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Journal of Clinical Oncology, Vol 25, No 23 (August 10), 2007: pp. 3553 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.3422
Type of Oncology Specialist and Treatment-Related Outcomes in Ovarian CancerLong Island Jewish Medical Center Campus of the Albert Einstein College of Medicine, New Hyde Park, NY To the Editor: As medical oncologists with an expertise in the treatment of ovarian cancer, we read with interest the article by Silber and colleagues1 and the associated editorial by Cannistra.2 Silber et al utilized a Surveillance, Epidemiology, and End Results–Medicare database from 1991 to 2001 to identify patients with ovarian cancer receiving chemotherapy over that time period. A matching algorithm was used to ensure similarity in important covariates between 44 patients treated by medical oncologists and 344 patients treated by gynecological oncologists. Outcome measures analyzed were overall survival, weeks on chemotherapy, and weeks with adverse effects. Overall survival was identical between the two groups. This is an important and reassuring observation, given the differences in practitioner background, training, and possibly treatment style between medical oncologists and gynecological oncologists. Planned analyses also revealed that medical oncologists' patients received chemotherapy for more weeks (mean, 16.5 v 12.1 weeks) and medical oncologists' patients had more adverse effects (16.2 v 8.9 weeks). Linking these two observations, the authors state that "[medical oncologists] seem to treat patients more intensively than [gynecological oncologists]" and given the increase in weeks with adverse side effects, "it may have been the case that [gynecological oncologists] had better intuition regarding when to reduce intensity in favor of quality of life." The authors subsequently insinuate that given these factors, patients might be better served by being treated by gynecological oncologists. In response we introduce the following points: 95% CIs are not given for the differences between the means for weeks on treatment and weeks with adverse effects. Small differences in mean weeks of treatment are likely of little clinical relevance, as many regimens like weekly paclitaxel and monthly liposomal doxorubicin have minimal or no significant toxicities. It is unclear which of the toxicities listed in Table 1 were increased in the medical oncologists' patients. An increase in mild anemia, neutropenia, and thrombocytopenia may have no clinical importance. With regards to mucositis, dehydration, nausea, diarrhea, and neuropathy, an increased prevalence in medical oncologists' patients, as also pointed out by Cannistra, may have been due to reporting bias. Medical oncologists' patients may have had more access to their oncologists, giving them more opportunity to report adverse effects. Medical oncologists may also have been more skilled at inquiring about treatment related issues. The authors insinuate that gynecological oncologists' patients had better quality of life (less time on treatment, less adverse effects). This is purely conjecture. Only a prospective study of matched patients with a validated quality of life instrument could answer this question. Most importantly, the technical task of giving chemotherapy is only one aspect of high quality cancer care. The equivalent survival of gynecological oncologists' and medical oncologists' patients attests to the equal proficiency of either specialty in this regard. However, another very important dimension is the attention paid to the psychosocial and emotional issues of ovarian cancer patients. There are many difficult transitions for patients along the ovarian cancer trajectory, such as initial diagnosis, relapse after initial treatment, progression after subsequent regimens with the necessity of changing therapy, and transition to palliative care. Individual patients may also have issues with coping, availability of support systems, depression and/or anxiety. Optimal handling of these transitions in the disease continuum, as well as addressing patients' emotional distress, by necessity requires a core proficiency in communication skills. Mark A. Hoffman and colleagues surveyed program directors of medical oncology, radiation oncology, gynecologic oncology, and surgical oncology programs regarding whether there was a component of communication skills training within their respective fellowships.3 Forty percent of medical oncology programs (36 of 91) had some form of communication skills training compared with 19% of gynecological oncology programs (three of 16). Thus, with a suboptimal background in communication skills, gynecological oncologists may not be positioned as well as medical oncologists to address and handle psychosocial concerns. This is clearly relevant to the issue of eliciting symptoms, as noted in our comment earlier. Communication skills can be taught,4 and would definitely be beneficial to both medical oncology and gynecological oncology trainees. In summary, we congratulate Silber and colleagues for their important contribution to the literature. We do feel, however, that conclusions regarding a potential superiority of either specialty in the care of ovarian cancer patients should be backed by a well-designed, prospective study with predetermined well-defined and objective end points including quality of life. However, such a study would probably be intrinsically flawed, as despite matching algorithms, the characteristics medical oncologists' and gynecological oncologists' patients likely differ secondary to biases, such as geographic and referral bias. As Dr Cannistra points out, both specialties "are allies fighting on the same side, in a battle where cancer is the enemy." AUTHORS' 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 2. Cannistra SA: Gynecologic oncology or medical oncology: What's in a name? J Clin Oncol 25:1157-1159, 2007 3. Hoffman MA, Ferri J, Sisson C, et al: Teaching communication skills: An AACE survey of oncology training programs. J Cancer Educ 19:220-224, 2004[CrossRef][Medline] 4. Back AL, Arnold RM, Baile WF, et al: Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 167:453-460, 2007 Related Reply
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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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