Researcher Describes Relationship Between Neoadjuvant Chemo and Readmission in Ovarian Cancer

Emma Barber, MD, a gynecologic oncology fellow at the University of North Carolina

Emma Barber, MD

Neoadjuvant chemotherapy reduces surgical morbidity and readmission rates among patients with ovarian cancer, Emma Barber, MD, reported in a presentation at the 2017 Society of Gynecologic Oncology (SGO) Annual Meeting.

Even with these positive effects, some patients may still receive a greater benefit with more aggressive surgery, despite the increased rate of surgical complications, noted Barber, a gynecologic oncology fellow at the University of North Carolina.

OncLive: Please summarize your talk on readmission rates in ovarian cancer?

In an interview with OncLive at the SGO meeting, Barber discussed the impact of neoadjuvant chemotherapy on readmission rates, and how the goal of lowering readmission rates in ovarian cancer may not always align with optimizing long-term outcomes. Barber: There’s been this overarching push with the Affordable Care Act to decrease hospital readmissions. The thought is that if someone comes into your hospital and they have a problem, they go home and then they come right back, you have not handled that problem appropriately, so there’s been a big push to decrease readmissions. That argument sounds very simple and straightforward, but it becomes a little bit more complicated than that with ovarian cancer because there’s a difference between short-term morbidity—what happens to you in the 30 days following surgery—and what happens to you over a long period of time.

Specifically, aggressive surgery for ovarian cancer is associated with more complications, and resection to no gross residual disease is associated with improved long-term outcomes, but increased rates of complication. So it’s an incentive that might be effecting our population differently.

I looked specifically at neoadjuvant chemotherapy, which has been shown to decrease surgical morbidity. If you give the chemotherapy first, the surgery is not as complicated, so your complication rates go down. Nobody has looked at readmission rates yet, but what I’m presenting shows that those go down as well.

Are there any next steps planned?

What would you like community oncologists to take away from your presentation?

How can it be determined which patients will respond better to the use of neoadjuvant chemotherapy?

The point is that if this overarching system—hospital administrators and Centers for Medicare and Medicaid Services—are pushing us to decrease readmissions, are we going to change how we care for women with ovarian cancer, and is that the best thing for them? And that’s the question that our abstract is posing. I think the next steps are to make sure that our patients are aware of this, that we advocate for this. This is a small community, and the policymakers that are thinking overall in the healthcare system aren’t focused on this small community where aggressive surgery is associated with improved outcomes, so I think we need to make that point to make sure that healthcare systems and providers aren’t pushed in a way that may not help patients in the long run. I think 1 point is that the use of neoadjuvant chemotherapy will decrease your readmission rate, if that’s a high priority. It is a treatment that’s associated with decreased short-term morbidity, even in populations that are at a high risk for readmission. On an individual basis, you have to decide if that’s the best thing for your patient long term. There may be patients for whom it is, and there may be others for whom it’s not. Making sure that we continue to advocate with an individualized approach for these women is important. We tend to think of neoadjuvant chemotherapy as reserved for people who are not going to do well with surgery, who are not going to be able to have a resection and no gross residual disease when the tumor is removed.

Speaking more generally, what other ovarian cancer trials are you interested in seeing results from?

In European randomized trials, the 2 approaches are surgery first, followed by chemotherapy, or chemotherapy first, followed by surgery, which have been shown to be equivalent. But in some patients with stage IIIC disease, even in those trials with patients with a smaller burden of disease, upfront surgery improves their survival. Even in that population, surgery first is going to be associated with more short-term morbidity. The trial that I’m excited to see the results of regarding this specific question of neoadjuvant chemotherapy is the SCORPION trial that’s happening right now in Italy. Criticisms of previous randomized controlled trials in this area have been that the surgery wasn’t as aggressive as we do it in the United States—there were low rates of optimal cytoreduction, and therefore there was lower survival. In that trial, they have published their short-term morbidity outcomes, and they’re doing very aggressive surgery. I think the question will be, is that associated with a survival benefit in the long term, because that will be new data to inform this question.