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Gaillard DHK, Lof P, Sistermans EA, Mokveld T, Horlings HM, Mom CH, Reinders MJT, Amant F, van den Broek D, Wessels LFA, Lok CAR. Evaluating the effectiveness of pre-operative diagnosis of ovarian cancer using minimally invasive liquid biopsies by combining serum human epididymis protein 4 and cell-free DNA in patients with an ovarian mass. Int J Gynecol Cancer 2024; 34:713-721. [PMID: 38388177 DOI: 10.1136/ijgc-2023-005073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE To assess the feasibility of scalable, objective, and minimally invasive liquid biopsy-derived biomarkers such as cell-free DNA copy number profiles, human epididymis protein 4 (HE4), and cancer antigen 125 (CA125) for pre-operative risk assessment of early-stage ovarian cancer in a clinically representative and diagnostically challenging population and to compare the performance of these biomarkers with the Risk of Malignancy Index (RMI). METHODS In this case-control study, we included 100 patients with an ovarian mass clinically suspected to be early-stage ovarian cancer. Of these 100 patients, 50 were confirmed to have a malignant mass (cases) and 50 had a benign mass (controls). Using WisecondorX, an algorithm used extensively in non-invasive prenatal testing, we calculated the benign-calibrated copy number profile abnormality score. This score represents how different a sample is from benign controls based on copy number profiles. We combined this score with HE4 serum concentration to separate cases and controls. RESULTS Combining the benign-calibrated copy number profile abnormality score with HE4, we obtained a model with a significantly higher sensitivity (42% vs 0%; p<0.002) at 99% specificity as compared with the RMI that is currently employed in clinical practice. Investigating performance in subgroups, we observed especially large differences in the advanced stage and non-high-grade serous ovarian cancer groups. CONCLUSION This study demonstrates that cell-free DNA can be successfully employed to perform pre-operative risk of malignancy assessment for ovarian masses; however, results warrant validation in a more extensive clinical study.
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Affiliation(s)
- Duco H K Gaillard
- Division of Molecular Carcinogenesis, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Delft Bioinformatics Lab, Delft University of Technology, Delft, Netherlands
| | - Pien Lof
- Department of Gynecological Oncology, Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
| | - Erik A Sistermans
- Department of Human Genetics, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam UMC Location VUmc, Amsterdam, Netherlands
| | - Tom Mokveld
- Delft Bioinformatics Lab, Delft University of Technology, Delft, Netherlands
| | - Hugo Mark Horlings
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Constantijne H Mom
- Department of Gynecological Oncology, Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
| | - Marcel J T Reinders
- Delft Bioinformatics Lab, Delft University of Technology, Delft, Netherlands
| | - Frédéric Amant
- Department of Gynecological Oncology, Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
- Division of Gynecologic Oncology, UZ Leuven, Leuven, Belgium
| | - Daan van den Broek
- Department of Laboratory Medicine, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Lodewyk F A Wessels
- Division of Molecular Carcinogenesis, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Christianne A R Lok
- Department of Gynecological Oncology, Center for Gynecologic Oncology Amsterdam, Amsterdam, Netherlands
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Kalinowska V, Huang Y, Buckley A, St Clair CM, Pua T, Khoury-Collado F, Hou JY, Hershman DL, Wright JD. Hospital Volume and Quality of Care for Emergency Gynecologic Care. Obstet Gynecol 2024; 143:303-311. [PMID: 38086058 DOI: 10.1097/aog.0000000000005481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/02/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To evaluate the association between hospital volume and the quality of gynecologic emergency care for tubal ectopic pregnancies, ovarian torsion, and pelvic inflammatory disease (PID). METHODS In this cross-sectional analysis, we analyzed patients who presented for emergency care for tubal ectopic pregnancies, ovarian torsion, and PID using the Premier Healthcare Database from 2006 to 2020. We measured the following outcomes: methotrexate use for ectopic pregnancy, ovarian cystectomy for torsion, and guideline-based antibiotic use for PID. For each condition, we measured outlier hospitals that performed the above interventions at below the 10th percentile. Multivariable logistic regression models were used to analyze associations between outlier care and hospital factors such as annualized mean case volume, urban or rural location, teaching status, bed capacity, and geographic region, as well as hospital-level patient population factors, including age, insurance status, and race. RESULTS A total of 602 hospitals treated patients with tubal ectopic pregnancies, of which 21.9% were outliers, with no cases managed with methotrexate. Of 512 hospitals treating patients with ovarian torsion, 17.4% were outliers, with no cases managed with cystectomy. Of 929 hospitals that treated patients with PID, 9.9% were deemed outliers with low rates of guideline-adherent antibiotic administration. Low-volume hospitals were more likely to be outliers with low rates of use of methotrexate for ectopic pregnancy (6.7% of high-volume hospitals vs 49.7% of low-volume hospitals were outliers; adjusted odds ratio [aOR] 0.13, 95% CI, 0.05-0.31 for high-volume hospitals) and cystectomy for torsion (34.9% of low-volume vs 2.4% of high-volume hospitals were outliers; aOR 0.05, 95% CI, 0.01-0.18 for high-volume hospitals). There was no association between hospital volume and lower rates of guideline-based antibiotic use for PID. CONCLUSION Higher hospital volume is associated with use of conservative, fertility-preserving treatment of emergency gynecologic conditions, including ectopic pregnancy and ovarian torsion.
