Variations in institutional infrastructure, physician specialization and experience, and outcome in ovarian cancer: a systematic review

Effect of quality control program on surgical management in advanced ovarian cancer

OBJECTIVE

We investigated the effect of our quality control (QC) program on the management strategy, completeness of the surgery, and clinical outcomes in advanced ovarian cancer.

METHODS

A retrospective review of medical records from January 2005 to December 2019 identified 129 patients with advanced ovarian cancer. Cases were categorized into group 1 (2005-2013) and group 2 (2014-2019) before and after implementation of the QC program. Comparisons included clinicopathological variables, operative details, recurrence and survival outcomes.

RESULTS

In Group 2 (n=44), after QC program implementation, primary debulking surgery (PDS) decreased (87.1% vs. 63.6%) and interval debulking surgery (IDS) increased (12.9% vs. 36.4%), indicating a shift in surgical strategy. Optimal resection rates improved significantly for PDS in group 2 (50.0% to 75.0%, p=0.007) and remained high for IDS in both groups (81.8% vs. 81.3%, p>0.999). Post-QC, advanced debulking procedures and co-operation with other departments increased in the IDS (p<0.05). Intra/post-operative complication rates were statistically comparable (p>0.05), whereas postoperative hospital stay was significantly shorter in group 2 (17 days vs. 22 days, p=0.001). Median recurrence-free survival increased after QC, although not statistically significant (19.18 months vs. 25.38 months, p=0.855).

CONCLUSION

With QC program, treatment strategies and clinical outcomes were significantly improved in advanced ovarian cancer. Systematic QC monitoring program should be considered as routine surveillance for better surgical outcomes.

Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review

BACKGROUND

Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs).

OBJECTIVES

This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers.

SEARCH STRATEGY

The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE.

SELECTION CRITERIA

Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included.

DATA COLLECTION AND ANALYSIS

Results were synthesized using narrative synthesis approach with emergence of key themes by frequency.

MAIN RESULTS

The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing.

CONCLUSIONS

A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.

Comparison of International Ovarian Tumor Analysis ADNEX model and Ovarian-Adnexal Reporting and Data System with final histological diagnosis in adnexal masses: a retrospective study

OBJECTIVE

The International ovarian tumor analysis (IOTA)-Assessment of Different NEoplasias in the adneXa (ADNEX) model and the ovarian-adnexal reporting and data system (O-RADS) were developed to improve the diagnostic accuracy of adnexal masses in the preoperative period. This study aimed to evaluate the predictive values of both models in patients who underwent surgery for an adnexal mass at our hospital, based on the final pathological results.

METHODS

This study included patients who underwent surgery for adnexal masses at our hospital between 2019 and 2021 and met the inclusion criteria. The IOTA ADNEX model and O-RADS scores were calculated preoperatively.

RESULTS

Of the 413 patients, 295 were diagnosed with benign tumors and 118 were diagnosed with malignant tumors. The mean cancer antigen 125 (CA-125) levels for patients diagnosed with benign and malignant were 15.2 unit/mL and 72.5 unit/mL, respectively. According to the receiver operator characteristic analysis for serum CA-125 in postmenopausal and premenopausal patients, the cutoff value of 34.8 unit/mL had a sensitivity of 70.8% and specificity of 83.8% and 180.5 unit/mL had a sensitivity of 32.1% and a specificity of 92.7%, respectively (P<0.001). The sensitivity and specificity values of the IOTA ADNEX model and O-RADS were found as 78.8-48.3% and 97.9-93.5% respectively (P<0.001). There was moderate agreement between the IOTA ADNEX model and O-RADS (Kappa=0.53).

CONCLUSION

The IOTA ADNEX model has a similar specificity to the O-RADS in malignancy risk assessment, but the sensitivity of the IOTA ADNEX model is higher than that of the O-RADS. The IOTA-ADNEX model can help avoid unnecessary surgeries.

Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study

OBJECTIVES

To study the association between hospital volume and outcomes in patients with invasive epithelial ovarian cancer (EOC).

METHODS

This study included 3988 patients diagnosed with invasive EOC between 2014 and 2018, selected from the population-based database of the Belgian Cancer Registry (BCR), and coupled with health insurance and vital status data. The associations between hospital volume and observed survival since diagnosis were assessed with Cox proportional hazard models, while volume associations with 30-day post-operative mortality and complicated recovery were evaluated using logistic regression models.

RESULTS

Treatment for EOC was very dispersed with half of the 100 centres treating fewer than six patients per year. The median survival of patients treated in centres with the highest-volume quartile was 2.5 years longer than in those with the lowest-volume quartile (4.2 years versus 1.7 years). When taking the case-mix of hospitals into account, patients treated in the lowest volume centres had a 47% higher hazard to die than patients treated in the highest volume centres (HR: 1.47, 95% CI: 1.11-1.93, p = 0.006) over the first five years after incidence. A similar association was found when focussing on the surgical volume of the hospitals and considering only operated patients with invasive EOC. Lastly, the 30-day post-operative mortality decreased significantly with increasing surgical volume.

CONCLUSIONS

The large dispersion of care and expertise within Belgium and the volume-outcome associations observed in this study support the implementation of the concentration of care for patients with invasive EOC in reference centres.

The impact of the institutional abdominoperineal resections volume on short-term outcomes and expenses: a nationwide study

BACKGROUND

The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system.

METHODS

This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system.

RESULTS

Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: < 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower.

CONCLUSIONS

Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.

Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.

Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful?

The use of minimally invasive surgical techniques is becoming increasingly important in gynecologic oncology due to technical advances and the increasing level of surgical expertise. In addition to laparoscopic approaches for the treatment of benign neoplasms, minimally invasive surgical methods have also become established in some areas for treating gynecologic malignancies. For tumor entities such as endometrial and cervical carcinoma, there are conclusive studies emphasizing the role of laparoscopy in surgical therapy. By contrast, due to a lack of prospective data with survival analyses, no clear conclusions can be drawn on the significance of laparoscopy in the surgical treatment of ovarian carcinoma. However, some smaller, mostly retrospective case-control studies and cohort studies open the way for a discussion, positing the possibility that laparoscopic surgical procedures, particularly for early ovarian carcinoma, are technically feasible and of a quality equivalent to that of conventional longitudinal laparotomy, and may also be associated with lower perioperative morbidity. In this article we discuss the most important aspects of using minimally invasive surgical techniques for ovarian carcinoma based on the current literature. In particular we look at the relevance of laparoscopy as a primary approach for surgical staging of early ovarian carcinoma, and we evaluate the role of diagnostic laparoscopy in assessing the operability of advanced ovarian carcinoma.

