• Users Online: 1671
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 158-162

Ovarian cancer practice survey from the South Asian Association for Regional Cooperation (SAARC) Nations


1 Department of Radiation Oncology, Kathmandu Cancer Centre, Mahamanjushree Nagarkot, Nepal
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Surgical Oncology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Web Publication20-Dec-2019

Correspondence Address:
Sampada Dessai
Sir H. N Reliance Hospital, Prarthana Samaj, Raja Rammohan Roy Road, Charni Road East, Girgaon, Mumbai - 400 004, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_41_19

Get Permissions

  Abstract 


Background: Management of ovarian cancer has evolved over time with innovations in surgical management as well as in systemic therapy. In the real world, treatment is often adapted to distinct settings based on the socioeconomic factors, physician and patient preference, availability of resources, need for referral, and controversies in the standard treatment. These deviations from conventional treatment can lead to suboptimal results and a better comprehension of this variability can help us to plan corrective measures for improvement in community practice.
Methods: The survey instrument consisted of four sections dealing with baseline details of participants, early-stage ovarian cancer practice patterns, surgical practice patterns, and adjuvant/neoadjuvant chemotherapy (NACT) in advanced-stage ovarian cancer. It was an anonymous survey sent as an email and the responses were electronically captured. No incentive was provided. Descriptive statistics were performed using the SPSS software version 20 and R studio.
Results: Seventy-five of 258 participants responded. Majority of participants (n = 67, 89.3%) were in favor of doing a fertility-preserving surgery in early-stage ovarian cancer with 86.7% opting for open surgery (n = 65) and only 13.3% (n = 10) using minimally invasive methods. The proportions of early-stage ovarian cancer patients receiving chemotherapy were >90% in 14.7% (n = 11), 75%–90% in 24% (n = 18), 50%–75% in 18.7% (n = 14), 10%–50% in 32% (n = 24), and <10% in 10.7% (n = 8). In the advanced stage, few centers had high rates of microscopically margin negative (R0) resection with primary cytoreduction. About 90.7% of participants (n = 68) avoided doing multiorgan resection for achieving an R0 resection. Sixty percent (n = 45) of the 75 participants offered NACT to all Stage III–IV patients.
Conclusion: Ovarian cancer management in the South Asian Association for Regional Cooperation countries is largely congruent with international guidelines. Differences in the administration of intensive chemotherapy schedules and targeted therapy are observed.

Keywords: Adjuvant chemotherapy, India, Low Middle Inome Country, ovarian cancer, practice pattern, South Asian Association for Regional Cooperation, surgery


How to cite this article:
Sapkota S, Abhyankar A, Dessai S. Ovarian cancer practice survey from the South Asian Association for Regional Cooperation (SAARC) Nations. Cancer Res Stat Treat 2019;2:158-62

How to cite this URL:
Sapkota S, Abhyankar A, Dessai S. Ovarian cancer practice survey from the South Asian Association for Regional Cooperation (SAARC) Nations. Cancer Res Stat Treat [serial online] 2019 [cited 2020 Feb 28];2:158-62. Available from: http://www.crstonline.com/text.asp?2019/2/2/158/273672




  Introduction Top


Ovarian cancer commonly presents in an advanced stage and requires multimodal management.[1],[2] Its management has evolved over time. Surgical management of this tumor aims at performing a staging laparotomy in early-stage ovarian cancer while the aim in advanced disease is to achieve optimal cytoreduction. The definition of optimal cytoreduction is a moving goal post. It has changed from gross residual disease <2 cm2 to no visible residual disease.[3],[4] Similar innovations have occurred in systemic therapy too. The adjuvant chemotherapy schedule has evolved from single-agent melphalan to a dose-intense paclitaxel-carboplatin regimen with or without angiogenic inhibitors.[5],[6],[7] However, controversy still exists in the sequencing of chemotherapy and surgery, the choice of the surgical procedure, chemotherapy regimen, and follow-up of these patients. This controversy results in variation in treatment across institutes.

Other factors contributing to variation in treatment protocols are the patient preference, physician preference, and lack of knowledge and implementation of standard guidelines. The dearth of different specialists in a single institute resulting in referral to other centers is common and plays a major role in the sequencing of treatment. Treatment protocols may also be altered due to logistic difficulties, especially in low- and middle-income countries. In these countries, standard treatment protocols become difficult to follow due to a paucity of resources.[8] The high patient-to-doctor ratio, lack of national health insurance, and low per capita income hamper the ability to administer intensive treatment protocols.[8],[9]

Hence, it is important to understand the variations in community practice and know the reasons for the same. This knowledge can help in planning corrective measures toward improvement in community practice. Hence, we conducted a survey in the South Asian Association for Regional Cooperation (SAARC) countries about the treatment pattern in ovarian cancer.


