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Algera MD, van Driel WJ, Slangen BFM, Wouters MWJM, Kruitwagen RFPM. Effect of surgical volume on short-term outcomes of cytoreductive surgery for advanced-stage ovarian cancer: A population-based study from the Dutch Gynecological Oncology Audit. Gynecol Oncol 2024; 186:144-153. [PMID: 38688188 DOI: 10.1016/j.ygyno.2024.04.002] [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: 12/19/2023] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted. METHODS This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes. RESULTS A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment. CONCLUSIONS Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.
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Affiliation(s)
- M D Algera
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands.
| | - W J van Driel
- Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Department of Gynecology, Amsterdam, the Netherlands
| | - B F M Slangen
- Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands
| | - M W J M Wouters
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - R F P M Kruitwagen
- Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands
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Weeks KS, Lynch CF, West MM, Carnahan RM, O'Rorke MA, Oleson JJ, McDonald ME, Charlton ME. Impact of Surgeon Type and Rurality on Treatment and Survival of Ovarian Cancer Patients. Am J Clin Oncol 2021; 44:544-551. [PMID: 34342289 PMCID: PMC8801132 DOI: 10.1097/coc.0000000000000860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Kristin S Weeks
- Carver College of Medicine
- Department of Epidemiology, College of Public Health, University of Iowa
| | - Charles F Lynch
- Department of Epidemiology, College of Public Health, University of Iowa
- Iowa Cancer Registry, State Health Registry of Iowa
| | | | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa
| | - Michael A O'Rorke
- Department of Epidemiology, College of Public Health, University of Iowa
| | - Jacob J Oleson
- Department of Biostatistics, College of Public Health, University of Iowa
| | - Megan E McDonald
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mary E Charlton
- Department of Epidemiology, College of Public Health, University of Iowa
- Iowa Cancer Registry, State Health Registry of Iowa
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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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Alejandra M, Gertych W, Pomel C, Ferron G, Lusque A, Angeles MA, Lambaudie E, Rouzier R, Bakrin N, Golfier F, Glehen O, Canis M, Bourdel N, Pouget N, Colombo PE, Guyon F, Meurette J, Querleu D. Adherence to French and ESGO Quality Indicators in Ovarian Cancer Surgery: An Ad-Hoc Analysis from the Prospective Multicentric CURSOC Study. Cancers (Basel) 2021; 13:cancers13071593. [PMID: 33808284 PMCID: PMC8037412 DOI: 10.3390/cancers13071593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/18/2021] [Accepted: 03/25/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Quality Indicators for ovarian cancer (OC) have been developed by the European Society of Gynaecological Oncology (ESGO) and by the French National Cancer Institute (Institut National du Cancer, INCa). The aim of the study was to characterize OC care distribution in France by case-volume and to prospectively evaluate the adherence of high-volume institutions to INCa/ESGO quality indicators. METHODS The cost-utility of radical surgery in ovarian cancer (CURSOC) trial is a prospective, multicenter, comparative and non-randomized study that includes patients with stage IIIC-IV epithelial OC treated in nine French health care tertiary institutions. Adherence to institutional quality indicators were anonymously assessed by an independent committee. OC care distribution in France were provided by the nationwide database of hospital procedures. RESULTS More than half of patients are treated in low-volume institutions. Among the nine high-volume centers participating in the study, four (44.4%) met all institutional INCa/ESGO quality indicators. The other five (55.6%) did not fulfil one of the quality indicator criteria. CONCLUSIONS Access to high-volume OC providers in France is restricted to a minority of patients, and yet half of the referral institutions included in this study failed to meet all recommended institutional quality indicators. It is mandatory that national authorities work both to improve OC centralization and to incorporate quality assurance programs into certified centers.
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Affiliation(s)
- Martinez Alejandra
- Surgical Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer—Toulouse Oncopole, 59500 Toulouse, France; (G.F.); (M.A.A.)
- Cancer Research Center of Toulouse (CRCT), INSERM UMR 1037, 31037 Toulouse, France
- Correspondence:
| | - Witold Gertych
- Obstetrics and Gynecology Department, University Hospital Lyon Sud, 69008 Lyon, France; (W.G.); (F.G.)
| | - Christophe Pomel
- Surgical Oncology Department, Centre Jean Perrin, 63000 Clermont Ferrand, France;
| | - Gwenael Ferron
- Surgical Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer—Toulouse Oncopole, 59500 Toulouse, France; (G.F.); (M.A.A.)