Gynaecological Oncology in India: Past, Present and Future

Gynaecological cancers contribute to a substantial portion of the global cancer burden. Traditionally, these cancers have been treated by generalists, including gynaecologists and surgeons. However, owing to increasing sophistication and challenges in their management, a new sub-speciality of Gynaecologic Oncology, dedicated to these women's comprehensive care, has emerged in recent times. The emergence and evolution of this sub-speciality will facilitate a holistic approach to treating women suffering from gynaecological cancers, including tailored surgical techniques, fertility preservation, precision medicine, hormone modulators, targeted therapy and immunotherapy, which can be achieved within the framework of multidisciplinary management. Hence, we decided to write this synopsis to shed light on the evolution of this discipline in India and offer current and future perspectives.

Variation in ovarian cancer care in Australia: An analysis of patterns of care in diagnosis and initial treatment in New South Wales

OBJECTIVE

Ovarian cancer has the highest mortality of all gynaecological cancers. This study aimed to identify the extent to which women across New South Wales experienced variation in their care in diagnosis and initial treatment for ovarian cancer against the national optimal care pathway for ovarian cancer.

METHOD

Clinical audit methodology was utilised to explore variations for women with primary ovarian cancer; 171 eligible cases were identified through by the NSW Cancer Registry for the period of 1 March 2017 to 28 February 2018.

RESULTS

Limited variation was detected with 86% of women being reviewed by a specialist gynaecological oncology multidisciplinary team; 54% of women received their first treatment within 28 days of their first specialist appointment, 66% of women having their first surgery completed by a gynaecological oncologist and 45% of women received their first treatment in a specialist gynaecological oncology hospital.

CONCLUSION

Deviation from effective ovarian cancer care is apparent particularly in the location and timeliness of first treatment, with implications for the quality of care received and care outcomes. Understanding factors that contribute to variation is critical to ensure optimal and appropriate ovarian cancer care and to tackle systemic barriers to the provision of effective care.

Clinical research in ovarian cancer: consensus recommendations from the Gynecologic Cancer InterGroup

The Gynecologic Cancer InterGroup (GCIG) sixth Ovarian Cancer Conference on Clinical Research was held virtually in October, 2021, following published consensus guidelines. The goal of the consensus meeting was to achieve harmonisation on the design elements of upcoming trials in ovarian cancer, to select important questions for future study, and to identify unmet needs. All 33 GCIG member groups participated in the development, refinement, and adoption of 20 statements within four topic groups on clinical research in ovarian cancer including first line treatment, recurrent disease, disease subgroups, and future trials. Unanimous consensus was obtained for 14 of 20 statements, with greater than 90% concordance in the remaining six statements. The high acceptance rate following active deliberation among the GCIG groups confirmed that a consensus process could be applied in a virtual setting. Together with detailed categorisation of unmet needs, these consensus statements will promote the harmonisation of international clinical research in ovarian cancer.

HE4 as a serum biomarker for the diagnosis of pelvic masses: a prospective, multicenter study in 965 patients

Background

To evaluate the diagnostic value of adding human epididymis protein 4 (HE4), cancer antigen 125 (CA125) and risk of malignancy algorithm (ROMA) to ultrasound for detecting ovarian cancer in patients with a pelvic mass.

Methods

This was a prospective, observational, multicenter study. Patients aged > 18 years who were scheduled to undergo surgery for a suspicious pelvic mass had CA125 and HE4 levels measured prior to surgery, in addition to a routine transvaginal ultrasound scan. The diagnostic performance of CA125, HE4 and ROMA for distinguishing between benign and malignant adnexal masses was assessed using receiver operating characteristic (ROC) analysis and the corresponding area under the curve (AUC).

Results

Of 965 evaluable patients, 804 were diagnosed with benign tumors and 161 were diagnosed with ovarian cancer. In late-stage ovarian cancer, CA125, HE4 and ROMA all had an excellent diagnostic performance (AUC > 0.92), whereas in stage I and II, diagnostic performance of all three biomarkers was less adequate (AUC < 0.77). In the differential diagnosis of ovarian cancer and endometriosis, ROMA and HE4 performed better than CA125 with 99 and 98.1% versus 75.0% sensitivity, respectively, at 75.4% specificity.

Conclusions

ROMA and HE4 could be valuable biomarkers to help with the diagnosis of ovarian cancer in premenopausal patients in order to differentiate from endometriosis, whereas CA125 may be more adequate for postmenopausal patients.

• Serum biomarkers can help to distinguish benign from malignant pelvic masses

• We evaluated the diagnostic value of adding HE4, CA125 and ROMA to ultrasound for detecting ovarian cancer

• In stage III and IV ovarian cancer all three biomarkers showed excellent performance

• ROMA and HE4 performed better than CA125 in the differential diagnosis of ovarian cancer and endometriosis

The role of acute care surgeons in treating rib fractures-a retrospective cohort study from a single level I trauma center

BACKGROUND

Rib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years.

METHODS

Data from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons.

RESULTS

A total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group.

CONCLUSIONS

Acute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.

Quality assurance and improvement in oncology using guideline-derived quality indicators - results of gynaecological cancer centres certified by the German cancer society (DKG)

PURPOSE

Based on the example of Gynaecological Cancer Centres (GCCs) certified by the German Cancer Society, this study evaluates the results of medical-guideline-derived quality indicators (QIs) for cervical cancer (CC) and ovarian cancer (OC), examines the development of indicator implementation over time as well as the status of guideline-compliant care and identifies improvement measures.

METHODS

QI results for patients with CC and OC treated in GCCs between 2015 and 2019 are analysed. The median, overall proportion and standard deviation of each QI were calculated. Two-sided Cochran-Armitage tests were applied.

RESULTS

QIs are divided into two categories: process-organization (PO-QIs) and treatment-procedures (TP-QIs), to allow a differentiated analysis for identifying improvement measures. PO-QIs that reflect the implementation of processes and structures show a high degree of application. PO-QIs have a tremendous influence on the quality of care and are easy to implement through SOPs. TP-QIs report on treatments that are performed in the GCC. TP-QIs that report on systemic therapies reach a plateau where the guideline is known, but patient-related-factors meaningfully prevent further increase. TP-QIs that report on surgical interventions fluctuate. The most relevant factors are practitioners' personal skills. Besides the discussion of results amongst peers during the audit, improvement measures could include surgical courses or coaching.

CONCLUSION

The analysis shows that a combination of different measures is necessary to anchor quality sustainably in health care and thus improve it.