  Methods Top


Survey instrument

The survey instrument was designed by Sampada Dessai and Simit Sapkota. The instrument had four sections [Supplementary Appendix 1]. The initial section dealt with the baseline details of participants. The details sought included the specialty, work place/place of work, the load of ovarian cancer patients, and practice area (country). The next section dealt with early-stage ovarian cancer practice pattern. Details asked for included the surgical practice pattern and adjuvant chemotherapy. Section three and four dealt with advanced ovarian cancer. Section 3 focused on identifying the surgical practice patterns in advanced ovarian cancer, whereas section 4 focused on adjuvant/neoadjuvant chemotherapy (NACT). The survey had 23 questions; most of the responses were Likert scale-based and automated response allowed to select only the most appropriate response. The survey instrument was made in Google forms.

Participants and survey distribution

It was an anonymous survey conducted between November 2018 and February 2019. Oncologists involved in ovarian cancer treatment in SAARC countries were invited to participate. In India, all members of the Association of Gynecologic Oncologists of India were invited. In the rest of the countries, a manual search was performed in the national databases or Google, and the oncologists were invited. The invitation was sent through email. The participants were reminded twice through email to respond to the survey. No incentive was provided for filling out the survey. The survey responses were electronically captured in Google sheets.

Statistical analysis

The electronically captured data from Google sheets were used for analysis. The SPSS version 20 and R studio were used for the analysis. Descriptive statistics were performed. The continuous variables were described in terms of the median with the interquartile range (IQR), and ordinal or nominal variables were expressed in terms of percentages, and the 95% confidence interval (CI) was provided.


  Results Top


Baseline characteristics

Two hundred and fifty-eight participants were invited to take part in the survey, of which 75 participants (29.1%; 95% CI, 23.9–34.9) responded. The participants belonged to the medical oncology fraternity (n = 31, 41.3%), surgical gynecologic-oncology fraternity (n = 15, 20%), gynecological fraternity (n = 13, 17.3%), radiation oncology fraternity (n = 11, 14.7%), and surgical oncology fraternity (n = 5, 6.7%). Majority of participants worked at government academic institutes (n = 50, 66.7%). The rest of the participants worked at non-governmental academic institutes (n = 8, 10.7%), nonacademic government institutes (n = 2, 2.7%) or were solo private practitioners (n = 15, 20%). The median number of ovarian cancer patients seen by each participant was 4/month (IQR, 4–30). The participants practiced either in India (n = 59, 78.7%) or Nepal (n = 16, 21.3%).

Ovarian cancer practice pattern

Early stage

Majority of participants (n = 67, 89.3%) were in favor of doing a fertility-preserving surgery in early-stage ovarian cancer. The mode of surgery opted for by most of the participants was open surgery (n = 65, 86.7%). Only 13.3% (n = 10) of participants were in favor of using minimally invasive methods for early-stage ovarian cancer. Majority of participants addressed the lymph nodes during staging laparotomy, the extent was either lymph node dissection (n = 34, 45.3%) or lymph node sampling (n = 27, 36.0%). The administration of adjuvant chemotherapy was variable between the participants. The proportions of early-stage ovarian cancer patients receiving chemotherapy in the participants' practices were >90% in 14.7% (n = 11), 75%–90% in 24% (n = 18), 50%–75% in 18.7% (n = 14), 10%–50% in 32% (n = 24), and <10% in 10.7% (n = 8). The median number of cycles of chemotherapy administered was 4 (IQR 4–6).

Advanced stage

[Table 1] gives the responses obtained for cytoreductive surgery in advanced ovarian cancer. As can be observed, only a few participants offer primary cytoreduction to most patients and similarly, few centers have high rates of microscopically margin-negative (R0) resection with primary cytoreduction. In general, the majority of participants performed pelvic lymph node dissection, but para-aortic lymph node dissection was recommended by very few participants. Forty-five (60%) of the 75 participants offered NACT to all Stage III–IV participants. Majority of participants, n = 68; 90.7%, would refrain from doing multiorgan resection if this was necessary to achieve an R0 resection. [Table 1] shows the responses obtained for performing intraperitoneal cisplatin instillation or hyperthermic intraperitoneal instillation of chemotherapy.
Table 1: Responses to questions dealing with surgical management of advanced epithelial ovarian cancer

