at least discuss the patient’s family history and offer referral to appropriate genetic counseling.
Additionally, the guideline consistently recommends referral of patients to settings with higher levels of care, including patients with stage I ovarian cancer who wish to undergo elective surgical staging. Clinicians need to “recognize the importance of specialization, skill, experience, and supporting systems in outcomes,” Dr. Vanderpuye said. “In particular, suboptimal surgery in advanced cases can equal a death sentence, and extensive surgery may require high-level multidisciplinary intervention only available at higher levels of care.”
She added that referral to centers with higher specialization and a greater number of resources could potentially lower the risk of morbidity and mortality.
Several recommendations regarding treatment of ovarian cancer were also made in the report. The guideline indicates that targeted therapies are not cost-effective in many resource-limited regions unless patients in these regions are receiving “enhanced” or “maximal” levels of care.
“I think this is so important as many [patients] are oblivious of the life-threatening toxicities of some medications and do not plan for these adverse events,” Dr. Vanderpuye said. “Many patients are lured to start these therapies without weighing the scales of benefit, including cost implications and associated toxicities, which can later lead to mistrust of the health system.”
In cases where referral to a higher level of care is not feasible, the guideline recommends against administering adjuvant chemotherapy in patients who have received surgery but have not received chemotherapy, specifically if the setting does not have the capability to administer platinum-based chemotherapy safely. Additionally, the guideline also recommends against adding targeted therapies in the basic setting for patients with stage IV disease who have undergone surgery but have not received chemotherapy.
1 .Vanderpuye VD, Clemenceau JRV, Temin S, et al: Assessment of adult women with ovarian masses and treatment of epithelial ovarian cancer: ASCO resource stratified guideline. JCO Glob Oncol 7:1032-1066, 2021.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, July 1, 2021. All rights reserved.