Between-hospital variations in 3-year survival among patients with newly diagnosed gastric, colorectal, and lung cancer

Due to increases in cancer survivability, quality assessments of cancer care must include long-term outcomes. This multicenter retrospective cohort study evaluated between-hospital variations in the 3-year survival rates of patients with gastric, colorectal, and lung cancer irrespective of treatment modality. We linked cancer registry data and administrative data from patients aged 18–99 years who were diagnosed with gastric, colorectal, or lung cancer between 2013 and 2015 in Osaka Prefecture, Japan. The 3-year survival rates were adjusted for potential prognostic factors using multilevel logistic regression models. Between-hospital variations were visually evaluated using funnel plots. We analyzed 10,296 gastric cancer patients from 30 hospitals, 9276 colorectal cancer patients from 30 hospitals, and 7978 lung cancer patients from 28 hospitals. The 3-year survival rate was 70.2%, 75.2%, and 45.0% for gastric, colorectal, and lung cancer, respectively. In the funnel plots, the adjusted survival rates of gastric and colorectal cancer for all hospitals lay between the lower and upper control limits of two standard deviations of the average survival rates. However, the adjusted survival rates of lung cancer for four hospitals lay below the lower limit while that for two hospitals lay above the upper limit. Older age, men, advanced cancer stage, comorbidities, functional disability, emergency admission, current/ex-smokers, and underweight were independently associated with poorer survival. In conclusion, there were between-hospital variations in 3-year survival for lung cancer even after adjusting for case mix. Quality improvement initiatives may be needed to raise the consistency of care.

Biomarker-Based Models for Preoperative Assessment of Adnexal Mass: A Multicenter Validation Study

Ovarian cancer (OC) is the most lethal genital malignancy in women. We aimed to develop and validate new proteomic-based models for non-invasive diagnosis of OC. We also compared them to the modified Risk of Ovarian Malignancy Algorithm (ROMA-50), the Copenhagen Index (CPH-I) and our earlier Proteomic Model 2017. Biomarkers were assessed using bead-based multiplex technology (Luminex®) in 356 women (250 with malignant and 106 with benign ovarian tumors) from five European centers. The training cohort included 279 women from three centers, and the validation cohort 77 women from two other centers. Of six previously studied serum proteins (CA125, HE4, osteopontin [OPN], prolactin, leptin, and macrophage migration inhibitory factor [MIF]), four contributed significantly to the Proteomic Model 2021 (CA125, OPN, prolactin, MIF), while leptin and HE4 were omitted by the algorithm. The Proteomic Model 2021 revealed a c-index of 0.98 (95% CI 0.96, 0.99) in the training cohort; however, in the validation cohort it only achieved a c-index of 0.82 (95% CI 0.72, 0.91). Adding patient age to the Proteomic Model 2021 constituted the Combined Model 2021, with a c-index of 0.99 (95% CI 0.97, 1) in the training cohort and a c-index of 0.86 (95% CI 0.78, 0.95) in the validation cohort. The Full Combined Model 2021 (all six proteins with age) yielded a c-index of 0.98 (95% CI 0.97, 0.99) in the training cohort and a c-index of 0.89 (95% CI 0.81, 0.97) in the validation cohort. The validation of our previous Proteomic Model 2017, as well as the ROMA-50 and CPH-I revealed a c-index of 0.9 (95% CI 0.82, 0.97), 0.54 (95% CI 0.38, 0.69) and 0.92 (95% CI 0.85, 0.98), respectively. In postmenopausal women, the three newly developed models all achieved a specificity of 1.00, a positive predictive value (PPV) of 1.00, and a sensitivity of >0.9. Performance in women under 50 years of age (c-index below 0.6) or with normal CA125 (c-index close to 0.5) was poor. CA125 and OPN had the best discriminating power as single markers. In summary, the CPH-I, the two combined 2021 Models, and the Proteomic Model 2017 showed satisfactory diagnostic accuracies, with no clear superiority of either model. Notably, although combining values of only four proteins with age, the Combined Model 2021 performed comparably to the Full Combined Model 2021. The models confirmed their exceptional diagnostic performance in women aged ≥50. All models outperformed the ROMA-50.

Gynecologic oncologist impact on adjuvant chemotherapy care for stage II-IV ovarian cancer patients

OBJECTIVE

We aim to evaluate the impact gynecologic oncologists have on ovarian cancer adjuvant chemotherapy care from their role as surgeons recommending adjuvant chemotherapy care and their role as adjuvant chemotherapy providers while considering rural-urban differences.

METHODS

Multivariable adjusted logistic regressions and Cox proportional hazards models were developed using a population-based, retrospective cohort of stage II-IV and unknown stage ovarian cancer patients diagnosed in Iowa, Kansas, and Missouri in 2010-2012 whose medical records were abstracted in 2017-2018.

RESULTS

Gynecologic oncologist surgeons (versus other type of surgeon) were associated with increased odds of adjuvant chemotherapy initiation (adjusted odds ratio (OR) 2.18; 95% confidence interval (CI) 1.10-4.33) and having a gynecologic oncologist adjuvant chemotherapy provider (OR 10.0; 95% CI 4.58-21.8). Independent of type of surgeon, rural patients were less likely to have a gynecologic oncologist chemotherapy provider (OR 0.52; 95% CI 0.30-0.91). Gynecologic oncologist adjuvant chemotherapy providers (versus other providers) were associated with decreased surgery-to-chemotherapy time (rural: 6 days; urban: 8 days) and increased distance to chemotherapy (rural: 22 miles; urban: 11 miles). Rural women (versus urban) traveled 38 miles farther when their chemotherapy provider was a gynecologic oncologist and 27 miles farther when it was not.

CONCLUSION

Gynecologic oncologist surgeons may impact adjuvant chemotherapy initiation. Gynecologic oncologists serving as adjuvant chemotherapy providers were associated with some care benefits, such as reduced time from surgery-to-chemotherapy, and some care barriers, such as travel distance. The barriers and benefits of having a gynecologic oncologist involved in adjuvant chemotherapy care, including rural-urban differences, warrant further research in other populations.

Association between cystoscopy at the time of hysterectomy performed by a gynecologic oncologist and delayed urinary tract injury

OBJECTIVE

Guidance regarding the use of cystoscopy at the time of hysterectomy is lacking in gynecologic oncology. We compare the rate of delayed urinary tract injury in women who underwent cystoscopy at the time of hysterectomy performed by a gynecologic oncologist for benign or malignant indication with those who did not.