Click here to view


The preferred regimen for adjuvant or NACT was paclitaxel and carboplatin (68, 90.7%) [Table 2]. The three-weekly schedule was the most common schedule used by 93.3% of participants (n = 70). The dose-dense schedule was used by the rest of the participants [Table 2]. The majority of participants (n = 67, 89.3%) refrained from using bevacizumab in the adjuvant setting. In patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) >2, flat dose carboplatin (n = 29, 38.7%), or weekly paclitaxel with carboplatin (n = 23, 30.7%) were the commonly used schedules. BRCA mutation analysis was performed regularly by 11 participants (14.7%) and on a case-to-case basis by 19 participants (25.3%).
Table 2: Responses to questions dealing with adjuvant-neoadjuvant medical management of advanced epithelial ovarian cancer

Click here to view



  Discussion Top


This is probably the first survey focusing on the ovarian cancer treatment practice pattern in SAARC countries. Nearly one-third of the invited participants responded. The response rate of the survey was low as compared to average response rates observed in physician surveys in the literature.[10],[11],[12] This is mainly because the survey was carried out only electronically, and there were no incentives provided for filling the survey. A similarly low response rate was reported in a recently published survey.[13] The majority of respondents of the survey were academic practitioners and there was a good mix of respondents from surgical, medical, and radiation backgrounds.

The survey highlighted that fertility-preserving surgery was considered as the option of choice in early-stage ovarian cancer by an overwhelming 89.3% of respondents. This is in accordance with the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) guidelines.[14],[15] Guidelines for both Stage IA and IB patients recommend the use of fertility-preserving surgery if fertility is desired. Open surgery was favored as the method for staging laparotomy. This is in line with the literature where there are hardly any studies supporting a minimally invasive surgical approach in epithelial ovarian cancer.[16] The role of minimally invasive surgery in pelvic cancer is controversial at present, with multiple large randomized studies questioning the benefit of such an approach.[17] Lymph nodes were addressed during staging laparotomy by a majority of the participants. The role of lymph node dissection is questionable; however, it helps in predicting the prognosis of the patient. Variability was noted in the survey regarding the administration of adjuvant chemotherapy. Adjuvant chemotherapy is recommended in early-stage ovarian cancer and needs to be offered in all patients barring Stage IA or IB Grade (1–2) tumors.[14],[15]

In the advanced stage, primary cytoreduction was offered by a minority of the participants as frequently patients have high disease burden, higher ECOG PS, malnutrition, and low serum albumin status.[2] It is also a reflection of the resource-constrained setting commonly seen in SAARC nations. Hence, even though the literature would recommend giving NACT for patients with ovarian cancer in whom R0 resection is not possible, this does not seem to be widely followed. The above-mentioned patient characteristics hamper the ability of the patients to tolerate long surgeries. In addition, due to a low doctor-to-patient ratio and limited centers providing oncology care, the waitlist for surgeries is long, and hence patients received NACT. Neoadjuvant or adjuvant chemotherapy of paclitaxel and carboplatin was the regimen of choice for most participants. The three-weekly schedule was preferred over the dose-dense schedule of paclitaxel and carboplatin, which are resource-consuming and without any apparent benefit.[7] Bevacizumab was used by a minority of participants. This is due to the lack of overall survival benefit with bevacizumab and also reflects the economic status of the patients in this region.[18],[19] BRCA mutation analysis was performed by a few participants, that too in mostly individual cases. This is due to a lack of centers performing these tests, limited genetic counseling, and managing facilities in the region and limited accessibility to BRCA inhibitor drugs.


  Conclusion Top


Ovarian cancer management in SAARC countries is principally in line with international guidelines. It differs mainly in the administration of intense chemotherapy schedules and targeted therapy. This practice pattern may be due to the socioeconomic status of this region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Supplementary Appendix Top



  Survey of ovarian cancer practice in SAARC countries Top


Dear Colleagues,

We are conducting a survey to better understand the management practices in epithelial ovarian cancer in the SAARC region. We sincerely request you to complete this form on the basis of last one year of your practice and return at the earliest. It will take 3-4 minutes of your precious time . The information provided in the form will be kept confidential, however will be used to summarize the needs and design for further research in this dreaded malignancy.

Dr Sampada Dessai

Gyn-Oncologist, Sir H. N. Reliance Foundation Hospital and Research Centre , Mumbai

* Required

1. 1.1 What is your speciality? *

Please choose the most appropriate option

Mark only one oval.

Surgical oncologist- General

Surgical Gyn-Oncologist

Gyencologist

Surgeon

Medical Oncologist

Radiation oncologist

2. 1.2 Where do you practice? *

Please select the most appropriate single option

Mark only one oval.

