Enhanced Recovery After Surgery for Ovarian Cancer Patients

Robert Neff, MD

As part of our coverage of the 2017 Society of Gynecological Oncology (SGO) Annual Meeting, held March 12–15 in National Harbor, Maryland, we are speaking with Robert Neff, MD, a gynecologic oncology fellow at the Ohio State University Medical Center in Columbus. Dr. Neff presented data at the meeting that compared the cost-effectiveness of an enhanced recovery program compared with usual care following patients who had surgical cytoreduction for their ovarian cancer.

-Interviewed by Anna Azvolinsky 

Cancer Network: First, can you describe this type of surgery. Is this a standard type of surgery that patients with ovarian cancer undergo, and which patients are eligible?

Dr. Neff: First, thank you for the offer to discuss this topic. In 2016 ovarian cancer will be diagnosed in about 22,000 women, and the majority of those women are diagnosed at an advanced stage, stage III or stage IV. This is important, because that means the disease has spread outside of the ovaries and is now throughout the abdomen and pelvis. When we talk about ovary cancer in the upfront treatment setting, the two main pieces for treatment include surgery and chemotherapy, and there is somewhat of a debate regarding the order of each at this point. But historically the primary treatment, and it still is today, is primary surgical management or a debulking procedure. The procedure is essentially an attempt to remove all of the visible disease from the abdomen and pelvis to get the patient down to a no gross residual disease, essentially no disease visible to the surgeon. The reason that’s important is that it has been shown over a number of studies that this increases the overall survival of patients who are able to have primary cytoreduction surgery.

The surgery, as you might imagine, can be long and entails a number of different procedures, which can include bowel resection in addition to removing the ovaries and the uterus, basically removing any organs or tissue that have cancer involved. Because of the size and complexity involved in these surgeries, these patients are often hospitalized for a prolonged period.

I think it’s important to note that really anyone who is diagnosed with ovarian cancer is eligible for this surgery. It is up to a board-certified gynecologic oncologist to make a determination as to whether they should proceed with surgery prior to doing chemotherapy, or if they feel that there is a better chance for them to get all of the disease out during surgery by starting with chemotherapy. So sometimes the patient starts out with chemotherapy, and then has surgery. Either way, the surgical procedures, in both cases, are similarly complex and involve a prolonged hospitalization, which is why this topic has grown in interest in our field.

Cancer Network: How does an enhanced recovery program differ from the usual pre- and post-operative care?

Dr. Neff: So enhanced recovery after surgery (ERAS) is essentially made up of pre-op, intra-op, and post-op changes to the way that we care for patients undergoing surgery. This movement toward enhanced recovery kind of began in the 1990s in the surgical field-it probably has been best studied in the colorectal surgery literature. You are attempting to preserve the pre-operative body state through the surgical course-essentially, trying to reduce the overall stress that these big surgical procedures put on the body in order to facilitate or improve the outcomes for the patients. And what is interesting is that in literature within the colorectal surgical field, they have actually shown that when you put patients into a program like this, you actually decrease the overall complication rate as well as decrease the amount of time the patient spends in the hospital. So it kind of has a twofold benefit, both for society and for patients.

In the colorectal surgical literature, they found that patients overall do better. From a society standpoint, where we are more concerned with the overall cost of care, the ability to affectively get a patient out of the hospital in a safe manner and in a quality manner for the patient, is a way to allow for some cost-savings into the system. The way that it’s basically different from older or usual care in the perioperative setting is that it standardizes the care that is given to the patient.

For anyone who has been through a surgical training program, they know that a lot of what goes into the care of a surgical patient is based on the historical experience of the institution they trained at-how the providers pass down what they know to their trainees. And it’s not always with a keen eye on what the research is that backs up those means of caring for the patient. So a lot of what is great about ERAS is that it standardizes what you do for the patient. For all patients that come through, it says, “What are we going to do for you prior to surgery and how are we going to keep you going during the surgery?” and “What are the things we will do to maximize your post-operative period in the hospital so that you are back up and functional in a more timely fashion?”

I think what it starts with, and the biggest difference to the older way of thinking, is that you are setting expectations with the patient. So when you meet with the patient prior to surgery, you are letting them know what to expect, and what you are going to provide for them with this enhanced recovery and discussing questions upfront, “How are we going to manage your pain and how are we going to manage your diet after surgery?” and “When are we going to allow you to eat and how often do we want to get you walking?” Those types of things.

If you inform the patient prior to the procedure, it allows for more effective care essentially. And the other important piece to it is that you have an emphasis on full implementation of a program rather than just trying to do individual pieces of it.

Cancer Network: Can you tell us about the results of your analysis comparing these two approaches?

Dr. Neff: So when we built the model-and this is a Markov transition state, which allows you to compare two different changing variables among a similar group of people-we basically built it so that all of the patients who would have hypothetically undergone a cytoreductive surgery for ovarian cancer would either be managed with an ERAS plan or usual care or historical care. We started by gathering data from the premier health database, which is a healthcare cost database that also has outcomes data. We were able to take hospitalization costs and mix that with how long the patient was staying in the hospital to come up with a model to say, “If we hypothetically took everyone from 2016 who had surgery for ovary cancer and managed them in one of these two pathways, what would be the cost-benefit or lack of cost-benefit by doing this within an enhanced recovery program?”

You build into the model certain assumptions based on things that you are going to do to both groups of people. For instance, one of those assumptions is that the patients in the ERAS group and usual care group both had a bowel resection 20% of the time during their debulking procedure. So when we ran that initial model with those baseline assumptions we found that for patients managed in an ERAS platform, from pre-op through post-op, it was less costly and it more efficiently got people out of the hospital compared to usual care or historical surgical care.

From that model, we changed up a couple of the variables. One of the tenets that people ascribe to ERAS is that there should be some component of regional anesthesia, or basically an epidural for post-operative pain control. So in our model, the way we set it up is that every single patient treated in the ERAS arm of the model would have gotten an epidural. So if you reduce the cost of the epidural, you are saving more money per patient per hospitalization.

Using our model we are continuing to analyze the cost difference, comparing ERAS to usual care, for if there was no difference or less of a difference in how quickly you got people out of the hospital.

Overall in the study we found that if you look at just who is managed in ERAS and who is managed in usual care, it is about $2,300 cheaper to manage a patient in an ERAS plan when compared to usual care. And that is significant savings when you are talking about thousands of patients across the country.

Cancer Network: Thank you so much for joining us, Dr. Neff.

Dr. Neff: Yes, thanks it was my pleasure.