METHODS

This was a retrospective cohort study of patients who had a hysterectomy performed by a gynecologic oncologist recorded in the National Surgical Quality Improvement Program between January 2014 and December 2017. The primary outcome was delayed urinary tract injury in the 30-day post-operative period. Secondary outcomes were operative time and urinary tract infection rate. The exposure of interest was cystoscopy at the time of hysterectomy and bivariable tests were used to examine associations.

RESULTS

We identified 33 355 women who underwent hysterectomy for benign (41%; n=13 621) or malignant (59%; n=19 734) indications performed by a gynecologic oncologist. Surgical approach was open (39%; n=12 974), laparoscopic or robotic-assisted laparoscopic (55%; n=18 272), and vaginal or vaginally-assisted (6%; n=2109). Overall, 12% of women (n=3873) underwent cystoscopy at the time of surgery; cystoscopy was more commonly performed in laparoscopic (15%; n=2829) and vaginal (12%; n=243) approaches than with open hysterectomy (6%; n=801) (p<0.001). There was no difference in the rate of delayed urinary tract injury in patients who underwent cystoscopy at the time of surgery compared with those who did not (0.4% vs 0.3%, p=0.32). However, patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (3% vs 2%, RR 1.3, 95% CI 1.1 to 1.6). In cases where cystoscopy was performed, median operative time was increased by 9 min (137 vs 128 min, p<0.001).

CONCLUSION

Cystoscopy at the time of hysterectomy performed by a gynecologic oncologist does not result in a lower rate of delayed urinary tract injury compared with no cystoscopy.

Effect of Quality Control Program in Surgical Management of Early Cervical Cancer

BACKGROUND

Regular assessments of clinical performance in gynecologic cancer surgery is important for the safety of patients. We evaluated the effects of quality control (QC) program on the treatment pattern and clinical outcomes of early cervical cancer.

METHODS

Medical records of cervical cancer patients who received operation in our institution from January 2007 to December 2018 were retrospectively reviewed. Cases were divided into 2 groups, before and after the initiation of QC program, group 1 (2007-2013) and group 2 (2014-2018), based on the operation date. Two groups were compared in clinicopathologic variables, surgical methods, operative details, adjuvant treatments, recurrence and survival.

RESULTS

A total of 305 cervical cancer patients were included in the analysis, 210 in group 1 and 95 in group 2. In group 2, minimally invasive surgery (MIS) was more frequently performed (60.0% vs. 76.8%, P = 0.004), especially in earlier stages (stage IA, 72.6% vs. 100.0%; stage IB, 52.2% vs. 69.5%). However, the median tumor size treated by MIS was decreased in stage IB (20 mm vs. 17 mm, P = 0.015). Frequency of adjuvant treatment was also reduced in stage IB (56.5% vs. 37.3%, P = 0.016). Recurrence within 3 years, 3-year disease free survival and overall survival did not show significant difference; however, 3-year recurrence after MIS was significantly reduced in stage IB.

CONCLUSION

QC program enforced stricter patient selection criteria for MIS and positively affected clinical outcomes in cervical cancer patients who underwent surgery. Systemic monitoring should be considered for patient safety.

Impact of Surgeon Type and Rurality on Treatment and Survival of Ovarian Cancer Patients

BACKGROUND

National Comprehensive Cancer Network guidelines recommend ovarian cancer patients receive cancer-directed surgery from a gynecologic oncologist surgeon. We aimed to determine if rurality impacts type of surgeon and estimate if the interaction between rurality and type of surgeon impacts cytoreductive surgery, chemotherapy initiation, and survival.

METHODS

Our population-based cohort of Iowan (N=675) ovarian cancer patients included women diagnosed with histologically confirmed stages IB-IV cancer in 2010 to 2016 at the ages of 18 to 89 years old and who received cancer-directed surgery in Iowa. Multivariable logistic regression analysis and Cox proportional hazards models were used.

RESULTS

Rural (vs. urban) patients were less likely to receive surgery from a gynecologic oncologist (adjusted odds ratio [OR]: 0.48; 95% confidence interval [CI]: 0.30-0.78). Rural patients with a gynecologic oncologist (vs. nongynecologic oncologist) surgeon were more likely to receive cytoreduction (OR: 2.84; 95% CI: 1.31-6.14) and chemotherapy (OR: 4.22; 95% CI: 1.82-9.78). Gynecologic oncologist-provided surgery conferred a 3-year cause-specific survival advantage among rural patients (adjusted hazard ratio: 0.57; 95% CI: 0.33-0.97) and disadvantage among urban patients (hazard ratio: 1.77; 95% CI: 1.02-3.06) in the model without treatment covariates. Significance dissipated in models with treatment variables.

DISCUSSION

The variation in the gynecologic oncologist survival advantage may be because of treatment, referral, volume, or nongynecologic oncologist surgeons' specialty difference by rurality. This is the first study to investigate the ovarian cancer survival advantage of having a gynecologic oncologist surgeon by rurality.

Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training?

OBJECTIVE

The objective of this study was to determine factors associated with performance of concomitant apical support procedures (ASPs) with benign hysterectomy at a regional medical system.

METHODS

Benign hysterectomies performed within 1 regional medical system from January 2011 to November 2017 were identified using International Classification of Diseases, Ninth and 10th Revision, and Current Procedural Terminology codes. Primary outcome was performance of concomitant ASP. χ2 Tests compared categorical variables. Multivariable logistic regression analysis was performed to determine factors associated with performance of concomitant ASP.

RESULTS

A total of 12,345 benign hysterectomies were performed during the study period. Uterovaginal prolapse was the primary diagnosis in 924 (7.48%) hysterectomies and an associated diagnosis in 1180 (9.56%) hysterectomies. A total of 686 patients (5.56%) had concurrent ASPs: 119 (17.3%) in patients without a diagnosis of prolapse and 567 (82.7%) with prolapse. Using multivariable logistic regression, controlling for age, race, insurance type, hospital type, procedure year, hysterectomy route, and surgeon training in patients with a diagnosis of prolapse, older age, supracervical hysterectomy, and surgeon training were associated with performance of ASPs.