Academic institute: Government

Academic institute : Non govermental

Private practioner



3. 1.3 How many ovarian cancer patients you seein a month *

Management - Early stage ovarian cancer

4. 2.1 Which is the commonest stage of presentation for epithelial ovarian cancer in yourpractice *

Please select the most appropriate single option

Mark only one oval.

Stage 1

Stage 2

Stage 3

Stage 4

5. 2.2 Do you recommend a fertility sparing surgery in stage I epithelial ovarian cancer *

Choose the most appropriate option

Mark only one oval.

Yes

No

Sometimes

Not applicable

6. 2.3 Do you recommend a minimally invasive surgery in stage I-II epithelial ovarian cancer *

Choose the most appropriate option

Mark only one oval.

Yes

No

Sometimes

Not applicable

7. 2.4 Which procedure do you recommend for lymph nodes in stage I-II epithelial ovarian cancer*

Choose the most appropriate option

Mark only one oval.

Lymph node dissection

Lymph node sampling

I don't address the lymph nodes

Not applicable

8. 2.5 What percentage of epithelial ovarian cancer stage I-II receive adjuvant chemotherapy *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

9. 2.6 In epithelial ovarian cancer stage I-II, if receive adjuvant chemotherapy, than how manycycles you prefer *

Choose the most appropriate option

Mark only one oval.

3

4

5

6


  Advanced stage ovarian cancer Top


10. 3.1 In stage III-IV ovarian cancer, what percentage patients in your practice undergo primarycytoreduction *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

11. 3.2 In stage III-IV ovarian cancer, what percentage patients in your practice undergo completeR0 primary cytoreduction *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

12. 3.3 In which circumstances do you give neoadjuvant chemotherapy in epithelial ovariancancer *

Choose the most appropriate option

Mark only one oval.

ſtPoor Performance status

ſtPresence of ascites

ſtRequiring multiorgan resection

ſtPresence of gastro-hepatic nodes

ſtAll stage III and IV

13. 3.4 In stage III-IV ovarian cancer, what percentage patients in your practice undergo completeR0 cytoreduction post neoadjuvant chemotherapy *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

14. 3.5 In stage III-IV ovarian cancer, what percentage patients in your practice undergo pelviclymph node dissection *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

15. 3.6 In stage III-IV ovarian cancer, what percentage patients in your practice undergo paraaorticlymph node dissection *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

16. 3.7 In stage III-IV ovarian cancer, what percentage patients in your practice undergo multi-organ resection *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

17. 3.7 In stage III-IV ovarian cancer, do you recommend-intraperitoneal instillation of cisplatin *

Choose the most appropriate option

Mark only one oval.

Yes

No

Sometimes- but it is rare

Sometimes-but it is common

18. 3.8 In stage III-IV ovarian cancer, do you recommend-HIPEC *

Yes

No

Sometimes- but it is rare

Sometimes-but it is common


  Advanced stage ovarian cancer Top


19. 4.1 Which chemotherapy regimens you use in your practice as adjuvant or neoadjuvanttherapy in epithelial ovarian cancer? *

Choose the most appropriate option

Mark only one oval.

ſtPaclitaxel -Carboplatin

ſtPaclitaxel-Cisplatin

ſtLipodox-Cisplatin

ſtLipodox carboplatin

ſtGemcitabine-Cisplatin

ſtGemcitabine- Carboplatin

ſtBevacuzimab in addition to chemotherapy

20. 4.2 What schedule of paclitaxel carboplatin you use routinely as adjuvant? *

Choose the most appropriate option

Mark only one oval.

3 weekly administration of paclitaxel-Carboplatin

weekly administration of paclitaxel and carboplatin

weekly administration of paclitaxel and 3 weekly of carboplatin

3 weekly administration of paclitaxel and weekly of carboplatin

21. 4.3 What percentages of your patients receive the dose intense schedule of Paclitaxel-carboplatin as adjuvant *

Choose the most appropriate option

Mark only one oval.

< 10%

10-50%

50-75%

75-90%

>90%

23. 4.5 In case of patients with PS-3 status due to disease load which chemotherapy regimen youadminister as neoadjuvant *

Mark only one oval.

Flat dose single agent carboplatin

Weekly Paclitaxel-Carboplatin

3 weekly paclitaxel- Carboplatin with 20-30% dose reduction

3 weekly paclitaxel-carboplatin without any dose reduction

Not applicable

24. 4.6 Do you consider doing BRCA mutation testing in upfront pathology sample *

Mark only one oval.

