In a study reported in JAMA Oncology, Alexander Melamed, MD, MPH, and colleagues found that improvements in median overall survival have been similar in patients from U.S. cancer programs that did vs did not increase their use of neoadjuvant chemotherapy for women with advanced ovarian cancer in recent years, but that increased use of neoadjuvant chemotherapy was associated with a reduction in short-term mortality.
Alexander Melamed, MD, MPH
Study Details
The difference-in-differences comparative effectiveness analysis included data from Commission on Cancer–accredited programs for women with a diagnosis of stage IIIC or IV epithelial ovarian cancer between January 2004 and December 2015, with follow-up through the end of 2018.
Survival outcomes were compared for programs with high usage of neoadjuvant chemotherapy (more often than expected based on case mix) and those that continued to restrict use after the 2010 publication of a clinical trial showing noninferiority of neoadjuvant chemotherapy vs primary surgery.
Key Findings
The analysis included two cohorts of patients according to high vs low use of neoadjuvant chemotherapy: 19,562 patients (mean age = 63.9 years; 3.2% Asian, 8.0% Black, 4.8% Hispanic, 82.5% White) treated in 332 programs that increased use of neoadjuvant chemotherapy from 21.7% in 2004 to 2009 to 42.2% in 2010 to 2015 (high use); and 19,737 patients (mean age = 63.5 years; 3.1% Asian, 7.7% Black, 6.5% Hispanic, 81.8% White) treated in 332 programs that had an increase in use from 20.1% to 22.5% across the two periods (low use).
Compared with the 2004 to 2009 period, standardized median overall improved from 31.6 months (interquartile range [IQR] = 12.3–70.1 months) to 37.9 months (IQR = 17.0–84.9 months) in high-use programs (difference = 6.3 months, 95% confidence interval [CI] = 4.2–8.3 months) and from 31.4 months (IQR = 12.1–67.2 months) to 36.8 months (IQR = 15.0-80.3 months) in low-use programs (difference = 5.4 months, 95% CI = 3.5–7.3 months). The difference in change between high- vs low-use programs was not significant (0.9 months, 95% CI = −1.9 to 3.7 months).
Compared with the 2004 to 2009 period, 1-year mortality decreased from 25.6% to 19.3% (risk difference = −5.2%, 95% CI = −6.4% to −4.1%) in high-use programs and from 24.9% to 21.8% (risk difference = −3.2%, 95% CI = −4.3% to −2.0%) in low-use programs. The difference in change between high- vs low-use programs was significant (−2.1%, 95% CI = −3.7% to −0.5%).
The investigators concluded, “In this comparative effectiveness research study, compared with cancer programs with low use of neoadjuvant chemotherapy, those with high use had similar improvements in median overall survival and larger declines in short-term mortality…. The study findings suggest that neoadjuvant chemotherapy may be an appropriate first-line treatment strategy for many patients with advanced-stage ovarian cancer.”
Alexander Melamed, MD, MPH, of the Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, is the corresponding author for the JAMA Oncology article.
Disclosure: The study was supported by the National Center for Advancing Translational Science and National Cancer Institute. For full disclosures of the study authors, visit jamanetwork.com.
