Alexander Vinita M, Gordon Alan N, Howard David H, Khanna Namita
*Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, School of Medicine; and †Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA.
Int J Gynecol Cancer. 2017 Sep;27(7):1333-1342. doi: 10.1097/IGC.0000000000001040.
The aim of this study was to determine whether there is a survival or cost benefit dependent on detection strategy of recurrent ovarian cancer (ie, imaging, physical examination findings, report of symptoms, or rising cancer antigen 125 [CA-125] levels).
METHODS/MATERIALS: A retrospective chart review of 112 ovarian cancer patients was conducted, and method of detection of recurrent disease was determined from medical records. The following primary outcomes were determined using Cox proportional hazards regression model: progression-free survival (PFS) after diagnosis of recurrence and time to death after diagnosis of recurrence (overall survival [OS]). Several approaches to disease surveillance were proposed, and a cost model was applied.
Median time to recurrence was 13.5 months. Overall, 6.3% presented with only physical examination findings; 24.1%, with elevating CA-125 levels; 34.8%, with imaging; and 32.1%, with symptoms. Most patients presenting with recurrent disease diagnosed by rising CA-125 were white (62.9%); those with imaging and symptomatic recurrences were blacks (56.4% and 57.1%, respectively). There was a small but not statistically significant OS benefit for recurrence detected via CA-125 (P = 0.85; OS per detection method: PE, 20.7 months; CA-125, 26.8 months; imaging, 17.8 months; and symptoms, 6.6 months). We modeled costs of surveillance in our patient cohort; up to 40.8% of cases of ovarian cancer recurrences would have been missed if no imaging were obtained during surveillance.
Results indicate minimal differences in PFS and statistically insignificant differences in OS, depending on detection method. Notably, black patients with Medicaid presented most often with symptomatic recurrences, which surprisingly did not affect patient OS and PFS; and interestingly, pr\ivate or self-pay insurance was associated with decreased OS among black patients. From our cost analysis, we estimate that the most cost-effective surveillance strategy for the first year costs $9.2 million annually and includes office visit biannually, biannual CA-125 levels, and annual asymptomatic imaging.
本研究旨在确定复发性卵巢癌的检测策略（即影像学检查、体格检查结果、症状报告或癌抗原125[CA-125]水平升高）是否存在生存获益或成本效益。
方法/材料：对112例卵巢癌患者进行回顾性病历审查，并从病历中确定复发性疾病的检测方法。使用Cox比例风险回归模型确定以下主要结局：复发诊断后的无进展生存期（PFS）和复发诊断后的死亡时间（总生存期[OS]）。提出了几种疾病监测方法，并应用了成本模型。
复发的中位时间为13.5个月。总体而言，6.3%的患者仅通过体格检查发现复发；24.1%的患者CA-125水平升高；34.8%的患者通过影像学检查发现复发；32.1%的患者有症状。大多数通过CA-125升高诊断为复发性疾病的患者为白人（62.9%）；通过影像学检查和有症状复发的患者为黑人（分别为56.4%和57.1%）。通过CA-125检测到的复发患者的总生存期有微小但无统计学意义的获益（P = 0.85；每种检测方法的总生存期：体格检查，20.7个月；CA-125，26.8个月；影像学检查，17.8个月；症状，6.6个月）。我们对患者队列中的监测成本进行了建模；如果在监测期间未进行影像学检查，高达40.8%的卵巢癌复发病例将被漏诊。
结果表明，根据检测方法的不同，PFS差异极小，OS差异无统计学意义。值得注意的是，接受医疗补助的黑人患者最常出现有症状的复发，令人惊讶的是，这并未影响患者的OS和PFS；有趣的是，私人或自费保险与黑人患者的OS降低有关。根据我们的成本分析，我们估计第一年最具成本效益的监测策略每年花费920万美元，包括每半年进行一次门诊就诊、每半年检测一次CA-125水平以及每年进行一次无症状影像学检查。
