Women and cancer treatment questioned

With a certain amount of regularity, the National Institutes of Health issue guidelines for the treatment of particular illnesses. These guidelines are generally the result of “consensus conferences,” where scientists meet to analyze the most recent scientific studies. Such was the case in 1990, when the NIH issued guidelines for the treatment of Stage III colon cancer.

Colon cancer is the fourth most common cancer in U.S. men (after skin, prostate and lung) and women (after skin, lung and breast). Cancers are classified into four stages based on how far they have spread. Stage III colon cancer has spread to lymph nodes but not to distant sites like the liver or the lungs.

The NIH guidelines addressed the use of adjuvant therapy. Adjuvant therapy is given after primary treatment, in this case surgery. The NIH guidelines recommended that all patients with Stage III colon cancer receive adjuvant chemotherapy because studies showed that it extends survival time.

What happens after these guidelines are issued? Do community doctors follow them? And are they really as beneficial as the original studies said, given that these studies are generally performed with younger, healthier participants than those out in the community?

Researchers from NIH wanted to know the answers to those questions. They looked at data collected from the National Cancer Data Base, a hospital-based registry of people who are diagnosed with or receive treatment for cancer in 1,430 U.S. hospitals.

The researchers found that, yes indeed, adjuvant therapy increased five-year survival rates. The survival advantage existed at all ages, in all ethnicities, and in both sexes.

How did doctors do at following the guidelines? Four years before the consensus guidelines, only 10 percent of patients got adjuvant chemotherapy. By 1991, 39 percent of patients received the adjuvant therapy. This increased to 64 percent in 2002. But there were disturbing findings as well. Blacks, women and the elderly were less likely to get the adjuvant chemotherapy.

The difference in the African-American group existed at the beginning and the middle of the study, but by 2002 blacks were getting the adjuvant therapy at the same rate as their white counterparts. Blacks had a somewhat worse survival rate than whites but still benefited from the adjuvant therapy.

For women and those patients older than 60, there were clear benefits to receiving adjuvant chemotherapy. And yet older patients and women did not get the additional therapy at the same rate as their younger, or male, counterparts.

Now, the National cancer Database does not include information about why decisions are made. In the older population, for example, there are often other health issues that could impact treatment decisions. And personal preference plays a role as well. So while the data show that elderly patients treated with adjuvant chemotherapy have better survival rates than those who don’t get it, the surgery-only group may have had significant health issues that excluded them from further treatment. Certainly, as we look at older patients in general, this is the case.

But what about women? Why aren’t they getting adjuvant chemotherapy at the same rate as their male counterparts? According to the data presented in this study, they stand to benefit from the added therapy as much as their male counterparts.

This kind of study just gives us a snapshot of how things are, not why. Clearly, the NIH guidelines had a significant impact on treatment decisions. The authors attempted to analyze why treatment decisions varied in some of the subgroups. Blacks tended to have lower survival rates in this analysis, as they have in other studies. But they still benefit from the adjuvant therapy. Decisions on treatment of the older patients include other existing illnesses and patient preference.

But why are women less likely to get adjuvant therapy? The authors don’t even address that question, probably because they couldn’t imagine any logical reason. Hopefully, after the publication of this article, that disparity will disappear.