Will patients benefit from regionalization of gynecologic cancer care? Outcomes in surgery for ovarian cancer. Specialized and high-volume care leads to better outcomes of ovarian cancer treatment in the Netherlands. Multiple cancer site comparison of adjusted survival by hospital of treatment: an East Anglian study. Survival in ovarian cancer in Wales: Prior to introduction of all Wales guidelines.
Patient chances for cure and palliation for a variety of malignancies may be greatly affected by the care provided by a treating hospital. We sought to determine the effect of volume and teaching status on patient outcomes for five gynecologic malignancies: endometrial, cervical, ovarian and vulvar carcinoma and uterine sarcoma.
                The Florida Cancer Data System dataset was queried for all patients undergoing treatment for gynecologic cancers from 1990-2000.
                Overall, 48,981 patients with gynecologic malignancies were identified. Endometrial tumors were the most common, representing 43.2% of the entire cohort, followed by ovarian cancer (30.9%), cervical cancer (20.8%), vulvar cancer (4.6%), and uterine sarcoma (0.5%). By univariate analysis, although patients treated at high volume centers (HVC) were significantly younger, they benefited from an improved short-term (30-day and/or 90-day) survival for cervical, ovarian and endometrial cancers. Multivariate analysis (MVA), however, failed to demonstrate significant survival benefit for gynecologic cancer patients treated at teaching facilities (TF) or HVC. Significant prognostic factors at presentation by MVA were age over 65 (HR = 2.6, p<0.01), African-American race (HR = 1.36, p<0.01), and advanced stage (regional HR = 2.08, p<0.01; advanced HR = 3.82, p<0.01, respectively). Surgery and use of chemotherapy were each significantly associated with improved survival.
                No difference in patient survival was observed for any gynecologic malignancy based upon treating hospital teaching or volume status. Although instances of improved outcomes may occur, overall further regionalization would not appear to significantly improve patient survival. Theobjective was to determine the relationship among hospital volume of ovarian cancer surgery,academic status of institution, surgical specialty, and outcomes of care (30-day postoperative mortality, reoperation rate, and overall survival).
                This population-based cohort study included all newly diagnosed ovarian cancer patients treated from 1992 to 1998 in Ontario, Canada. Hospitalization and surgical billing databases were used. Logistic regression was used to evaluate the importance of hospital type, hospital volume, surgical specialty, and surgeon volume of ovarian cancer operations on postoperative mortality, reoperation rates, and survival.
                Ovarian cancer surgery was performed on 3815 women between April 1992 and March 1998. When adjusted for age, comorbidity, acuity of the operation, and metastatic disease, no factors influenced postoperative mortality. The adjusted relative risk for reoperation within 3 months of the initial surgery showed that patients were less likely to have a repeat operation if the initial operation was done in a high- or intermediate-volume hospital (RR 0.24 95% CI 0.12-0.48, RR 0.29 95% CI 0.20-0.42, respectively), a hospital with a gynecologic oncologist (RR 0.29 95% CI 0.15-0.56), by a gynecologic oncologist (RR 0.04 95% CI 0.01-0.12) or gynecologist (RR 0.37 95% CI 0.21-0.66), or by a high-volume surgeon (RR 0.09 95% CI 0.03-0.23). The adjusted survival was improved if the initial surgery was done by a gynecologic oncologist (HR 0.70 95% CI 0.57-0.85) or gynecologist (HR 0.65 95% CI 0.53-0.79).
                There is a relationship between hospital volume and reoperation rate. Institution type only influenced reoperation rate. Statistically significant associations were found between surgical specialty and all three outcome variables. The volume of surgery performed by an individual surgeon only influenced reoperation rate. Our results are preliminary but support the need for further studies examining factors such as stage. We investigated the influence of hospital and gynecologist level of specialization and volume on surgical results and on survival of ovarian cancer patients.
                Data were collected from 1077 ovarian cancer patients treated from 1996 to 2003 in a random sample of 18 Dutch hospitals. Hospitals and gynecologists were classified according to specialization (general, semi-specialized or specialized) and by volume (<or=6, 7-12, or >12 cases/year). Outcomes were percentage of adequately staged and optimally debulked patients and length of overall survival. Data were analyzed using multivariable logistic regression (surgical results) and Cox regression (survival).
                The level of specialization and the volume of hospitals and of gynecologists were strongly related to the proportion of adequately staged patients (adjusted odds ratio (OR) specialized hospitals 3.9 (95% confidence interval (CI) 2.0-7.6); specialized gynecologists 9.5 (95% CI 4.7-19)). Patients with stage III disease had a higher chance of optimal debulking when treated in specialized hospitals (adjusted OR 1.7 (95% CI 1.1-2.7)) or by high volume gynecologists (adjusted OR 2.8 (95% CI 1.4-5.7)). Overall survival was best in patients treated in specialized hospitals and by high-volume gynecologists.
                The specialization level of hospitals and the surgical volume of gynecologists positively influence outcomes of surgery and survival. Concentration of ovarian cancer care thus seems warranted. We performed a preliminary investigation into which hospitals would benefit from investment and development, and which should have services restricted, with respect to the implementation of the Calman-Hine strategy of specialist cancer care. A retrospective study approach was used implementing uniform definitions for colon, rectal, breast, melanoma, bladder and ovarian cancers. A total of 14 527 cases registered by the East Anglian cancer registry and diagnosed between 1989 and 1993 were included. The cases were analysed in two age groups (< 75, 75+ years) and two hospital groups: group 1, those treated at hospitals with radiotherapy and oncology departments; group 2, other district general hospitals. Adjusted hazard ratios derived from Cox's proportional hazards model and adjusted conditional survival curves were presented. We found that after adjustment for age, sex and tumour stage at diagnosis, survival up to 5 years after diagnosis was usually worse in group 2 hospitals and significantly so for patients aged < 75 years with breast, ovarian and rectal tumours. Hospital workload produced little significant effect independently from hospital group. Analysing the selected cancer sites using uniform definitions and consistent staging supports the view that the strategy proposed in the Calman-Hine report is likely to be beneficial, but particular priority for change should be given to younger patients with breast, ovarian and rectal tumours. The objective of the study was to review referral practice, overall management, and survival in women with suspected ovarian cancer in Wales. This study was done prior to introduction of cancer management guidelines in the region. A confidential study questionnaire was sent to 20 participating hospitals. Data on 287 consecutive women with suspected ovarian cancer were collected, of which 250 women underwent primary laparotomy. Information was obtained on referral pattern, preoperative investigations, place of primary surgery, specialty of the primary surgeon, surgical parameters recorded at the time of operation, a final overall stage, adjuvant treatment, and survival outcome. There was a wide variation in referral practice and management of ovarian cancer in Wales. Stage of the disease, attempt at optimal debulking, residual disease, management by a cancer centre multidisciplinary team, and platinum-based chemotherapy were associated with improved overall survival and progression-free survival. More women were alive if managed in the cancer centre at 1 and 3 year after diagnosis (P = 0.022). This study has highlighted the acute issue of the standards of clinical care in the area of ovarian cancer management and will emphasize the implementation of better care pathways for ovarian cancers.
We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.
Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.