| | Cytoreduction of Stage III-IV Ovarian Cancer
Purpose
To examine the initial surgical care of Stage III-IV ovarian cancer at Gundersen-Lutheran Medical Center, with emphasis on achievement of optimal cytoreduction.
Background
Although many factors impact five year survival of women with Stage III-IV ovarian cancer, one consistent factor has proven to be the ability to achieve optimal cytoreduction, that is, at a minimum (1), there is no remaining cancer implant (tumor) following surgery greater than 2.0 cm in size. Such cytoreduction, or tumor debulking, appears to improve the efficacy of chemotherapy administered postoperatively. A review of the available literature indicates there is no minimum standard as to optimal cytoreduction, but reported results show that optimal cytoreduction is achievable in 63.3% to 87.1 % of patients with advanced epithelial ovarian cancer (1-3). These results are reported from large institutions with gynecologic oncology services. As a Cancer Center, it is imperative that Gundersen Lutheran has results equal to or better than that reported in the available literature.
Aims
1. To meet or exceed the benchmark of optimal cytoreduction defined as less than or equal to a 2.0 cm implant after surgical tumor debulking in patients with Stage III-IV ovarian cancer.
2. To explore ways to improve Gundersen Lutheran’s rate of optimal debulking where possible.
Changes
Since December 1995, Dr. Renwick has coordinated gynecologic oncology services at Gundersen Lutheran Health System. Consultation occurs with Dr. Julian Schink, a gynecologic oncology consultant from UW Madison, as well as with general surgery and other surgical specialty consultants from Gundersen Lutheran.
Methods/ Measures
Retrospective chart review was conducted of all patients in the Gundersen Lutheran Cancer Registry with a primary diagnosis of ovarian cancer undergoing their primary surgery at Gundersen Lutheran Medical Center from January 1999 through December 2002. (N=25) The physician reviewer did staging of patients according to the International Federation of Gynecology and Obstetrics (FIGO) definitions. Optimal cytoreduction is defined as tumor debulking with residual implant (tumor) less than or equal to 2 cm in size within the abdominal cavity. Consultation is having additional surgical specialists assisting with the primary surgery. Fisher exact testing was used for statistical analysis.
Benchmark
Catholic University, Rome, Italy. (1)
Results
Conclusions
1. Although the numbers are small, optimal cytoreduction of patients with Stage III-IV ovarian cancer undergoing primary surgery at Gundersen Lutheran Medical Center is as good as the benchmark. (p =0.056).
2. Seventy-six percent of patients have less than 1 cm of residual tumor remaining after cytoreductive surgery.
3. Almost ninety percent of patients have benefited from the collaborative coordinated approach to surgical treatment of stage III and IV ovarian cancer.
Impact
Patients having primary surgery for stage III and IV Ovarian Cancer at Gundersen Lutheran can be confident their care is as good as care received at larger facilities. Achieving optimal cytoreduction has the potential to improve survival in this group of patients.
Next Steps
1. Continue to monitor this rate over time. For those who do not undergo optimal cytoreduction, review whether this was possible at the time of surgery.
2. “Raising the bar”- Although residual implants of <2 cm is acceptable, better long-term survival may result from cytoreduction to implants <1.5 cm or even <1.0 cm. Given the systems in place and our experience, it may be reasonable, to set a lower size goal of cytoreduction.
References
(1) Benedetti-Panici P, Maneschi F, Scambia G, Cutillo G, Greggi S and Mancuso S. The Pelvic Retroperitoneal Approach in the Treatment of Advanced Ovarian Carcinoma. Ob Gyn 1996; 87:532-8.
(2 )Hoskins WJ, McGuire WP, Brady MF, Homesley HD, Creasman WT et al. The Effect of Largest Residual Disease on Survival After primary Cytoreductive Surgery in Patients with Suboptimal Residual Epithelial Ovarian Carcinoma. Am J Ob Gyn 1994; 170:974-80.
(3) Heintz APM, Hacker NF, Berek JS, Rose TP, Munoz AK and LaGasse LD. Cytoreductive Surgery in Ovarian Carcinoma: Feasibility and Morbidity. Ob Gyn 67:783- 88, 1986.
Activity Leaders
Kenneth W. Merkitch MD, Richard F. Renwick MD
Acknowledgements
Susan Bobenmoyer- Gynecology Data Specialist, Cheryl Strom, RN, Quality and Performance Improvement
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