CONCLUSIONS

Even in patients with a preoperative diagnosis of uterovaginal prolapse, ASPs are not routinely performed at time of hysterectomy. Fellowship-trained surgeons were more likely to perform ASPs. Ongoing educational efforts during training and postgraduate at the national and regional level on the importance of reestablishing apical vaginal support at time of hysterectomy is needed to prevent incident and recurrent post-hysterectomy vaginal vault prolapse.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

Joint IARC/NCI International Cancer Seminar Series Report: expert consensus on future directions for ovarian carcinoma research

Recently, ovarian cancer research has evolved considerably because of the emerging recognition that rather than a single disease, ovarian carcinomas comprise several different histotypes that vary by etiologic origin, risk factors, molecular profiles, therapeutic approaches and clinical outcome. Despite significant progress in our understanding of the etiologic heterogeneity of ovarian cancer, as well as important clinical advances, it remains the eighth most frequently diagnosed cancer in women worldwide and the most fatal gynecologic cancer. The International Agency for Research on Cancer and the United States National Cancer Institute jointly convened an expert panel on ovarian carcinoma to develop consensus research priorities based on evolving scientific discoveries. Expertise ranged from etiology, prevention, early detection, pathology, model systems, molecular characterization and treatment/clinical management. This report summarizes the current state of knowledge and highlights expert consensus on future directions to continue advancing etiologic, epidemiologic and prognostic research on ovarian carcinoma.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

SEOM clinical guideline in ovarian cancer (2020)

Despite remarkable advances in the knowledge of molecular biology and treatment, ovarian cancer remains the leading cause of death from gynecologic cancer. In the last decade, there have been important advances both in systemic and surgical treatment. However, there is no doubt that the incorporation of PARP inhibitors as maintenance after the response to platinum-based chemotherapy, first in recurrent disease and recently also in first line, will change the natural history of the disease.The objective of this guide is to summarize the current evidence for the diagnosis, treatment, and follow-up of ovarian cancer, and to provide evidence-based recommendations for clinical practice.

An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery

OBJECTIVE

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.

METHODS

This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.

RESULTS

Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.

CONCLUSIONS

Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.

Measuring research in the big data era: The evolution of performance measurement systems in the Italian teaching hospitals

BACKGROUND

In the healthcare system, Teaching Hospitals(THs) not only provide care, but also train healthcare professionals and carry out research activities. Research is a fundamental pillar of THs' mission and relevant for the healthcare system monitored by Performance Evaluation Systems. Research activities can be measured using citation index services and this paper highlights differences between two services based on bibliometrics, describes opportunities and risks when performance indicators rely on data collected, controlled and validated by external services and discusses the possible impact on health policy at a system and provider level.

METHODS

A bibliometric analysis was done on data between 2014-2016 from ISI Web of Science and Scopus of 18.255 physicians working in 26 Italian THs. Quantity was defined as the number of publications and quality as Impact Factor or Field-Weighted Citation Impact.

RESULTS

Overall, 41.233 and 66.409 documents were extracted from respectively ISI Web of Science and Scopus. While benchmarking results, significant differences in ranked position both in metrics emerged.

DISCUSSION

Utilizing secondary data sources to measure research activities of THs allows benchmarking at an (inter)national level and overcoming self-referment. To utilize indicators for multiple governance purposes at the system and provider level, indicators need to be profoundly understood, require formalizations in data validation, internal analysis and a sharing process among health professionals, management and policymakers.

Validation of IOTA-ADNEX Model in Discriminating Characteristics of Adnexal Masses: A Comparison with Subjective Assessment

(1) Background: The aim of this study is to compare the IOTA-ADNEX (international ovarian tumor analysis–assessment of different neoplasias in the adnexa) model with gynecologic experts in differentiating ovarian diseases. (2) Methods: All participants in this prospective study underwent ultrasonography (US) equipped with the IOTA-ADNEX^TM model and subjective assessment by a sonographic expert. Receiver operating characteristic (ROC) curves were also generated to compare overall accuracies. The optimal cut-off value of the ADNEX model for excluding benign diseases was calculated. (3) Results: Fifty-nine participants were eligible: 54 and 5 underwent surgery and follow-up computed tomography (CT), respectively. Benign and malignant diseases were confirmed in 49 (83.1%) and 10 (16.9%) participants, respectively. The specificity of the ADNEX model was 0.816 (95% confidence interval (CI): 0.680–0.912) in all participants and 0.795 (95% CI, 0.647–0.902) in the surgical group. The area under the ROC curve of the ADNEX model (0.924) was not significantly different from that of subjective assessment (0.953 in all participants, 0.951 in the surgical group; p = 0.391 in all participants, p = 0.407 in the surgical group). The optimal cut-off point using the ADNEX model was 47.3%, with a specificity of 0.977 (95% CI: 0.880–0.999). (4) Conclusions: The IOTA-ADNEX model is equal to gynecologic US experts in excluding benign ovarian tumors. Subsequently, being familiar with this US software may help gynecologic beginners to reduce unnecessary surgery.

Diagnostic Value of Risk of Malignancy Algorithm (ROMA) in Adnexal Masses

Background

Differentiating malignancy from benign diseases is the key to successful management of adnexal masses. Risk of malignancy algorithm (ROMA) has been used for this purpose. We have prospectively studied the diagnostic value of ROMA in patients presented with adnexal masses.

Methods

We prospective calculated ROMA values prior to surgery for adnexal masses. The risk calculated was then correlated with the histological findings, and results were analyzed according to menopausal status. ROMA cutoff value was determined using ROC curve, and sensitivity, specificity and predictive values were calculated. Statistics were performed on SPSS software (version 20.0).

Results

There were 94 patients with adnexal masses included in the study, 65 (69.1%) had epithelial ovarian cancer and 29 (30.9%) were diagnosed benign on histopathology. In both pre- and postmenopausal patients, ROMA values were significantly higher in patients with malignancy compared to those with benign disease (p < 0.05). ROMA score was of a significant diagnostic value in both premenopausal (AUC = 0.914, Z = 10.81, p < 0.001) and postmenopausal patients (AUC = 0.975, Z = 21.51, p < 0.001). In premenopausal females, ROMA > 13.3% was able to discriminate malignant from benign patients with 97.06% sensitivity and 85.00% specificity. The positive and negative predictive values were 91.7% and 94.4%. Similarly, in postmenopausal females, ROMA value of > 76% achieved 87.10% sensitivity and 100.00% specificity in discriminating malignant from benign patients with 100% positive and 69.2% negative predictive value. The overall accuracy of ROMA in pre- and postmenopausal patients was 87.0% and 85%, respectively.

Conclusions

ROMA is a useful and accurate test for differentiating epithelial ovarian cancer from benign ovarian masses. Further studies are needed to compare performance of ROMA with the Risk of Malignancy Index (RMI), CA 125 and HE4. Such comparative studies will be helpful to the clinician in deciding the best diagnostic tool for women with adnexal masses.