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Affiliation(s)
- Vanessa Kalinowska
- Columbia University College of Physicians and Surgeons, the Joseph L. Mailman School of Public Health, Columbia University, the Herbert Irving Comprehensive Cancer Center, and NewYork-Presbyterian Hospital, New York, New York
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3
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Savoye I, Silversmit G, Bourgeois J, De Gendt C, Leroy R, Peacock HM, Stordeur S, de Sutter P, Goffin F, Luyckx M, Orye G, Van Dam P, Van Gorp T, Verleye L. Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study. Eur J Cancer 2023; 195:113402. [PMID: 37922631 DOI: 10.1016/j.ejca.2023.113402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Isabelle Savoye
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium.
| | | | | | | | - Roos Leroy
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | | | - Sabine Stordeur
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | | | - Frédéric Goffin
- Obstetrics and Gynecology, University of Liege, Liege, Belgium
| | - Mathieu Luyckx
- Service de gynécologie et Andrologie and Institut Roi Albert II, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guy Orye
- Department of Obstetrics and Gynecology, Jessa Hospital, Hasselt, Belgium
| | - Peter Van Dam
- Division of Gynecologic Oncology, Multidisciplinary Oncologic Center, Antwerp University Hospital, Edegem, Belgium
| | - Toon Van Gorp
- University Hospital Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Leen Verleye
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
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4
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Algera MD, Baldewpersad Tewarie NMS, Driel WJV, van Ham MAPC, Slangen BFM, Kruitwagen RFPM, Wouters MWJM. Case-mix adjustment to compare hospital performances regarding complications after cytoreductive surgery for ovarian cancer: a nationwide population-based study. Int J Gynecol Cancer 2022; 33:534-542. [PMID: 36581486 DOI: 10.1136/ijgc-2022-003981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Complication rates after cytoreductive surgery are important quality indicators for hospitals that treat patients with advanced-stage ovarian cancer. Case-mix factors are patient and tumor characteristics that may influence hospital outcomes such as the complication rates. Currently, no case-mix adjustment model exists for complications after cytoreductive surgery; therefore, it is unclear whether hospitals are being compared correctly. This study aims to develop the first case-mix adjustment model for complications after surgery for advanced-stage ovarian cancer, enabling an accurate comparison between hospitals. METHODS This population-based study included all patients undergoing cytoreductive surgery for advanced-stage ovarian cancer registered in the Netherlands in 2017-2019. Case-mix variables were identified and assessed using logistic regressions. The primary outcome was the composite outcome measure 'complicated course'. Patients had a complicated course when at least one of the following criteria were met: (1) any complication combined with a prolonged length of hospital stay; (2) complication requiring reintervention; (3) any complication with a prolonged length of stay in the intensive care unit; or (4) 30-day mortality or in-hospital mortality during admission following surgery. Inter-hospital variation was analyzed using univariable and multivariable logistic regressions and visualized using funnel plots. RESULTS A total of 1822 patients were included, of which 10.7% (n=195) had a complicated course. Comorbidity and tumor stage had a significant impact on complicated course rates in multivariable logistic regression. Inter-hospital variation was not significant for case-mix factors. Complicated course rates ranged between 2.2% and 29.1%, and case-mix adjusted observed/expected ratios ranged from 0.20 to 2.67 between hospitals. Three hospitals performed outside the confidence intervals for complicated course rates. These hospitals remained outliers after case-mix adjustment. CONCLUSION There is variation between hospitals regarding complicated course rates after cytoreductive surgery for ovarian cancer in the Netherlands. While comorbidity and tumor stage significantly affected the complicated course rates, adjusting for case-mix factors did not significantly affect hospital outcomes. The limited impact of case-mix adjustment could be a result of the Dutch centralized healthcare model.
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Affiliation(s)
- Marc Daniël Algera
- Gynecologic Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands .,Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Nishita M S Baldewpersad Tewarie
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Obstetrics and Gynecology, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Brigitte F M Slangen
- Gynecologic Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Roy F P M Kruitwagen
- Gynecologic Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, van Doorn HC, van Beekhuizen HJ. Factors Predicting 30-Day Grade IIIa-V Clavien-Dindo Classification Complications and Delayed Chemotherapy Initiation after Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Prospective Cohort Study. Cancers (Basel) 2022; 14:4181. [PMID: 36077721 PMCID: PMC9454550 DOI: 10.3390/cancers14174181] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: The aim of this study was to evaluate factors associated with 30-day postoperative Clavien−Dindo classification (CDC) grade IIIa or greater complications and delayed initiation of chemotherapy after cytoreductive surgery (CRS) for primary advanced-stage epithelial ovarian cancer (AEOC). Methods: This was a prospective study involving 300 patients who underwent primary or interval CRS for AEOC between February 2018 and September 2020. Postoperative complications were graded according to the CDC. Logistic regression analysis was used to evaluate factors predicting CDC grade ≥IIIa and time to chemotherapy (TTC) >42 days. Results: Interval CRS was performed in 255 (85%) patients. CDC grade ≥IIIa occurred in 51 (17%) patients. In multivariable analysis, age (p = 0.036), cardiovascular comorbidity (p < 0.001), diaphragmatic surgery (p < 0.001), intraoperative urinary tract injury (p = 0.017), and upper-abdominal visceral injury (e.g., pancreas, stomach, liver, or spleen) (p = 0.012) were associated with CDC grade ≥IIIa. In 26% of cases, TTC was >42 days (median (IQR) 39 (29−50) days) in patients with CDC grade ≥IIIa versus 33 (25−41) days in patients without CDC grade ≥ IIIa (p = 0.008). The adjusted odds ratio of developing TTC >42 days was significantly higher in patients associated with WHO performance grade ≥2 (p = 0.045), intraoperative bowel injury (p = 0.043), upper-abdominal visceral injury (p = 0.008), and postoperative CDC grade ≥IIIa (p = 0.032). Conclusions: Patients with advanced age, with cardiovascular comorbidity, and who required diaphragmatic surgery had an increased adjusted odds ratio of developing CDC grade ≥IIIa complications. CDC grade ≥IIIa complications were independently associated with TTC >42 days. Proper patient selection and prevention of intraoperative injury are essential in order to prevent postoperative complications and delayed initiation of chemotherapy.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi 11120, Thailand
