Improving Decision-Making in Treatments for Advanced Ovarian Cancer

A new study published in Cancer found that women with advanced ovarian cancer were willing to accept moderately higher risks related to surgery in exchange for the likelihood of extension of overall survival (OS). The study results may help guide treatment-related decision-making between primary debulking surgery and neoadjuvant chemotherapy with interval debulking in ovarian cancer.

“There are those who question the benefits of radical upfront surgery given its known risks,” wrote study authors led by Laura J. Havrilesky, MD, MHSc, of Duke University Medical Center in Durham, North Carolina. “The clinician’s judgment of the relative importance of treatment benefits and risks may not be resonant with that of the patient.”

Studies have suggested that neoadjuvant chemotherapy and interval debulking can reduce morbidity and mortality, but it is not clear that this option has similar survival outcomes.        

The new study aimed to better describe patient preferences in this setting. The investigators conducted a discrete-choice experiment, consisting of eight choice tasks that allowed women to assess treatment options in terms of order, extent of surgery and risk of ostomy, chance of death from surgical complications, readmission to the hospital for complications, progression-free survival (PFS), and OS.

The study included a total of 101 survivors of ovarian cancer; of those, 30% were currently receiving chemotherapy, and 33% had previously experienced disease recurrence. Most patients were white (88%), and the mean age was 58 years.          

Patients did not have a significant preference regarding the order of chemotherapy and surgery (P = 0.18). They did, however, significantly prefer less extensive over more extensive surgery (P < 0.05). In general, the participants preferred longer over shorter OS and PFS, though there was no difference to them with regard to 1 year of PFS vs 1.5 years.          

OS was the most important attribute to the participants, with a weight of 36 (importance weights of all attributes sum to 100). This was followed by complications requiring readmission, with a weight of 23; PFS, with a weight of 19; surgical mortality, with a weight of 16; extent of surgery, with a weight of 4; and treatment order, with a weight of 2.          

“Participants would tolerate higher risks of operative morbidity and mortality to achieve more substantial gains in survival outcomes,” the authors wrote.

For example, to increase OS from 3 to 3.5 years, participants would accept a 4-percentage point increase in the risk of surgical mortality, or a 15-percentage point increase in the risk of readmission. In contrast, no improvement in operative mortality was sufficient to induce the women to forego more than 12 months of OS.          

“Ideally, the availability of a user-friendly, structured preference elicitation process may guide clinicians to discuss treatment preferences with their patients during the initial evaluation for advanced stage ovarian cancer,” the authors concluded.

In an accompanying editorial, Stephanie A. Sullivan, MD, of Virginia Commonwealth University in Richmond, Virginia, and Sarah M. Temkin, MD, of the Anne Arundel Medical Center in Annapolis, Maryland, agreed that a “formalized” method to quantify patient preferences in decision-making, especially for increasingly complicated disease settings such as advanced ovarian cancer, may prove to be an invaluable tool in making those complicated treatment decisions.

“Ultimately, shared decision‐making and patient preferences may improve patient satisfaction and reduce regret about medical choices,” they wrote.