Patterns of surgical care for women with ovarian cancer in New South Wales

BACKGROUND

Little is known about the delivery of surgical services and outcomes for women with ovarian cancer across New South Wales (NSW).

AIM

The study objective was to provide a descriptive analysis of the proportion of women who had surgery for ovarian cancer in NSW in specialist gynaecological oncology hospitals and compare outcomes for women attending specialist and non-specialist services in NSW.

MATERIALS AND METHODS

This study is a retrospective analysis of women with primary ovarian, fallopian tube or peritoneal cancer from 2009 to 2012. Data were analysed from the NSW Cancer Registry, NSW Admitted Patient Data Collection and Register of Births Deaths and Marriages. Treating hospitals were characterised as public specialist, public non-specialist and private. Morbidity and mortality outcomes are reported.

RESULTS

The study included 1106 women. Fifty-seven hospitals performed surgery: seven public specialist, 27 private and 23 public non-specialist hospitals. The highest proportion of surgery was performed in public specialist hospitals (61%). There was considerable variation in the utilisation of public specialist hospitals between local health districts. There was no significant difference in outcomes related to the type of hospital where surgery was performed.

CONCLUSIONS

Although the majority of women are having surgery in a specialist gynaecological oncology public hospital across NSW, many are not. Women living in regional and remote NSW were less likely to have their surgery in a specialist hospital. This is the first step in understanding where women in NSW are currently receiving their surgical care, as well as the outcomes related to this.

Quality Indicators and Survival Outcome in Stage IIIB-IVB Epithelial Ovarian Cancer Treated at a Single Institution

BACKGROUND/AIM

To investigate the overall survival rate, quality indicators and treatment outcome in FIGO stage IIIB-IVB epithelial ovarian cancer at a University Hospital in Sweden between 2006 and 2015.

MATERIALS AND METHODS

A cohort of 110 patients was followed-up for 3-12 years after cancer diagnosis. Three main groups (primary surgery, neoadjuvant chemotherapy, palliative treatment), and six subgroups were defined according to treatment modality.

RESULTS

The mean age was 65 years. Patients were observed for a mean of 50 months. The total resection frequency was 83%. Significant differences in overall survival at 5 years were observed between the groups varying from 60% to 12%.

CONCLUSION

Patient age, tumor stage and complete tumor removal at surgery were significant, independent prognostic factors of overall survival. Complication rate was a significant adverse prognostic factor in univariate analysis. Data discrepancy was observed between public quality reports and locally obtained data.

[Retrospective study: Late surgery post chemotherapy versus after 3-4 cures in treatment of advanced ovarian cancer]

INTRODUCTION

Treatment in locally advanced ovarian cancer is optimal surgery followed by chemotherapy. Patients with significant tumor spread, OMS>2, age>75 years old are poor candidates for aggressive primary surgery. Interval surgery, after neo-adjuvant chemotherapy, aims to achieve more complete surgery, increase survival, and reduce surgical morbidity. The primary endpoint was progression-free survival. Secondary outcomes were overall survival and postoperative morbidity and mortality.

METHOD

This is a retrospective study conducted in 2 French referral centers between January 2000 and December 2015. Patients who could not benefit from a complete initial surgery were operated after 3 cures of chemotherapy at the François Baclesse center and after least 5 cures at the center René Gauducheau.

RESULTS

The population analyzed included 104 patients, 43 (41.0%) patients treated at the René Gauducheau center (group 1) and 61 (59.0%) patients treated at the François Baclesse center (group 2). Progression-free and overall survival were similar between the 2 groups, they were, respectively, 15.9 months and 34 months in group 1 vs. 15.4 months and 37.6 months in group 2 (P=0.72; P=0.65). Mean hospital stay and postoperative morbidity were similar in both groups.

CONCLUSION

For weak patients, to limit invasive surgery, doing more than 5 courses of chemotherapy may be a reasonable option.

Well-trained gynecologic oncologists can perform bowel resection and upper abdominal surgery safely

Objective

This study was performed to examine the safety of bowel resection and upper abdominal surgery in patients with advanced ovarian cancer performed by gynecologic oncologists after training in a monodisciplinary surgical team.

Methods

We implemented a monodisciplinary surgical team consisting of specialized gynecologic oncologist for advanced ovarian cancer. In the initial learning period in 65 patients with International Federation of Gynecology and Obstetrics (FIGO) III/IV, a gynecologic oncologist who had a certification as a general surgeon trained 2 other gynecologic oncologists in bowel resection and upper abdominal surgery for 4 years. After the initial learning period, the trained gynecologic oncologists performed surgeries without the certificated general surgeon in 195 patients with FIGO III/IV. The surgical outcomes and perioperative complications during the 2 periods were evaluated.

Results

The rates of achieving no gross disease after cytoreductive surgery were 80.0% in the initial learning period and 83.6% in the post-learning period (p=0.560). The incidence of anastomotic leakage after rectosigmoid resection, symptomatic pleural effusion or pneumothorax after right diaphragm resection, and pancreatic fistula after splenectomy with distal pancreatectomy in the 2 periods were 2 of 34 (6.0%), 1 of 33 (3.0%), and 3 of 15 (20.0%) patients in the initial learning period, and 12 of 147 (8.2%), 1 of 118 (0.8%), and 11 of 84 (13.1%) patients in the post-learning period, respectively. There were no significant differences between the 2 groups (p=0.270, p=0.440, p=0.520, respectively).

Conclusion

Bowel resection and upper abdominal surgery can be performed safely by gynecologic oncologists.

Interpreting Randomized Clinical Trials in Gynecologic Oncology Surgery: Does One Size Fit All?

Randomized clinical trials (RCTs) are considered the gold standard of clinical research. They are designed to eliminate bias and to produce objective and generalizable results about new treatment paradigms. Although RCTs have recognized limitations, including long completion time and high cost, they also have transformed clinical research and improved the quality of health care by rigorously evaluating countless new treatment options. Surgical RCTs present their own unique set of limitations including an inability to standardize surgical technique and expertise; an inability to overcome enrollment bias by enrolling surgeons; and a lack of generalizability with respect to institutional resources and abilities. Here, we discuss surgical RCTs in two domains: upfront management of advanced ovarian cancer and surgical management of early-stage cervical cancer. Familiarity with the abundant retrospective data available for both of these clinical scenarios as well as recognition of the strengths and limitations of surgical RCTs are critical to determine the best treatment for an individual patient.