| | - Gatske M. Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - Stephen J. Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Helena C. van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Heleen J. van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Lof P, Retèl V, Algera M, van Gent M, Gaarenstroom K, van Driel W. Clinical implementation of routine diagnostic laparoscopy to guide initial treatment in patients with advanced-stage epithelial ovarian cancer in Dutch clinical practice: Evaluation of support and a budget impact analysis. Gynecol Oncol 2022; 165:459-465. [DOI: 10.1016/j.ygyno.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/28/2022]
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7
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Postoperative outcomes of primary and interval cytoreductive surgery for advanced ovarian cancer registered in the Dutch Gynecological Oncology Audit (DGOA). Gynecol Oncol 2021; 162:331-338. [PMID: 34147284 DOI: 10.1016/j.ygyno.2021.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The challenge when performing cytoreductive surgery (CRS) is to balance the benefits and risks. The aim of this study was to report short term postoperative morbidity and mortality in relation to surgical outcome in patients undergoing primary debulking surgery (PDS) or interval debulking (IDS) surgery in the Netherlands. METHODS The Dutch Gynecological Oncology Audit (DGOA) was used for retrospective analysis. Patients undergoing PDS or IDS between January 1st, 2015 - December 31st, 2018 were included. Outcome was frequency of postoperative complications. Median time to adjuvant chemotherapy and severity of complications were related to outcome of CRS. Complications with Clavien-Dindo ≥3 were analyzed per region and case mix corrected. Statistical analysis was performed with R.Studio. RESULTS 1027 patients with PDS and 1355 patients with IDS were included. Complications with re-invention were significantly higher in PDS compared to IDS (5.7% vs. 3.6%, p = 0.048). Complete cytoreduction was 69.7% in PDS and 62.1% IDS, p < 0.001. Time to adjuvant chemotherapy was 49 days in patients with complete CRS and a complication with re-intervention. Regional variation for severe complications showed one region outside confidence intervals. CONCLUSIONS Higher complete cytoreduction rate in the PDS group indicates that the correct patients have been selected, but is associated with a higher percentage of complication with re-intervention. As result, time to start adjuvant chemotherapy is longer in this group. Maintaining a balance in aggressiveness of surgery and outcome of the surgical procedure with respect to severe complications is underlined. Bench marked data should be discussed nationally to improve this balance.
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The Volume-Outcome Paradigm for Gynecologic Surgery: Clinical and Policy Implications. Clin Obstet Gynecol 2021; 63:252-265. [PMID: 31929332 DOI: 10.1097/grf.0000000000000518] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Studies over the past decade have clearly demonstrated an association between high surgeon and hospital volume and improved outcomes for women undergoing gynecologic surgical procedures. In contrast to procedures associated with higher morbidity, the association between higher volume and improved outcomes is often modest for gynecologic surgeries. The lower magnitude of this association has limited actionable policy changes for gynecologic surgery. These data have been driving initiatives such as regionalization of care, targeted quality improvement at low volume centers and volume-based credentialing in gynecology.
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Implementation of National Guidelines increased survival in advanced ovarian cancer - A population-based nationwide SweGCG study. Gynecol Oncol 2021; 161:244-250. [PMID: 33581846 DOI: 10.1016/j.ygyno.2021.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 01/31/2023]
Abstract
AIM The first Swedish National Guidelines for Ovarian Cancer (NGOC) were published in 2012. We aimed to evaluate surgical outcomes and survival in patients with stage IIIC-IV disease, before and after the NGOC implementation. METHOD Women with primary epithelial ovarian cancer, FIGO stage IIIC-IV, registered in the Swedish Quality Registry for Gynecologic Cancer 2008-2011 and 2013-2016 were included. Surgical outcomes were analyzed, including frequency of complete cytoreduction (R0). Relative survival (RS) and excess mortality rate ratios (EMRRs) were computed as measures of survival. Univariable and multivariable regression (Poisson) were calculated. RESULTS In total, 3728 women were identified, 1746 before and 1982 after NGOC. After adjusting for age and stage, survival was improved 2013-2016 vs. 2008-2011 (EMRR 0.89; 95%CI:0.82-0.96, p < 0.05). For women undergoing primary debulking surgery (PDS), R0 frequency (28.9% vs. 53.3%; p < 0.001) and 5-year RS (29.6% (95%CI:26.8-32.8) vs. 37.4% (95%CI:33.6-41.7)) were increased, but fewer patients (58% vs. 44%, p < 0.001) underwent PDS after NGOC implementation. Median survival for the PDS cohort increased from 35 months (95%CI,32.8-39.2) to 43 months (95%CI,40.9-46.4). In the neoadjuvant chemotherapy (NACT) + interval debulking surgery (IDS) cohort, R0 increased (36.8% to 50.1%, p < 0.001), but not 5-year RS (17.5% vs. 20.7%, ns). Compared to PDS, the EMRR was 1.32 (95%CI,1.19-1.47, p < 0.001) for NACT+IDS and 3.00 (95%CI,2.66-3.38, p < 0.001) for chemotherapy alone. In multivariable analyses, PDS, R0, age ≤ 70 years, and stage IIIC were found to be independent factors for improved RS. CONCLUSION Implementation of the first National Guidelines for Ovarian Cancer improved relative survival in advanced ovarian cancer.