- Cancer Research Center of Toulouse (CRCT), INSERM UMR 1037, 31037 Toulouse, France
| | - Amelie Lusque
- Biostatistics Department, Institut Claudius Regaud, Institut Universitaire du Cancer—Toulouse Oncopole, 59500 Toulouse, France;
| | - Martina Aida Angeles
- Surgical Oncology Department, Institut Claudius Regaud, Institut Universitaire du Cancer—Toulouse Oncopole, 59500 Toulouse, France; (G.F.); (M.A.A.)
| | - Eric Lambaudie
- Surgical Oncology Department, Institut Paoli Calmettes, 13009 Marseille, France;
| | - Roman Rouzier
- Surgical Oncology Department, Institut Curie, 75248 Paris, France; (R.R.); (N.P.)
| | - Naoual Bakrin
- Visceral and Digestive Surgery, University Hospital of Lyon Sud, 69008 Lyon, France; (N.B.); (O.G.)
| | - Francois Golfier
- Obstetrics and Gynecology Department, University Hospital Lyon Sud, 69008 Lyon, France; (W.G.); (F.G.)
| | - Olivier Glehen
- Visceral and Digestive Surgery, University Hospital of Lyon Sud, 69008 Lyon, France; (N.B.); (O.G.)
| | - Michel Canis
- Obstetrics and Gynecology, University Hospital Clermont Ferrand, 63000 Clermont Ferrand, France; (M.C.); (N.B.)
| | - Nicolas Bourdel
- Obstetrics and Gynecology, University Hospital Clermont Ferrand, 63000 Clermont Ferrand, France; (M.C.); (N.B.)
| | - Nicolas Pouget
- Surgical Oncology Department, Institut Curie, 75248 Paris, France; (R.R.); (N.P.)
| | | | - Frédéric Guyon
- Surgical Oncology, Institut Bergonié, 33000 Bordeaux, France;
| | | | - Denis Querleu
- Department of Gynecologic Oncology, Agostino Gemelli University Hospital, 00168 Rome, Italy;
- Department of Obstetrics and Gynecology, University Hospital of Strasbourg, 67091 Strasbourg, France
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Knisely A, Huang Y, Melamed A, Tergas AI, St. Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel. Am J Obstet Gynecol 2020; 222:58.e1-58.e10. [PMID: 31344350 DOI: 10.1016/j.ajog.2019.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/10/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.
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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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White KM, Seale H, Harrison R. Enhancing ovarian cancer care: a systematic review of guideline adherence and clinical variation. BMC Public Health 2019; 19:296. [PMID: 30866891 PMCID: PMC6416902 DOI: 10.1186/s12889-019-6633-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/06/2019] [Indexed: 12/21/2022] Open
Abstract
Background Clinical variation in ovarian cancer care has been reported internationally. Using Wennberg’s classification of clinical variation as effective care we can conceptualise variation through deviation from clinical guidelines. The aim of this review was to address knowledge gaps in the effectiveness of attempts to reduce unwarranted clinical variation through addressing the following questions: What is the evidence of guideline adherence in ovarian cancer and its deviation?; what are the key factors associated with variation in guideline adherence in ovarian cancer care?; and what quality improvement approaches have been used and what is the evidence of their effectiveness in enhancing guideline adherence in ovarian cancer care?. Methods Keywords and synonyms for the major concepts of ovarian cancer, guideline adherence and safety were developed and combined to form the search strategy. Systematic searches of four electronic databases were undertaken of publications from January 2007 to November 2018. Retrieved articles were assessed against the eligibility criteria to determine those for inclusion. Results Thirty-two papers were included in the review with three broad groupings identified: adherence to and deviation from guidelines (either local, national or international guidelines); factors impacting guidelines adherence; and quality improvement approaches. Conclusions Unwarranted clinical variation may be used as a marker for the effectiveness of a health system, based on the outcome of this systematic review. This review found that the implementation of quality indicators through a formal quality improvement program lead to improvements in guideline adherent care. Further research on outcomes of implementing quality improvement programs in ovarian cancer care will improve the ability to implement centralised care and further identify factors that to improve outcomes in ovarian cancer care. Electronic supplementary material The online version of this article (10.1186/s12889-019-6633-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kahren M White
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia. .,Cancer Institute NSW, PO Box 41, Alexandria, NSW, 1435, Australia.
| | - Holly Seale
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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Abstract
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.
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Affiliation(s)
- Stephanie Lumpkin
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA.
