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Journal of Clinical Oncology, Vol 25, No 23 (August 10), 2007: pp. 3554 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.4974
Does Ovarian Cancer Treatment and Survival Differ by the Specialty Providing Chemotherapy?Department of Gynecologic Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX To the Editor: The chemotherapeutic management of gynecologic malignancies, particularly ovarian cancer, is rather unique in oncology as two groups of physicians, with different specialty backgrounds (internal medicine v obstetrics/gynecology), receive specific subspecialty training in the area, leading to board certification in their respective disciplines (medical oncology v gynecologic oncology). Over the past several decades, outstanding clinical research in the management of advanced ovarian cancer, conducted jointly by gynecologic and medical oncologists, has led to solid evidence-based management guidelines, and where such data are not available, highly rational decision pathways have been developed. Thus, the finding by Silber et al,1 using Surveillance, Epidemiology and End Results data, that there is no difference in survival depending on which subspecialty provided primary management would appear to be an obvious outcome. In fact, one can quite reasonably suggest that if the investigators had reached a different conclusion it is far more likely there would have been a fundamental problem in the methodology employed, rather than that the conclusion was valid. Utilizing poorly characterized information within this database, these investigators then noted that medical oncologists appear to treat ovarian cancer patients slightly longer, and their patients have more recorded adverse events, than women managed by gynecologic oncologists. As noted by Cannistra,2 the superficial nature of the data reported within the Surveillance, Epidemiology and End Results database, including the inability to capture highly clinically relevant variables such as fundamental differences in the patient populations (eg, amount and intensity of prior therapy, baseline performance status), referral patterns, comorbidity (except those voluntarily provided), management philosophy (both patient and physician), quality of life (impacted by the disease and therapy), specific improvement in cancer-related symptoms, or even comanagement by gynecologic and medical oncologists, does not permit any objectively valid statement regarding implications of their observations. Thus, it is rather astounding, one might even say self-serving and insulting, that the authors of this report use these uncharacterized differences between the groups to conclude, "In light of our observations, one might argue that optimal care was observed when a patient received chemotherapy from a physician who specializes in the management of the patient's specific disease, rather than from a physician who concentrates on a particular clinical technique. In the case of ovarian cancer management, one could argue that the [gynecologic oncologists] may have better understood the course of a patient's disease and were, therefore, more able to treat women without undue morbidity or excess treatment."1 Finally, without any knowledge of the actual experience of the patients included in this analysis, they proclaim: "From the patient's perspective, these results raise the question of whether patients should choose physicians that train and practice in a more technique-specific or a more disease-specific paradigm."1 As a medical oncologist who has had the profound pleasure over the past 25 years to work closely with gynecologic oncologists at four major institutions and on a national level with dozens of individual members of this subspecialty, I can state without equivocation that there are no more intelligent, knowledgeable, dedicated, and compassionate group of physicians in clinical medicine. The training of gynecologic oncologists emphasizes comprehensive, longitudinal, and multidisciplinary care. There is much all oncologists can learn from this outstanding group of physicians. However, the specific background, training, and knowledge of medical oncologists also brings much to the care of women with gynecologic cancers, as documented over the past several decades in the development of evidence-based treatment paradigms. Thus, rather than employing these essentially uninterpretable data to make a statement regarding the better intuition of one group of physicians, the authors of this report could have made an important contribution by stressing the complementary nature of the two subspecialties and encouraging community-based and academic medical and gynecologic oncologists to work together to optimize the care of women with ovarian cancer. Further, they could have asked that the leadership of institutional training programs in these respective disciplines seek to find ways to ensure their trainees benefited from their similar, yet also unique, perspectives on disease management. It is most unfortunate that this opportunity was lost. 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 2. Cannistra SA: Gynecologic oncology or medical oncology: What's in a name? J Clin Oncol 25:1157-1159, 2007
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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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