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10
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Baldewpersad Tewarie NMS, van Driel WJ, van Ham M, Wouters MW, Kruitwagen R. Clinical auditing as an instrument to improve care for patients with ovarian cancer: The Dutch Gynecological Oncology Audit (DGOA). Eur J Surg Oncol 2021; 47:1691-1697. [PMID: 33581966 DOI: 10.1016/j.ejso.2021.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/18/2021] [Accepted: 01/23/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The Dutch Gynecological Oncology Audit (DGOA) was initiated in 2014 to serve as a nationwide audit, which registers the four most prevalent gynecological malignancies. This study presents the first results of clinical auditing for ovarian cancer in the Netherlands. METHODS The Dutch Gynecological Oncology Audit is facilitated by the Dutch Institute of Clinical Auditing (DICA) and run by a scientific committee. Items are collected through a web-based registration based on a set of predefined quality indicators. Results of quality indicators are shown, and benchmarked information is given back to the user. Data verification was done in 2016. RESULTS Between January 01, 2014 and December 31, 2018, 6535 patients with ovarian cancer were registered. The case ascertainment was 98.3% in 2016. The number of patients with ovarian cancer who start therapy within 28 days decreased over time from 68.7% in 2014 to 62.7% in 2018 (p < 0.001). The percentage of patients with primary cytoreductive surgery decreased over time (57.8%-39.7%, P < 0.001). However, patients with complete primary cytoreductive surgery improved over time (53.5%-69.1%, P < 0.001). Other quality indicators did not significantly change over time. CONCLUSION The Dutch Gynecological Oncology Audit provides valuable data on the quality of care on patients with ovarian cancer in the Netherlands. Data show variation between hospitals with regard to pre-determined quality indicators. Results of 'best practices' will be shared with all participants of the clinical audit with the aim of improving quality of care nationwide.
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Affiliation(s)
- N M S Baldewpersad Tewarie
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, the Netherlands; Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands.
| | - W J van Driel
- Center of Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Department of Gynecology, Amsterdam, the Netherlands
| | - M van Ham
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, the Netherlands
| | - M W Wouters
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands
| | - R Kruitwagen
- Maastricht University Medical Centre (MUMC), Department of Obstetrics and Gynecology, and GROW- School for Oncology and Developmental Biology, Maastricht, the Netherlands
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11
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Increased disease-free and relative survival in advanced ovarian cancer after centralized primary treatment. Gynecol Oncol 2020; 159:409-417. [PMID: 32943206 DOI: 10.1016/j.ygyno.2020.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/04/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To analyze 5-year disease-free survival (DFS) and relative survival (RS) before and after the 2011 implementation of centralized primary treatment of patients with advanced ovarian cancer. METHODS A population-based cohort study using the Swedish Quality Registry for Gynecological Cancer (SQRGC). Women with FIGO stage III and IV epithelial ovarian and Fallopian tube cancers were divided into two cohorts: before and after centralization. We estimated RS using the Ederer II method, analyzed the difference in the excess mortality rate ratio (EMRR) and estimated 5-year DFS in a Cox proportional hazard regression model with centralization, age, primary treatment and complete cytoreduction as variables. RESULTS A total of 495 women were identified with 244 women before (2008-2010) and 251 after (2011-2013) centralization. An increased 5-year RS from 24% (95%CI:19-31) to 37% (95%CI:31-44) and an increased median RS from 27 months (95%CI:23-34) to 44 months (95%CI:40-52), p < 0.001 (log-rank), were observed in the total cohort regardless of primary treatment. EMRR was found to be 0.62 (95%CI:0.51-0.76) in 2011-2013 compared to 2008-2010 for all patients. After centralization, 5-year DFS was significantly longer, hazard ratio of 0.77 (95%CI:0.64-0.93) and centralization was found to be an independent significant factor for both survival and DFS. Complete cytoreduction was found to be a significant independent factor associated with increased RS and DFS. CONCLUSION Centralization of primary treatment of advanced ovarian cancer was associated with significantly increased complete cytoreduction, 5-year RS and DFS, and was found to be a significant independent factor for both RS and DFS.
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Brunekreeft KL, Paijens ST, Wouters MC, Komdeur FL, Eggink FA, Lubbers JM, Workel HH, Van Der Slikke EC, Pröpper NE, Leffers N, Adam J, Pijper H, Plat A, Kol A, Nijman HW, De Bruyn M. Deep immune profiling of ovarian tumors identifies minimal MHC-I expression after neoadjuvant chemotherapy as negatively associated with T-cell-dependent outcome. Oncoimmunology 2020; 9:1760705. [PMID: 32923120 PMCID: PMC7458665 DOI: 10.1080/2162402x.2020.1760705] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
Epithelial Ovarian cancer (EOC) is the most lethal gynecological malignancy and has limited curative therapeutic options. Immunotherapy for EOC is promising, but clinical efficacy remains restricted to a small percentage of patients. Several lines of evidence suggest that the low response rate might be improved by combining immunotherapy with carboplatin and paclitaxel, the standard-of-care chemotherapy for EOC. Here, we assessed the immune contexture of EOC tumors, draining lymph nodes, and peripheral blood mononuclear cells during carboplatin/paclitaxel chemotherapy. We observed that the immune contexture of EOC patients is defined by the tissue of origin, independent of exposure to chemotherapy. Summarized, draining lymph nodes were characterized by a quiescent microenvironment composed of mostly non-proliferating naïve CD4 + T cells. Circulating T cells shared phenotypic features of both lymph nodes and tumor-infiltrating immune cells. Immunologically 'hot' ovarian tumors were characterized by ICOS, GITR, and PD-1 expression on CD4 + and CD8 + cells, independent of chemotherapy. The presence of PD-1 + cells in tumors prior to, but not after, chemotherapy was associated with disease-specific survival (DSS). Accordingly, we observed high MHC-I expression in tumors prior to chemotherapy, but minimal MHC-I expression in tumors after neoadjuvant chemotherapy, even though there were no differences in the number of tumor-infiltrating lymphocytes (TIL) in both groups. We therefore speculate that the TIL influx into the chemotherapy tumor microenvironment may be a consequence of the general inflammatory nature of chemotherapy-experienced tumors. Strategies to upregulate MHC-I during or after neoadjuvant chemotherapy may thus improve treatment outcome in these patients.
