Study Suggests Patients with Ovarian Cancer Will Accept Higher Risk of Complications for Better OS

A study published in Cancer indicated that patients recently diagnosed with ovarian cancer would accept a moderately higher risk of perioperative complications and surgical mortality in exchange for substantial gains in survival. 

This research provides clinicians with a framework to discuss treatment preferences with patients and to incorporate preferences into clinical trial design.

“While the use of algorithms such as surgical risk scores to direct PDS [primary debulking surgery] versus NACT [neoadjuvant chemotherapy] may simplify clinical decisions, such rules implicitly incorporate value judgements about the relative importance of benefits and risks that do not necessarily align with patient values,” the researchers wrote.

In this cohort of 101 ovarian cancer survivors, participants completed a discrete-choice experiment (DCE) consisting of 8 choice tasks presenting treatment alternatives. Overall, participants would tolerate a 15-percentage point increase in risk of major complications (95% CI, 3%-29%) or a 4-percentage point increase in the risk of surgical mortality (95% CI, 2%-13%) in order to increase their expected overall survival from 3 to 3.5 years.

In order of greatest importance to participants, overall survival was put first (36%), followed by risk of readmission due to complications (23%), progression-free survival (19%), surgical mortality (16%), extent of surgery (4%), and order of surgery and chemotherapy (2%).

“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 researchers wrote.

Participants also viewed four 1- to 4-minute educational videos to become familiar with initial treatment options, the key attributes being studied, and their associated levels. Visual representations of probabilistic information were provided to test participants’ understanding of percentages, and descriptive information was included at the end of each video. If a participant answered any question incorrectly, an explanation for the correct answer was given.

Between 93% and 100% of respondents correctly answered each of 3 survey questions that were designed to test understanding of the educational videos presented, suggesting that women who completed the DCE understood the information provided and were attentive to the questions presented. 

Researchers suggested that based on the data, it would be appropriate to suggest NACT for women who have a strong aversion to operative morbidity and a relatively high surgical risk score, whereas women who have a lower aversion to short-term morbidity and who meet lower surgical risk criteria might be counseled for PDS.

One potentially important limitation of the study was that while all participants had a diagnosis of ovarian cancer, 33% had already experienced at least one recurrence and almost all had been treated with chemotherapy. Future studies may be necessary to include only women who were making their initial treatment decision.

The European TRUST randomized controlled trial should provide more data on the possible advantage provided by PDS in specific patient cohorts, as well as patients for which preference elicitation would be most warranted. The trial seeks to impose strict surgical quality control to demonstrate whether PDS confers a survival advantage.

References:

Havrilesky LJ, Yang J, Lee PS, et al. Patient Preferences for Attributes of Primary Surgical Debulking Versus Neoadjuvant Chemotherapy for Treatment of Newly Diagnosed Ovarian Cancer. Cancer. doi:10.1002/cncr.32447.