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Journal of Clinical Oncology, Vol 25, No 10 (April 1), 2007: pp. 1157-1159 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.10.2228
Gynecologic Oncology or Medical Oncology: What's in a Name?Program in Gynecologic Medical Oncology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA Patients with advanced epithelial ovarian cancer generally require postoperative platinum-based chemotherapy in an attempt to prolong both disease-free and overall survival. Unlike most other areas of oncology, where chemotherapy has traditionally been administered by medical oncologists, postoperative chemotherapy for ovarian cancer may also be administered by gynecologic oncologists, who receive chemotherapy training as part of a surgically oriented fellowship. Nonetheless, the division of labor between gynecologic oncologists primarily trained to operate and medical oncologists trained in chemotherapy decision making, dosing, and adverse effect management, seems natural to many physicians involved in the care of patients with ovarian cancer. Physicians often work as a team, with the gynecologic oncologist managing the surgical aspects of this disease and the medical oncologist being responsible for chemotherapy administration. However, this paradigm is not universal, and the model of the gynecologic oncologist delivering both surgical as well as chemotherapeutic care is active in many parts of the United States and elsewhere in the world. In this issue of the Journal, Silber et al use the Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess survival, chemotherapy usage, and adverse effects for patients with epithelial ovarian cancer who received chemotherapy under the care of either gynecologic oncologists or medical oncologists.1 The authors hypothesized that the survival of patients treated by medical oncologists would be superior in view of their training. Instead, Silber et al found that survival was equivalent between these two groups of subspecialists when adjusting for stage, age, histology, ethnicity, medical comorbidity, and the initial operating physician (usually a gynecologic oncologist). However, patients treated by medical oncologists tended to receive chemotherapy more frequently and have more reported adverse effects than those treated by gynecologic oncologists. The authors conclude that perhaps "medical oncologists believed in treatment intensity more than gynecologic oncologists," and "that gynecologic oncologists had better intuition regarding when to reduce intensity in favor of quality of life."1 Regarding this last point, it should be noted that quality of life was not assessed as part of this study, making it impossible to draw conclusions about the effects of treatment frequency on this outcome. The authors were careful to discuss the limitations of their study, but it is important to highlight several biases that could influence these data. The first involves lack of information regarding the residual disease status of patients treated by gynecologic oncologists compared with medical oncologists. The prognostic importance of residual disease status is well-known, with patients who have residual tumors larger than 1 cm in diameter faring less well than those with lesser amounts of disease.2 To compare the survival outcomes between gynecologic oncologists and medical oncologists, it is critical to ensure that both groups were balanced for this important prognostic factor. Unfortunately, this information was not available to the authors through the SEER database. The authors contend that the two groups are probably balanced for residual disease status, based on the fact that gynecologic oncologists performed initial surgery on an equivalent number of patients in both groups, thereby controlling for technical expertise. However, I do not find this to be very reassuring based on my own experience. Almost all of my patients are operated on by well-trained gynecologic oncologists, and yet my medical oncology practice is enriched with suboptimally debulked patients who are either self-referred due to their poor prognosis, or referred by a gynecologic oncologist for clinical trial consideration. The second problem relates to the higher frequency of chemotherapy use, as well as greater number of reported adverse effects, observed in the medical oncology group. In this regard, weekly scheduling of drugs such as paclitaxel is known to be effective and often better tolerated than conventional dosing, and this approach is frequently used in medical oncology practices.3 Thus, it is conceivable that the use of weekly dosing schedules might be partly responsible for inflating the frequency of chemotherapy administration observed in the medical oncology group. Unfortunately, the authors could not ensure that gynecologic oncologists and medical oncologists were balanced for this type of treatment approach. Furthermore, the adverse event data are subject to reporting bias because it is possible that more events were captured by medical oncologists, either because patients were more frequently assessed for the development of such events or medical oncologists might have been more compulsive about reporting these details. Most importantly, this analysis does not address whether quality of life was affected by the reported increase in adverse effects. There are several examples of effective regimens in gynecologic oncology that cause an increase in adverse effects, but do not compromise quality of life, and yet offer patients the chance of benefit. In randomized trials comparing carboplatin with carboplatin plus gemcitabine,4 liposomal doxorubicin with topotecan,5 or cisplatin with cisplatin plus topotecan,6,7 quality of life was not compromised in the more toxic treatment arm. Thus, an increase in adverse effects does not automatically translate into a decrease in quality of life. In fact, the increased use of chemotherapy might result in greater palliative benefit, as measured by a decrease in disease-related symptoms, despite a transient increase in adverse effects, which in turn may lead to improvement in quality of life. We must be careful to avoid overestimating the clinical significance of adverse effects, especially if there is the potential for reporting bias, and especially if we do not have correlative quality of life data that enables us to place this into proper perspective. Ignoring some of the fundamental problems mentioned previously, it is interesting to ask whether the authors' original hypothesis was reasonable to consider. Based on the intensive training that a medical oncologist receives in chemotherapy administration and adverse effect management, the authors hypothesize that "survival after surgery would be better in patients receiving chemotherapy from a medical oncologist as compared with those receiving chemotherapy from a gynecologic oncologist."1 As a medical oncologist who specializes in gynecologic malignancies, I am flattered that the authors would even consider this possibility, although I think that they are perhaps asking the wrong question. I have never met a medical oncologist who felt that he or she can cure ovarian cancer more effectively