NCCN-Recommended Therapy for Ovarian Cancer Currently Underused in Medicare Patients

A look at more than 10 years of data has shown that many patients with ovarian cancer covered by Medicare are not receiving treatment consistent with National Comprehensive Cancer Network (NCCN) recommendations, despite these having been shown to improve outcomes without increasing costs. 

NCCN guidelines for the treatment of ovarian cancer advise surgery and 6 cycles of chemotherapy. The combination of both surgery and chemotherapy can lead to high costs for patients as well as a number of adverse side effects. Therefore, it is important to identify the most cost-effective treatment strategies to ensure that patients receive the highest possible benefit at manageable costs. 

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Researchers led by Renata R Urban, MD, University of Washington, Seattle, used Surveillance, Epidemiology, and End Results (SEER) registry data to review the costs associated with treatment plans consistent with NCCN guidelines for ovarian cancer versus other treatment plans in the first year after diagnosis. Their results were published in the Journal of the National Comprehensive Cancer Network

The study identified all patients older than 65 years diagnosed with stage III and IV ovarian cancer in the SEER cancer registries from January 1, 1995, to December 31, 2007. Patients were excluded from the study if they were diagnosed after death; if they had nonepithelial malignancies or borderline or invasive pathology; prior malignancies before or after ovarian cancer diagnosis; or if they were not eligible for Medicare coverage (Part A and B without Health Maintenance Organization plans) for at least 3 months before the date of their diagnosis and for at least 12 months after the date of diagnosis. 

Using these parameters, the researchers identified 9491 patients with stage III or IV ovarian cancer between 1995 and 2007 for inclusion in the study. At initial diagnosis, 7064 patients (74.4%) were between 65 and 80 years of age and 3233 patients (34.1%) were older than 80 years of age. 

Of these patients, 2902 (30.6%) were treated with surgery followed by chemotherapy; 940 patients (9.9%) received neoadjuvant chemotherapy and then surgery; 2597 patients (27.4%) received only chemotherapy; 734 patients (7.7%) had only surgery; and 2318 patients (24.4%) did not receive any treatment. 

The researchers then categorized patients based on whether they received surgical and chemotherapeutic treatment consistent with NCCN guidelines. In all, only 2689 patents (28%) received treatment that adhered to the guidelines, although 1183 patients (12.5%) did receive treatment that was consistent with other guidelines. Additionally, the rate of NCCN-consistent treatment increased over the 12-year study period.

The cost analysis revealed that median cost of therapy  consistent with NCCN guidelines was $85,987, compared with $89,148 for treatment not consistent with NCCN guidelines. For the entire cohort, after adjusting for all potential confounding factors, the researchers determined the mean total costs of treatments that included surgery and chemotherapy were $7564 greater for treatment plans not consistent with NCCN guidelines than for treatment plans that were consistent with the guidelines.

Higher costs were typically found in regimens that included the use of PET (positron emission tomography) or CT (computed tomography) scans. Additionally, the use of neoadjuvant chemotherapy was associated with costs that were $14,390 higher than for regimens of surgery followed by chemotherapy.

Researchers concluded that treatment for ovarian cancer that is consistent with NCCN guidelines is currently underused in this patient population and is associated with lower total costs of treatment. Stricter adherence to NCCN guidelines may lead to better control of treatment costs for patients with ovarian cancer. —Sean McGuire

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Urban RR, He H, Alfonso-Cristancho R, Hardesty MM, Goff BA. The cost of initial care for Medicare patients with advanced ovarian cancer. J Natl Compr Canc Netw. 2016;14(4):429-37.