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Chemotherapy Administration for Ovarian Cancer by Gynecologic Oncologists and Medical Oncologists

Society of Gynecologic Oncologists; Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC

To the Editor:

The leadership of the Society of Gynecologic Oncologists read with great interest the recent article by Silber et al¹ as well as the accompanying editorial by Dr Cannistra, a medical oncologist whose practice focuses on ovarian cancer.²

The article found no difference in survival of women with advanced ovarian cancer based on whether they received chemotherapy treatment from a gynecologic oncologist or medical oncologist. Treatment by medical oncologists was on average more intense and associated with greater adverse effects. We agree with Dr Cannistra that the question of which specialty treats ovarian cancer more effectively is a small issue in view of the poor survival of these patients regardless of who administers the chemotherapy. In addition, Dr Cannistra appropriately noted the important role that gynecologic oncologists play in effectively debulking advanced ovarian cancer before the administration of chemotherapy, as this translates into improved median survival. Gynecologic oncologists have special expertise and training in this area, but unfortunately many primary operations for ovarian cancer are still performed by general Ob/Gyns and/or general surgeons. In response to this persistent problem, the Society of Gynecologic Oncologists has produced guidelines for referral of women with known or suspected ovarian cancer.^3,4

We do not agree with Dr Cannistra's statement that gynecologic oncology is primarily a surgical field. The subspecialty was conceived with the notion that gynecologic oncologists should provide comprehensive care to women with pelvic cancers. In addition to surgical training, gynecologic oncology fellows receive considerable education and experience with chemotherapy. In most medical centers, women with advanced ovarian cancer receive chemotherapy and ongoing care from the gynecologic oncologist who performed their surgery. This includes the palliative and end of life care that these patients almost invariably require. Because gynecologic oncologists focus on just a few cancer types, we generally have the broadest knowledge and experience in all aspects of ovarian cancer that comes from managing hundreds of women throughout the entire course of their disease. As with other diseases, practitioners who manage high volumes of patients with ovarian cancer are likely to provide better care than those who care for relatively few cases.

The paradigm of a gynecologic oncologist caring for the patient throughout the entire course of her disease is our theoretic ideal. However, whether a patient receives chemotherapy from a gynecologic oncologist or medical oncologist is dependent on a wide range of factors that vary considerable from one institution and patient to the next. In very few academic centers, such as Dr Cannistra's, medical oncologists who specialize in the treatment of ovarian cancer work closely with their gynecologic oncology colleagues. However, in most centers gynecologic oncologists are responsible for both primary and second-line chemotherapy. That said, when the disease becomes chemotherapy resistant, some patients are referred to medical oncologists to explore options for investigational therapies. In addition, some patients who undergo debulking surgery with a gynecologic oncologist may live several hours away and subsequently chose to receive chemotherapy with medical oncologists in their local community. Most gynecologic oncologists have healthy collaborative relationships with medical oncologists in their region, with whom they share patients on an ongoing basis.

We agree that improvements in ovarian cancer mortality will only be attained through research. A better understanding of the molecular and epidemiological causes of ovarian cancer has the potential to improve prevention and early detection. And of course we need more effective therapy for advanced disease. Despite being highly sensitive to platin/taxane chemotherapy, most patients with advanced ovarian cancer relapse and die after having achieved a complete clinical response to primary therapy. The addition of a third cytotoxic agent to first-line therapy has not proven to be the answer thus far.

Medical oncologists and gynecologic oncologists are working together in partnership towards the goal of developing curative therapy for ovarian cancer in the context of the Gynecologic Oncology Group. The currently ongoing Gynecologic Oncology Group phase III study in advanced ovarian cancer involves the addition of bevacizumab to carboplatin/paclitaxel. The role of maintenance taxane therapy is also under investigation. Soon to be opened studies of patients who have been optimally debulked will continue to explore the role of intraperitoneal chemotherapy. Hopefully, these joint efforts of gynecologic and medical oncologists will lead toward a reduction in deaths from ovarian cancer in the future.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

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[Abstract/Free Full Text]

2. Cannistra SA: Gynecologic oncology or medical oncology: What's in a name? J Clin Oncol 25:1157-1159, 2007[Free Full Text]

3. Society of Gynecologic Oncologists: Committee opinion: The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. 2002. http://www.sgo.org/images/pdfs/publications/generalist.pdf

4. Society of Gynecologic Oncologists: Guidelines for referral to a gynecologic oncologist: Rationale and benefits. Gynecol Oncol 78:S1-S13, 2000. http://www.sgo.org/images/pdfs/publications/referralguide.pdf[CrossRef][Medline]

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Related Reply

• In Reply
  Jeffrey H. Silber and Paul R. Rosenbaum
  JCO 2007 25: 3555-3557 [Full Text]
• In Reply
  Stephen A. Cannistra
  JCO 2007 25: 3557-3558 [Full Text]

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