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Journal of Clinical Oncology, Vol 25, No 23 (August 10), 2007: pp. 3554-3555 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.5229
Ovarian Cancer and the Battle of the SpecialistsWeinberg Cancer Institute, Franklin Square Hospital Center, Baltimore MD To the Editor: I read with both surprise and bemusement the recent article by Silber and colleagues,1 who compared outcomes of patients with advanced ovarian cancer treated after debulking surgery by either medical oncologists or gynecologic oncologists. Not surprisingly, the survivals of both groups of patients were similar since intrinsic biologic factors have more impact on outcome than who does what to the patient after diagnosis. Similarly, and to a lesser extent, it is initial chemotherapy rather than any specific approach to the patient with recurrent disease that likely has the greatest impact on survival, and it is difficult to imagine how either of these subspecialists could give carboplatin and paclitaxel in some way to influence survival. We even launch trials with hundreds of patients evaluating a new systemic therapy and claim victory with a survival difference of 10% to 15%. Is it any surprise that a retrospective study of 688 patients failed to show any survival difference when only the specialty administering the therapy was the variable? The second aspect of the data presented by Silber et al from the Surveillance, Epidemiology, and End Results database concerned the amount of therapy and its attendant toxicity by subspecialty. The interpretation by the authors was that medical oncologists give more chemotherapy leading to more symptoms than gynecologic oncologists. They opined that gynecologic oncologists may be more intuitive regarding when to withdraw therapeutically in favor of quality of life. Unfortunately, these conclusions seem a stretch, at best, and are appropriately brought into question by Cannistra2 in the accompanying editorial. The Surveillance, Epidemiology, and End Results database does not allow one to make any conclusions about quality of life. To assume that more therapy or more adverse events equates to a decrement in quality of life is fallacious, as Cannistra points out. In one example cited in the editorial,3 carboplatin monotherapy was compared with carboplatin and gemcitabine in recurrent, platinum-sensitive ovarian cancer. The increase in toxicity from the combination was easily managed hematologic toxicity without abrogation of quality of life (formally measured), and the combination significantly improved progression-free survival. So, as indicated by Cannistra, one cannot equate more toxicity or more therapy with a decrement in quality of life. I disagree with Cannistra that gynecologic oncology is primarily a surgical discipline as these subspecialists have formal training in the use of antineoplastic agents and management of their adverse effects, albeit less than in medical oncology training. And although there are several retrospective studies showing outcomes are best when primary surgery is performed by a gynecologic oncologist as compared with a general surgeon or general gynecologist, I think all of us, whether medical or gynecologic oncologist, know that tumor biology trumps much of surgical skill. I also wonder about the value of the continuing battle over what constitutes adequate debulking surgery and who is qualified to perform it.4 Thus, I totally agree with Cannistra when he correctly points out that the real enemy here is ovarian cancer and that the goal of all who wage war on it is several fold. Increase in the cure rate is obviously the primary and laudable goal but often a frustrating and elusive one. Another goal should be to provide treatment that improves median survival, but the Silber et al article confirms the expected, which is that current therapy administered by a physician trained as a gynecologic or a medical oncologist performs equally well or poorly as the case may be. So it seems to me that who provides the postoperative chemotherapy should depend more on patient preference issues, which may revolve around comfort with the provider's communication skills, geographic convenience, trust, and for a select few and highly motivated patients, the availability of clinical trials. All of us who treat this disease know that patients may not receive all their multiple chemotherapeutic regimens from the same provider. As such, probably the best solution is a team that consists of both gynecologic and medical oncologists who may assume primary care at various points in the patient's trajectory through the illness. This not being possible then it would appear that either performs adequately and neither well enough. So, what is in a name? In this case, the common denominator is oncology, and the patient really cares little about the modifier as much as she cares about living as long and as well as possible. 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 3. 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 4. Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al: The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC-IV epithelial ovarian cancer. Gyncol Oncol 103:1083-1090, 2006[CrossRef]
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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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