Optimization of surgical treatment of advanced ovarian cancer: a Spanish expert perspective

BACKGROUND

Optimal upfront treatment of patients with advanced ovarian cancer is complex and requires the adequate function of a multidisciplinary team. Specific standard of quality of care needs to be taken into consideration.

METHODS

A literature search in PubMed was performed using the following criteria: ("ovarian neoplasms"[MeSH Terms] OR ("ovarian"[All Fields] AND "neoplasms"[All Fields]) OR "ovarian neoplasms"[All Fields] OR ("ovarian"[All Fields] AND "cancer"[All Fields]) OR "ovarian cancer"[All Fields])"[Date - Publication]: "2018/01/14"[Date - Publication]).

RESULTS

This article describes how to optimize the surgical management of advanced ovarian cancer, to achieve the best results in terms of survival and quality of life. For this purpose, this document will cover aspects related to pre-, intra- and postoperative care of newly diagnosed advanced ovarian cancer patients.

CONCLUSION

Optimizing upfront treatment of patients with advanced ovarian cancer is complex and requires a structured quality management program including the wise judgment of a multidisciplinary team. Surgeries performed by gynecologic oncologists with formal training in cytoreductive techniques at referral centers are crucial factors to obtain better clinical and oncological outcomes. However, other factors such as the patient's clinical status, the hospital infrastructure and equipment, as well as the tumor biology of each individual patient should also be taken into account before deciding on an initial therapeutic strategy for advanced-stage ovarian cancer to offer patients the best quality of care.

Assessment of Diagnostic Values among CA-125, RMI, HE4, and ROMA for Cancer Prediction in Women with Nonfunctional Ovarian Cysts

Objectives

To evaluate the diagnostic performance among CA-125, RMI, HE4, and ROMA for cancer detection in women with nonfunctional ovarian cysts at King Chulalongkorn Memorial Hospital (KCMH). Secondary objective is to reconsider the proper cutoff value of HE4.

Methods

This is a prospective analytic study in women with nonfunctional ovarian cysts larger than 3 cm who scheduled for surgery at KCMH during 3^rd June 2015 to 31^st May 2016. Ultrasonogram and blood sample collection were completed before the operation. Patients' demographic information and pathologic results were obtained. SPSS software version 17 was used for statistical evaluation.

Results

A total of 281 participants were evaluated. 19.9% of them were malignant. Compared with CA-125, HE4 had lower sensitivity (53.4% vs. 87.9%) and NPV (89% vs. 93.6%) but higher specificity (97.8% vs. 46.2%) and PPV (86.1% vs. 29.8%). ROMA had slightly lower sensitivity (79.3% vs. 87.9%) and similar NPV (93.7% vs. 93.6%), but higher specificity (79.8% vs. 46.2%) and PPV (50.5% vs. 29.8%) compared with CA-125. The model that achieves the highest area under the ROC curve in differentiating benign versus malignant ovarian tumor was ROMA. Cutoff value of HE4 at 70 pMol/L (from 150 pMol/L) would give sensitivity 74.1% and specificity 86.5% that are comparable with ROMA.

Conclusions

HE4 and ROMA had better performance (higher specificity, PPV) compared to CA-125 and RMI. HE4 at 70 pMol/L could be the new cutoff value for Thai women with ovarian cysts, giving higher sensitivity and specificity.

Regionalization and Its Alternatives

This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.

When and Who Should Perform Epithelial Ovarian Cancer Surgery?

Abstract

Epithelial ovarian cancer is the most common cause of death due to gynecologic malignancies. Most patients will be diagnosed at an advanced stage, and despite progress in both surgical procedures and novel targeted therapies, the overall survival of these patients remains very low. Among prognostic factors, the International Federation of Gynecology and Obstetrics stage and residual tumor after debulking surgery are the most widely reported. The current review aims to highlight the disparities in the treatment of patients with ovarian cancer and the need for postgraduate training programs in order to accredit gynecologic oncologists. Despite an increase over the centralization of these patients, many are still not receiving specialized surgery.

Is Ovarian Cancer Being Managed According to Clinical Guidelines? Evidence From a Population-Based Clinical Audit

BACKGROUND

In the northwestern Italian region of Piedmont, current statistics on hospitalizations show that surgical treatment for ovarian cancer (OC) is taking place in many small hospitals, as opposed to a more centralized approach. A population-based clinical audit was promoted to investigate whether OC is being managed according to clinical guidelines, identify determinants of lack of adherence to guidelines, and evaluate the association between adherence to guidelines and survival.

PATIENTS AND METHODS

Residents diagnosed with OC in 2009 were identified in the regional hospital discharge records database. All hospitalizations within 2 years from diagnosis were reviewed. Patients were classified according to their initial pattern of care, defined as "with curative intent" (CIPC) if including debulking surgery aimed at maximal cytoreduction. Adherence to guidelines for surgery and chemotherapy and the effects of this adherence on OC survival were investigated with logistic regression and Cox models.

RESULTS

The final study sample consisted of 344 patients with OC, 215 (62.5%) of whom received CIPC. Increasing age, comorbidities, and metastases were negatively associated with receiving CIPC. In the CIPC group, surgical treatment was adherent to guidelines in 35.2%, whereas chemotherapy was adherent in 87.8%. Surgical treatment that was adherent to guidelines [hazard ratio (HR), 0.72; 95% confidence interval (CI), 0.45-1.15] and absence of residual tumor (HR, 0.55; 95% CI, 0.32-0.94) were associated with better survival in the CIPC group, and chemotherapy that was adherent to guidelines was associated with a significant reduction in the risk of death (HR, 0.49; 95% CI, 0.28-0.87).

CONCLUSIONS

Results support the need to reorganize the clinical pathway of patients with OC in the Piedmont Region and the need for better adherence to current guidelines.

A Comparison of Survival Outcomes in Advanced Serous Ovarian Cancer Patients Treated With Primary Debulking Surgery Versus Neoadjuvant Chemotherapy

OBJECTIVE

The management of women with advanced-stage serous ovarian cancer includes a combination of surgery and chemotherapy. The choice of treatment with primary debulking surgery or neoadjuvant chemotherapy varies by institution. The objective of this study was to report 5-year survival outcomes for ovarian cancer patients treated at a single institution with primary debulking surgery or neoadjuvant chemotherapy.

METHODS

This study included a retrospective chart review of 303 patients with stage IIIC or IV serous ovarian carcinoma diagnosed in Calgary, Canada. The patients were categorized into 1 of the 2 treatment arms: primary debulking surgery or neoadjuvant chemotherapy. The 5-year ovarian cancer-specific survival rates were estimated using Kaplan-Meier curves.