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Affiliation(s)
- Kim L. Brunekreeft
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Sterre T. Paijens
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | | | - Fenne L. Komdeur
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Florine A. Eggink
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Joyce M. Lubbers
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Hagma H. Workel
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Elisabeth C. Van Der Slikke
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Noor E.J. Pröpper
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Ninke Leffers
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Julien Adam
- Department of Clinical Biology, Institut De Cancérologie Gustave Roussy, Paris, France
| | - Harry Pijper
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Annechien Plat
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Arjan Kol
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Hans W. Nijman
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Marco De Bruyn
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, The Netherlands
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Zijlstra M, Timmermans M, Fransen H, van der Aa M, Reyners A, Raijmakers N, van de Poll-Franse L. Treatment patterns and associated factors in patients with advanced epithelial ovarian cancer: a population-based study. Int J Gynecol Cancer 2020; 29:1032-1037. [PMID: 31263022 DOI: 10.1136/ijgc-2019-000489] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/02/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES A significant proportion of women with advanced-stage ovarian cancer receive no cancer-directed treatment and limited research has been devoted to this group. This population-based study aimed to gain insight into treatment patterns and trends in patients with advanced epithelial ovarian cancer in the Netherlands and the main reasons for deciding for no cancer-directed treatment. METHODS All patients diagnosed with advanced epithelial ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) classification IIB-IV, between 2008 and 2016 were identified from the Netherlands Cancer Registry. Trends in the number of patients receiving cancer-directed treatment were analyzed. Multivariable logistic regression analysis was used to identify factors associated with no cancer-directed treatment. The main reasons for no cancer-directed treatment were analyzed. RESULTS A total of 9303 patients were included, of whom 14% (n=1270) received no cancer-directed treatment while 67% (n=6218) received a combination of cytoreductive surgery and chemotherapy. Some 15% (n=1399) received chemotherapy only, and 4.5% (n=416) surgical resection or hormonal therapy only. The proportion of patients receiving no cancer-directed treatment was higher in 2014-2016 (16%, n=496/3175) compared with 2008-2010 (11%, n=349/3057, p<0.001). Associated factors with no cancer-directed treatment were higher age, FIGO stage IV, lower socioeconomic status, co-morbidity, and more recent years of diagnosis (p<0.001). Main reasons for no cancer-directed treatment were patient's choice (40%) and poor condition of the patient (29%). CONCLUSIONS The proportion of patients with advanced epithelial ovarian cancer not receiving cancer-directed treatment has increased in the last decade in the Netherlands. Patient's choice was the main reason for the decision to undergo no cancer-directed treatment, which indicates patient involvement in the decision-making process. The second most common reason for no cancer-directed treatment was poor condition of the patient, which might indicate careful selection of patients for treatment. Decision-making regarding treatment is well-considered, but more insight is needed, especially from the patient's perspective.
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Affiliation(s)
- Myrte Zijlstra
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Medical Oncology, Maxima Medical Centre, Eindhoven, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Maite Timmermans
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Gynaecology, Haga Hospital, The Hague, The Netherlands
| | - Heidi Fransen
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Maaike van der Aa
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - An Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Natasja Raijmakers
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Netherlands Association for Palliative Care (PZNL), Utrecht, The Netherlands
| | - Lonneke van de Poll-Franse
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,CoRPS- Center of Research on Psychology in Somatic diseases, Department of Medicaland Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Elzakkers JCJ, van der Aa MA, van Altena AM, de Hullu JA, Harmsen MG. Further insights into the role of tumour characteristics in survival of young women with epithelial ovarian cancer. Gynecol Oncol 2019; 155:213-219. [PMID: 31477282 DOI: 10.1016/j.ygyno.2019.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Optimizing the counselling of women ≤40years with epithelial ovarian cancer (EOC) by investigating the role of young age and tumour characteristics on overall survival (OS). METHODS A retrospective population-based study was done using data of EOC patients diagnosed between 1990 and 2014 registered in the Netherlands Cancer Registry. Descriptive statistics were performed to analyse clinical and tumour characteristics. Five- and 10-year OS rates were calculated using Kaplan Meier curves. To determine prognostic factors, univariable and multivariable survival analyses were performed. RESULTS 1407 women ≤40years and 29,022 women >40years old were included. OS was higher for the younger women compared to older group (5-year survival of 65.6% vs. 32.7%, 10-year survival of 57.5% vs. 22.5%, respectively). The younger women had more often a mucinous (36.4%), well-differentiated (31.8%) tumour in early stage of disease (49.9%). Serous tumours (43.0%), high-grade (36.0%) and stage III (47.1%) were most frequently found in the older women. Histology, grade, stage, incidence year, and age group are independent prognostic factors for survival. OS of the young women for several combinations of tumour characteristics were calculated. CONCLUSIONS Age is an independent prognostic factor for OS in EOC patients. Counselling on prognosis could be more individualised in young EOC patients using the tumour characteristics histology, stage and grade.