Yes

No

Maybe- sometimes

maybe-Rarely

Not applicable





 
  References Top

1.
Dessai SB, Patil VM, Chakraborty S, Babu S, Bhattacharjee A, Nayanar S, et al. An audit of cytoreductive surgeries in ovarian cancer from a rural based cancer center. Indian J Cancer 2016;53:284-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Maheshwari A, Kumar N, Gupta S, Rekhi B, Shylasree TS, Dusane R, et al. Outcomes of advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy. Indian J Cancer 2018;55:50-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shashikant L, Kesterson Joshua P. In pursuit of optimal cytoreduction in ovarian cancer patients: The role of surgery and surgeon. J Obstet Gynaecol India 2009;59:209-16.  Back to cited text no. 3
    
4.
Shih KK, Chi DS. Maximal cytoreductive effort in epithelial ovarian cancer surgery. J Gynecol Oncol 2010;21:75-80.  Back to cited text no. 4
    
5.
Young RC, Walton LA, Ellenberg SS, Homesley HD, Wilbanks GD, Decker DG, et al. Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials. N Engl J Med 1990;322:1021-7.  Back to cited text no. 5
    
6.
Wadler S, Yeap B, Vogl S, Carbone P. Randomized trial of initial therapy with melphalan versus cisplatin-based combination chemotherapy in patients with advanced ovarian carcinoma: Initial and long term results – Eastern cooperative oncology group study E2878. Cancer 1996;77:733-42.  Back to cited text no. 6
    
7.
Chan JK, Brady MF, Penson RT, Huang H, Birrer MJ, Walker JL, et al. Weekly vs. Every-3-week paclitaxel and carboplatin for ovarian cancer. N Engl J Med 2016;374:738-48.  Back to cited text no. 7
    
8.
Sirohi B. Cancer care delivery in India at the grassroot level: Improve outcomes. Indian J Med Paediatr Oncol 2014;35:187-91.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Philip CC, Mathew A, John MJ. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 9
  [Full text]  
10.
Livingston EH, Wislar JS. Minimum response rates for survey research. Arch Surg 2012;147:110.  Back to cited text no. 10
    
11.
Brtnikova M, Crane LA, Allison MA, Hurley LP, Beaty BL, Kempe A, et al. Amethod for achieving high response rates in national surveys of U.S. Primary care physicians. PLoS One 2018;13:e0202755.  Back to cited text no. 11
    
12.
Noronha V, Talreja V, Joshi A, Patil V, Prabhash K. Survey for geriatric assessment in practicing oncologists in India. Cancer Res Stat Treat 2019;2:232-6.  Back to cited text no. 12
  [Full text]  
13.
Goyal G, Patil VM, Noronha V, Joshi A, Khaddar S, Kakkar S, Pruthy R, Parikh P, Prabhash K. Once-a-week versus once-every-3-weeks cisplatin in patients receiving chemoradiation for locally advanced head-and-neck cancer: A survey of practice in India. Cancer Res Stat Treat 2018;1:63-7.  Back to cited text no. 13
  [Full text]  
14.
Morgan RJ Jr., Armstrong DK, Alvarez RD, Bakkum-Gamez JN, Behbakht K, Chen LM, et al. Ovarian cancer, version 1.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2016;14:1134-63.  Back to cited text no. 14
    
15.
Colombo N, Sessa C, Bois AD, Ledermann J, McCluggage WG, McNeish I, et al. ESMO-ESGO consensus conference recommendations on ovarian cancer: Pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease. Ann Oncol. 2019;30:672-705.  Back to cited text no. 15
    
16.
Fagotti A, Perelli F, Pedone L, Scambia G. Current recommendations for minimally invasive surgical staging in ovarian cancer. Curr Treat Options Oncol 2016;17:3.  Back to cited text no. 16
    
17.
Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 2018;379:1895-904.  Back to cited text no. 17
    
18.
Burger RA, Brady MF, Bookman MA, Fleming GF, Monk BJ, Huang H, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med 2011;365:2473-83.  Back to cited text no. 18
    
19.
Perren TJ, Swart AM, Pfisterer J, Ledermann JA, Pujade-Lauraine E, Kristensen G, et al. Aphase 3 trial of bevacizumab in ovarian cancer. N Engl J Med 2011;365:2484-96.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
Supplementary Ap...
Survey of ovaria...
Advanced stage o...
Advanced stage o...
References
Article Tables

 Article Access Statistics
    Viewed214    
    Printed32    
    Emailed0    
    PDF Downloaded45    
    Comments [Add]    

Recommend this journal