RESULTS

Among the 303 eligible patients, 142 patients (47%) underwent primary debulking surgery, and 161 patients (53%) were treated with neoadjuvant chemotherapy. Five-year survival was better for patients undergoing primary debulking surgery (39%) than for patients who received neoadjuvant chemotherapy (27%; P = 0.02). Women with no residual disease experienced better overall survival than those with any residual disease (47% vs. 26%, respectively; P = 0.0002). This difference was significant for those who had primary debulking surgery (P = 0.0004) but not for the patients who received neoadjuvant chemotherapy (P = 0.09). Women who received intraperitoneal chemotherapy had better overall survival as compared with patients who received intravenous chemotherapy (44% vs 30%, respectively; P = 0.002).

CONCLUSIONS

Our findings suggest that among women with no residual disease, survival is better among those who undergo primary debulking surgery than treatment with neoadjuvant chemotherapy. The latter should be reserved for women who are deemed not to be candidates for primary debulking surgery.

European Surgical Education and Training in Gynecologic Oncology: The impact of an Accredited Fellowship

OBJECTIVE

The aim of this study was to understand the current situation of surgical education and training in Europe among members of the European Society of Gynecological Oncology (ESGO) and its impact on the daily surgical practice of those that have completed an accredited fellowship in gynecologic oncology.

METHODS

A questionnaire addressing topics of interest in surgical training was designed and sent to ESGO members with surgical experience in gynecologic oncology. The survey was completely confidentially and could be completed in less than 5 minutes. Responses from 349 members from 42 European countries were obtained, which was 38% of the potential target population. The respondents were divided into 2 groups depending on whether they had undergone an official accreditation process.

RESULTS

Two thirds of respondents said they had received a good surgical education. However, accredited gynecologists felt that global surgical training was significantly better. Surgical self-confidence among accredited specialists was significantly higher regarding most surgical oncological procedures than it was among their peers without such accreditation. However, the rate of self-assurance in ultraradical operations, and bowel and urinary reconstruction was quite low in both groups. There was a general request for standardizing surgical education across the ESGO area. Respondents demanded further training in laparoscopy, ultraradical procedures, bowel and urinary reconstruction, and postoperative management of complications. Furthermore, they requested the creation of fellowship programs in places where they are not now accredited and the promotion of rotations and exchange in centers of excellence. Finally, respondents want supporting training in disadvantaged countries of the ESGO area.

CONCLUSIONS

Specialists in gynecologic oncology that have obtained a formal accreditation received a significantly better surgical education than those that have not. The ESGO responders recognize that their society should lead the standardization of surgical training and promote ways of improving members' surgical skills.

Top 10 Tips Palliative Care Clinicians Should Know When Caring for Patients with Ovarian Cancer

The vast majority of women diagnosed with ovarian cancer present with advanced-stage disease with a five-year survival rate less than 50%. Studies have shown that in the past, gynecologic oncologists were not routinely collaborating with palliative care physicians resulting in goals of care planning often not occurring until the last 30 days before death. In recent years, professional societies have been increasingly more vocal about the importance of incorporating palliative care early in a patient's disease course. As these calls increase, palliative care clinicians will be likely to comanage patients with ovarian cancer and may benefit from additional targeted education on this unique population. We brought together a team of gynecologic oncology and palliative care experts to collate practical pearls for the care of women with epithelial ovarian cancer. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians understand a patient's prognosis, address common misconceptions about ovarian cancer, and improve the quality of shared decision making and goals-of-care discussions.

Impact of institutional accreditation by the Japan Society of Gynecologic Oncology on the treatment and survival of women with cervical cancer

Objective

The Japan Society of Gynecologic Oncology (JSGO) initiated a nation-wide training system for the education and certification for gynecologic oncologists in 2005. To assess the impact of the quality of the JSGO-accredited institutions, JSGO undertook an analysis of the Uterine Cervical Cancer Registry of the Japan Society of Obstetrics and Gynecology (JSOG) to determine the effectiveness of the JSGO-accredited institutions on the treatment and survival of women with cervical cancer.

Methods

The effectiveness of 119 JSGO-accredited institutions and 125 non-JSGO-accredited institutions on the treatment and survival of women with cervical cancer were compared by analyzing the tumor characteristics, treatment patterns, and survival outcomes of women with stage T1B–T4 cervical cancer utilizing the data in the JSOG nation-wide registry for cervical cancer (2006–2009).

Results

A total of 14,185 eligible women were identified: 10,920 (77.0%) cases for 119 JSGO-accredited institutions and 3,265 (23.0%) cases for 125 non-accredited institutions. A multivariate analysis showed that age, stage, histology type, and treatment pattern were independently associated with mortality. Moreover, women who received treatment at the JSGO-accredited institutions had a significantly decreased mortality risk compared to non-accredited institutions (adjusted hazard ratio [aHR]=0.843; 95% confidence interval [CI]=0.784–0.905). Similar findings on multivariate analysis were seen among subset of women who received surgery alone (aHR=0.552; 95% CI=0.393–0.775) and among women who received radiotherapy (aHR=0.845; 95% CI=0.766–0.931).

Conclusion

Successful implementation of gynecologic oncology accrediting institution was associated with improved survival outcome of women with cervical cancer in Japan.

Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules

Ovarian cancer, the fifth most common cause of cancer death among women, has the highest mortality rate of all gynecologic cancers. General survival rate is <50% but can reach 90% if disease is detected early. Ultrasound is presently the best modality to differentiate between benign and malignant status. The patient with a malignant mass should be referred to an oncology surgeon since results have been shown to be superior to treatment by a specialist. Several ultrasound-based scoring systems exist for assessing the risk of an ovarian tumor to be malignant. The International Ovarian Tumor Analysis group published 2 such systems: the ultrasound Simple Rules and the Assessment of Different NEoplasias in the adneXa model. The Simple Rules classifies a tumor as benign, malignant, or indeterminate and the Assessment of Different NEoplasias in the adneXa model determines the risk for a tumor to be benign or malignant and, if malignant, the risk of various stages. Sensitivity of the Simple Rules and Assessment of Different NEoplasias in the adneXa model (using a cut-off of 10% to predict malignancy) are 92% and 96.5%, respectively, and specificities are 96% and 71.3%, respectively. These models are the best predictive tests for the preoperative classification of adnexal tumors. Their intent is to help the specialist make management decisions when faced with a patient with a persistent ovarian mass. The models are simple, are easy to use, and have been validated in multiple reports but not in the United States. We suggest they should be validated and widely introduced into medical practice in the United States.