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Affiliation(s)
- J C J Elzakkers
- Radboud university medical center, Dept. of Obstetrics and Gynaecology, 791, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - M A van der Aa
- Integraal kankercentrum Nederland, PO Box 19079, 3501, DB, Utrecht, the Netherlands
| | - A M van Altena
- Radboud university medical center, Dept. of Obstetrics and Gynaecology, 791, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - J A de Hullu
- Radboud university medical center, Dept. of Obstetrics and Gynaecology, 791, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - M G Harmsen
- Radboud university medical center, Dept. of Obstetrics and Gynaecology, 791, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
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15
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Regionalization of care for women with ovarian cancer. Gynecol Oncol 2019; 154:394-400. [DOI: 10.1016/j.ygyno.2019.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 11/24/2022]
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16
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Timmermans M, Sonke GS, Slangen BFM, Baalbergen A, Bekkers RLM, Fons G, Gerestein CG, Kruse AJ, Roes EM, Zusterzeel PLM, Van de Vijver KK, Kruitwagen RFPM, van der Aa MA. Outcome of surgery in advanced ovarian cancer varies between geographical regions; opportunities for improvement in The Netherlands. Eur J Surg Oncol 2019; 45:1425-1431. [PMID: 31027945 DOI: 10.1016/j.ejso.2019.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/29/2019] [Accepted: 04/09/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The care for patients with epithelial ovarian cancer(EOC) is organised in eight different geographical regions in the Netherlands. This situation allows us to study differences in practice patterns and outcomes between geographical regions for patients with FIGO stage IIIC and IV. METHODS We identified all EOC patients who were diagnosed with FIGO stage IIIC or IV between 01.01.2008 and 31.12.2015 from the Netherlands Cancer Registry. Descriptive statistics were used to summarize treatment and treatment sequence(primary cytoreductive surgery(PCS) or neoadjuvant chemotherapy and interval cytoreductive surgery(NACT-ICS)). Moreover, outcome of surgery was compared between geographical regions. Multilevel logistic regression was used to assess whether existing variation is explained by geographical region and case-mix factors. RESULTS Overall, 6,741 patients were diagnosed with FIGO IIIC or IV disease. There were no differences in the percentage of patients that received any form of treatment between the geographical regions(range 80-86%, P = 0.162). In patients that received cytoreductive surgery and chemotherapy, a significant variation between the geographical regions was observed in the use of PCS and NACT-ICS(PCS: 24-48%, P < 0.001). The percentage of complete cytoreductive surgeries after PCS ranged from 10 to 59%(P < 0.001) and after NACT-ICS from 37 to 70%(P < 0.001). Moreover, geographical region was independently associated with the outcome of surgery, also when adjusted for treatment sequence(P < 0.001). CONCLUSION We observed a significant variation in treatment approach for advanced EOC between geographical regions in the Netherlands. Furthermore, the probability to achieve no residual disease differed significantly between regions, regardless of treatment sequence. This may suggest that surgical outcomes can be improved across geographical regions.
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Affiliation(s)
- M Timmermans
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht, the Netherlands.
| | - G S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - B F M Slangen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - A Baalbergen
- Department of Obstetrics and Gynaecology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - R L M Bekkers
- Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, the Netherlands
| | - G Fons
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - C G Gerestein
- Department of Obstetrics and Gynaecology, Meander Medical Centre, Amersfoort, the Netherlands
| | - A J Kruse
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht, the Netherlands; Department of Obstetrics and Gynaecology, Isala Hospital, Zwolle, the Netherlands
| | - E M Roes
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - P L M Zusterzeel
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - K K Van de Vijver
- Department of Pathology, Ghent University Hospital, Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - R F P M Kruitwagen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - M A van der Aa
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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Reade CJ, Elit LM. Current Quality of Gynecologic Cancer Care in North America. Obstet Gynecol Clin North Am 2019; 46:1-17. [PMID: 30683257 DOI: 10.1016/j.ogc.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Evaluating the quality of care received by gynecologic cancer patients in the real world is essential for excellent outcomes. The recent population-based literature looking at quality of care was reviewed for all gynecologic malignancies. Outcomes are generally highest when care is provided by high-volume providers in high-volume cancer centers. Provision of care according to clinical practice guidelines has also been demonstrated to improve outcomes in many situations. Disparities exist for marginalized groups in terms of the care they receive and subsequent outcomes. Health systems need to improve care for these populations.
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Affiliation(s)
- Clare J Reade
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Juravinski Cancer Centre, 699 Concession Street, Hamilton, Ontario L8V 5C2, Canada
| | - Laurie M Elit
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Juravinski Cancer Centre, 699 Concession Street, Hamilton, Ontario L8V 5C2, Canada.
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Optimization of surgical treatment of advanced ovarian cancer: a Spanish expert perspective. Clin Transl Oncol 2018; 21:656-664. [PMID: 30377941 DOI: 10.1007/s12094-018-1967-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/13/2018] [Indexed: 10/28/2022]
Abstract
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.