than a gynecologic oncologist using the same chemotherapy agents. The survival of patients with ovarian cancer is not only related to our treatment, but is largely a function of genetic changes that dictate the tumor's growth rate, metastatic potential, or response to chemotherapy.8,9 As much as we would like to take credit for a patient's long survival, we are very much at the mercy of tumor biology. The equivalent survival noted by Silber et al, regardless of who administered the chemotherapy, undoubtedly reflects the fact that both gynecologic oncologists and medical oncologists are equally ineffective at curing this disease, and that disease biology is the great equalizer among subspecialists. Given our limited ability to cure advanced ovarian cancer at the present time, the more realistic question in my view is not whether survival is superior in the hands of medical oncologists compared with gynecologic oncologists, but whether patients' quality of life differs between these two subspecialties. The data from Silber et al do not provide an answer to this important question. Accepting the possibility that medical oncologists give more chemotherapy than gynecologic oncologists, I would like to propose that this phenomenon may not always be physician-driven, and that it has little to do with "better intuition" on the part of gynecologic oncologists. Rather, I believe that this difference occurs in part because medical oncologists and gynecologic oncologists may see different types of patients. After surgery with a gynecologic oncologist, what makes a patient decide to receive her chemotherapy care under the direction of a medical oncologist? Could it be that such patients are more proactive, more aggressive in their treatment expectations, and perhaps more interested in clinical trials? My own practice tends to attract patients who are very well-informed, who are interested in a physician who encourages active patient participation in decision making, and who expect more than standard therapeutic approaches in their care. Such patients expect that I will pursue every reasonable treatment option, both standard and experimental, in an attempt to battle a disease that is frightening and often fatal. Even in the absence of a survival benefit, the mere promise of obtaining a response that might improve quality of life offers many patients hope in the face of a devastating illness. The patient is often the one who desires more treatment after considering all of the facts, and we try our best to channel that energy into clinical trials whenever possible. Obviously I am referring only to patients whose performance status justifies safe administration of additional chemotherapy or clinical trial participation. Medical oncologists are fully aware that the chance of obtaining a response to third- and fourth-line chemotherapy may be low, but we do not always feel comfortable denying our patients that chance. I know that many gynecologic oncologists feel the same way. So when the authors refer to "patient satisfaction" at the end of their article, 1 I find it interesting to consider that many of my patients would be very dissatisfied if I did not offer them additional chemotherapy, especially because some appear to derive palliative benefit from such treatment. The Silber et al analysis does not provide a perspective from those who we care about the most, our patients, many of whom might actually prefer to receive their care from a physician who keeps a hopeful and open-minded approach to the use of additional chemotherapy when appropriate. Thus, patient satisfaction needs to be interpreted in the context of patient expectations, which might differ depending on the types of patients that are self-selected for medical oncology versus gynecologic oncology practices. If we fail to recognize this point, then we have lost an opportunity to understand how medical oncologists and gynecologic oncologists actually complement each other's efforts, rather than compete for them. Based on these considerations, it would seem that conclusions regarding "better intuition" of gynecologic oncologists may not be the most productive way to interpret these data. Instead, it is better to view this study as a springboard for future research to determine how decisions regarding chemotherapy usage are actually made, and how these decisions might impact quality of life and patient satisfaction, using objective and validated instruments. Such work would hopefully place less emphasis on the differences between gynecologic and medical oncologists, and call greater attention to the needs and expectations of individual patients, regardless of who is caring for them. Like Shakespeare, we should ask, "What's in a name? That which we call a rose, by any other word would smell as sweet." This famous quotation from Romeo and Juliet suggests that our names do not make us who we are, but rather our abilities and actions. Let us not forget that both medical and gynecologic oncologists are allies fighting on the same side, in a battle where cancer is the enemy. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author or immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment: N/A Leadership: N/A Consultant: N/A Stock: N/A Honoraria: N/A Research Funds: Stephen A. Cannistra, Genentech, Pfizer Testimony: N/A Other: N/A REFERENCES
1. Silber JH, Rosenbaum PR, Polsky D, et al: Does ovarian cancer treatment and survival differ by the specialty providing chemotherapy? J Clin Oncol 25:1169-1175, 2007 2. Cannistra SA: Cancer of the ovary. N Engl J Med 351:2519-2529, 2004 3. Markman M, Blessing J, Rubin SC, et al: Phase II trial of weekly paclitaxel (80 mg/m2) in platinum and paclitaxel-resistant ovarian and primary peritoneal cancers: A Gynecologic Oncology Group study. Gynecol Oncol 101:436-440, 2006[CrossRef][Medline] 4. Pfisterer J, Plante M, Vergote I, et al: Gemcitabine plus carboplatin compared with carboplatin in patients with platinum-sensitive recurrent ovarian cancer: An intergroup trial of the AGO-OVAR, the NCIC CTG, and the EORTC GCG. J Clin Oncol 24:4699-4707, 2006 5. Gordon AN, Fleagle JT, Guthrie D, et al: Recurrent epithelial ovarian carcinoma: A randomized phase III study of pegylated liposomal doxorubicin versus topotecan. J Clin Oncol 19:3312-3322, 2001 6. Long HJ 3rd, Bundy BN, Grendys EC Jr, et al: Randomized phase III trial of cisplatin with or without topotecan in carcinoma of the uterine cervix: A Gynecologic Oncology Group study. J Clin Oncol 23:4626-4633, 2005 7. Monk BJ, Huang HQ, Cella D, et al: Quality of life outcomes from a randomized phase III trial of cisplatin with or without topotecan in advanced carcinoma of the cervix: A Gynecologic Oncology Group Study. J Clin Oncol 23:4617-4625, 2005 8. Spentzos D, Levine DA, Kolia S, et al: Unique gene expression profile based on pathologic response in epithelial ovarian cancer. J Clin Oncol 23:7911-7918, 2005 9. Spentzos D, Levine DA, Ramoni MF, et al: Gene expression signature with independent prognostic significance in epithelial ovarian cancer. J Clin Oncol 22:4700-4710, 2004 Related Article
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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