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Is Nighttime Really Not the Right Time for a Laparoscopic Cholecystectomy? Can J Gastroenterol Hepatol 2018; 2018:6076948. [PMID: 30151356 PMCID: PMC6087598 DOI: 10.1155/2018/6076948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/10/2018] [Accepted: 07/24/2018] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The impact of an out-of-hours laparoscopic cholecystectomy on outcome is controversial. We sought to determine the association between an out-of-hours procedure and postoperative complications within 90 days. METHODS Between 2014 and 2016, 1553 laparoscopic cholecystectomies were performed. Therapeutic, operative, and outcome data were prospectively collected and analyzed. We defined out of hours as during weekends, national holidays, and daily between 5PM and 8AM. RESULTS Most patients operated on were female (n=988; 63.6%) and the majority of procedures were electives (n=1341; 86.3%). Although all procedures were performed with a laparoscopic intent, 42 (2.7%) were converted to open procedure. In total, 145 (9.3%) procedures were out of hours, all nonelective, and in most cases for acute cholecystitis (n=111; 7.1%). Overall, there were 212 complications in 191 patients (12.3%), most (n=153; 9.9%) classified as minor. The conversion rate in the out-of-hours group was significantly higher (9.7% vs 2.0%; p<0.001). While univariate analyses revealed out-of-hours procedure (OR=1.83; p=0.008) to be associated with an increased risk of complications, when controlling for confounding factors by multivariate analysis, this association was not found. However, operation by surgical staff (OR=1.71) and conversion to laparotomy (OR=3.74) were found to be independently associated with an increased risk of complications (both p<0.05), while an emergency procedure tended to be associated with postoperative morbidity (OR=1.82; p=0.069). CONCLUSION An out-of-hours laparoscopic cholecystectomy was not found to be an independent risk factor for developing postoperative morbidity and time of day should therefore only be a relative contraindication.
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Neoadjuvant chemotherapy or primary debulking surgery in FIGO IIIC and IV patients; results from a survey study in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2018. [PMID: 29525755 DOI: 10.1016/j.ejogrb.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Primary debulking surgery (PDS) followed by adjuvant chemotherapy is historically recommended as first line treatment for advanced stage ovarian cancer. Two randomized controlled trials, however, showed similar efficacy and reduced toxicity with neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS). Nevertheless, uptake of NACT-IDS varies widely between hospitals, which cannot be explained by difference in patient populations. In this survey, we therefore aimed to evaluate the views on NACT-IDS among all Dutch gynaecologists and medical oncologists involved in the treatment of ovarian cancer. STUDY DESIGN An e-mail link to the online questionnaire was sent to all medical oncologists and gynaecologists in the Netherlands, regardless of their (sub)specializations. The data was analysed using descriptive statistics and chi-square tests were used to analyse differences between groups. RESULTS Three-hundred-forty physicians were invited to fill out the questionnaire. After two reminders, 167 of them responded (49%). Among the responders, 82% of the gynaecologists versus 93% of the medical oncologists considered the available evidence sufficiently convincing to treat advanced stage ovarian cancer patients with NACT-IDS (p = 0.076). Moreover, 33% of gynaecologists and 62% of medical oncologists preferred NACT-IDS to PDS as first line treatment (p = 0.001). While most responders (86%) indicated that selecting the right patients for NACT-IDS is difficult, those with bulky disease, FIGO stage IV or metastases near the porta hepatica were most likely to undergo NACT-IDS. CONCLUSION The majority of Dutch gynaecologists and medical oncologists adopted NACT-IDS as an alternative treatment approach for advanced stage primary ovarian cancer. About two-thirds of medical oncologists and one-third of gynaecologists prefer NACT-IDS to PDS as first line treatment in this setting. Improving patient selection is considered of paramount importance.
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Mesman R, Faber MJ, Berden BJ, Westert GP. Evaluation of minimum volume standards for surgery in the Netherlands (2003–2017): A successful policy? Health Policy 2017; 121:1263-1273. [DOI: 10.1016/j.healthpol.2017.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 01/29/2023]
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Timmermans M, Sonke GS, Van de Vijver KK, van der Aa MA, Kruitwagen RFPM. No improvement in long-term survival for epithelial ovarian cancer patients: A population-based study between 1989 and 2014 in the Netherlands. Eur J Cancer 2017; 88:31-37. [PMID: 29179135 DOI: 10.1016/j.ejca.2017.10.030] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/20/2017] [Accepted: 10/28/2017] [Indexed: 12/30/2022]
Abstract
AIM This study investigates changes in therapy and long-term survival for patients with epithelial ovarian cancer (EOC) in the Netherlands. METHODS All patients with EOC, including peritoneal and fallopian tube carcinoma, diagnosed in the Netherlands between 1989 and 2014 were selected from the Netherlands Cancer Registry. Changes in therapy were studied and related to overall survival (OS) using multivariable Cox regression models. RESULTS A total of 32,540 patients were diagnosed with EOC of whom 22,047 (68%) had advanced stage disease. In early stage, lymph node dissection as part of surgical staging procedures increased over time from 4% in 1989-1993 to 62% in 2009-2014 (P < 0.001). In advanced stage, the number of patients receiving optimal treatment with surgery and chemotherapy increased from 55% in 1989-1993 to 67% in 2009-2014 (P < 0.001). Five-year survival rates improved in both early stage (74% versus 79%) and advanced stage (16% versus 24%) as well as in all patients combined (31% versus 34%). Ten-year survival rates, however, slightly improved in early stage (62% versus 67%) and advanced stage (10% versus 13%) but remained essentially unchanged at 24% for all patients combined. CONCLUSION Despite intensified treatment and staging procedures, long-term survival for women with EOC has not improved in the last 25 years. The observed improvements in 5-year OS reflect a more prolonged disease control rather than better chances for cure. Furthermore, the apparent better long-term outcome, when early and advanced stage patients are analysed separately, is largely due to improved staging procedures and the ensuing stage migration. These effects disappear in a combined analysis of all patients.
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Affiliation(s)
- M Timmermans
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands; GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - G S Sonke
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - K K Van de Vijver
- Divisions of Diagnostic Oncology and Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M A van der Aa
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - R F P M Kruitwagen
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Centralization of ovarian cancer in the Netherlands: Hospital of diagnosis no longer determines patients' probability of undergoing surgery. Gynecol Oncol 2017; 148:56-61. [PMID: 29129391 DOI: 10.1016/j.ygyno.2017.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/23/2017] [Accepted: 11/04/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Surgical care for advanced stage epithelial ovarian cancer (EOC) patients has been centralized in the Netherlands since 2012. We evaluated whether the likelihood for patients to undergo surgery depends on the hospital of initial diagnosis before and after centralization of surgical care. METHODS Patients with EOC FIGO stage IIB-IV, diagnosed in the Netherlands between 2000 and 2015, were identified from the Netherlands Cancer Registry. Multilevel multivariate logistic regression was used to study the association between hospital of diagnosis and patients' likelihood of undergoing surgery in subsequent time periods. Furthermore, changes in overall survival were analyzed by multivariable Cox regression models. RESULTS 15,314 EOC patients were selected from the NCR. Hospital of diagnosis was identified as a significant level for patients' likelihood of undergoing surgery in 2000-2005 (LR test p<0.001), as well as in 2006-2011 (LR test p=0.002) but not in 2012-2015 (LR test p=0.127). Patients who underwent surgery in 2012-2015 had a better survival when compared to 2006-2011 (HR 0.90(0.84-0.96)). CONCLUSION This study shows that centralization of surgical care resolved the variation between hospitals in the probability to undergo cytoreductive surgery for patients with advanced EOC. Since centralization was established in 2012, the decision to operate patients seems solely attributable to patient and tumor characteristics. This supports the growing evidence in favor of centralizing (surgical) treatment for complex and heterogeneous diseases such as EOC.
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Surgery for patients with newly diagnosed advanced ovarian cancer: which patient, when and extent? Curr Opin Oncol 2017; 29:351-358. [PMID: 28614136 DOI: 10.1097/cco.0000000000000387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Cytoreduction to no residual disease is the mainstay of primary treatment for advanced epithelial ovarian cancer (AdvEOC). This review addresses recent insights on optimal patient selection, timing, and extent of surgery, intended to optimize cytoreduction in patients with AdvEOC. RECENT FINDINGS Clinical guidelines recommend primary cytoreductive surgery (PCS) for AdvEOC patients with a high likelihood of achieving complete cytoreduction with acceptable morbidity. In line with this, preoperative prediction markers such as cancer antigen-125, histologic and genomic factors, innovative imaging modalities, and the performance of a diagnostic laparoscopy have been suggested to improve clinical decision-making with regard to optimal timing of cytoreductive surgery. To determine whether these strategies should be incorporated into clinical practice validation in randomized clinical trials is essential. SUMMARY The past decade has seen a paradigm shift in the number of AvdEOC patients that are being treated with upfront neoadjuvant chemotherapy instead of PCS. However, although neoadjuvant chemotherapy may reduce morbidity at the time of interval cytoreductive surgery, no favorable impact on survival has been demonstrated and it may induce resistance to chemotherapy. Therefore, optimizing patient selection for PCS is crucial. Furthermore, surgical innovations in patients diagnosed with AvdEOC should focus on improving survival outcomes.
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Abstract
OBJECTIVE To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer. METHODS We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01-5, 5.01-9, 9.01-19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics. RESULTS A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5-66.4%) at low-volume to 77.4% (95% CI 77.0-77.8%) at high-volume centers and from 66.5% (95% CI 65.5-67.5%) at low-quality to 77.3% (95% CI 76.8-77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4-64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2-70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals. CONCLUSION Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.
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Barber EL, Dusetzina SB, Stitzenberg KB, Rossi EC, Gehrig PA, Boggess JF, Garrett JM. Variation in neoadjuvant chemotherapy utilization for epithelial ovarian cancer at high volume hospitals in the United States and associated survival. Gynecol Oncol 2017; 145:500-507. [PMID: 28366545 PMCID: PMC5503107 DOI: 10.1016/j.ygyno.2017.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. METHODS We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (>20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. RESULTS We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n=2494) of patients and use varied widely by hospital, from 5%-55%. High utilization hospitals (n=1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23-55%), while low utilization hospitals (n=2671, 14 hospitals) had a median rate of 10% (range 5-17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83-0.97 and HR 0.85 95% CI 0.75-0.95). CONCLUSIONS Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.
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Affiliation(s)
- Emma L Barber
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States.
| | - Stacie B Dusetzina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Karyn B Stitzenberg
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, NC, United States
| | - Emma C Rossi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Paola A Gehrig
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - John F Boggess
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Joanne M Garrett
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
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Alcázar JL. Ultrasound-based IOTA simple rules allow accurate malignancy risk estimation for adnexal masses. ACTA ACUST UNITED AC 2016; 21:197. [PMID: 27506445 DOI: 10.1136/ebmed-2016-110459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Juan Luis Alcázar
- Department of Obstetrics and Gynecology, University of Navarre, Pamplona, Spain
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