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Saif MW, Heaton A, Lilischkis K, Garner J, Brown DM. Pharmacology and toxicology of the novel investigational agent Cantrixil (TRX-E-002-1). Cancer Chemother Pharmacol 2016; 79:303-314. [PMID: 28013349 PMCID: PMC5306062 DOI: 10.1007/s00280-016-3224-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/12/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Recurrent, chemo-resistant ovarian cancer is thought to be due to a subgroup of slow-growing, drug-resistant cancer cells with stem-like properties and a high capacity for tumour repair. Cantrixil targets this sub-population of cells and is being developed as an intraperitoneal therapy to be used as first-line therapy in combination with carboplatin for epithelial ovarian cancer. The studies presented here justify further development. METHODS A GLP dog CV study using a 4 × 4 Latin Square Crossover study was conducted using telemetric ECG recordings from dogs post IP administration to assess for cardiac abnormalities. Mutagenic potential was assessed using the bacterial reverse mutation assay. Clastogenicity was assessed by determining micronuclei formation in the bone marrow of SPF Arc(S) Swiss mice dosed at clinical concentrations. TRX-E-002-1 toxicology was evaluated in GLP-compliant MTD and 28-day repeat-dose studies in rats and dogs. RESULTS In vitro TRX-E-002-1 has potent cytotoxic activity against human cancer cells including CD44+/MyD88+ ovarian cancer stem cells. TRX-E-002-1 increased phosphorylated c-Jun levels in these cancer cells resulting in caspase-mediated apoptosis. In vivo, Cantrixil was active in a model of disseminated ovarian cancer as a monotherapy and in combination with Cisplatin. Cantrixil was active as maintenance therapy in a model of drug-resistant, recurrent ovarian cancer and in an orthotopic model of pancreatic cancer. CONCLUSIONS In animals, this clinical formulation and route of administration of Cantrixil demonstrated acceptable activity, safety pharmacology, genotoxicity and toxicology profile and constituted a successful Investigational New Drug application to the US Food and Drug Administration.
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Affiliation(s)
- Muhammad Wasif Saif
- Department of Medicine and Cancer Center, Tufts Medical Center, 800 Washington Street, Box 245, Boston, MA, 02111, USA.
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Doll KM, Meng K, Gehrig PA, Brewster WR, Meyer AM. Referral patterns between high- and low-volume centers and associations with uterine cancer treatment and survival: a population-based study of Medicare, Medicaid, and privately insured women. Am J Obstet Gynecol 2016; 215:447.e1-447.e13. [PMID: 27130238 PMCID: PMC5045768 DOI: 10.1016/j.ajog.2016.04.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/03/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND High-volume center surgery and gynecologic oncology care are associated with improved outcomes for women with uterine cancer. Referral patterns, from biopsy through to chemotherapy, may have patients interacting with high-volume centers for all, a portion, or none of their care. The relative frequency, the underlying factors that contribute to referral, and the potential impact of these referral patterns on treatment outcomes are unknown. OBJECTIVE We sought to analyze the referral patterns and subsequent impact of care sites on treatment for women with high- and low-risk uterine cancer. STUDY DESIGN This is a population-based retrospective cohort study of uterine cancer cases from 2004 through 2009 in North Carolina. Using state cancer registry files linked to Medicare, Medicaid, and private payer insurance claims, we analyzed referral and treatment patterns by annual surgical volume (high ≥12/y). We examined clinical and demographic factors associated with referral and used modified Poisson regression to evaluate risk of referral, lymphadenectomy, and chemotherapy. Stratified Kaplan-Meier plots and Cox proportional hazard models were used to examine survival. RESULTS A total of 2053 women were analyzed, including 34% (n = 677) with grade 3 histology. Of 1630 (80%) women with preoperative biopsies, referral patterns (biopsy to surgery) were: low volume to high volume (n = 652, 40%), followed by high volume to high volume (n = 605, 37%), then low volume to low volume (n = 318, 20%), and the rare high volume to low volume (n = 50, 3%). Women retained in low-volume centers after biopsy were older, were less likely to have private insurance, and had more comorbidities. High-risk histology (aRR, 1.14; 95% confidence interval, 1.04-1.25) was positively associated with referral, while Medicaid insurance was negatively associated with referral (aRR, 0.64; 95% confidence interval, 0.42-0.96). Most women (74%, n = 1557) had surgery at high-volume centers. Lymphadenectomy was less likely at low-volume centers (aRR, 0.71; 95% confidence interval, 0.64-0.77). Similarly, for high-risk patients, the relationship between low-volume center surgery and subsequent chemotherapy was aRR, 0.71 (95% confidence interval, 0.48-1.02). Of 290 women who received chemotherapy, the referral patterns (surgery to chemotherapy) were: high volume-all (high volume to high volume), high volume-hybrid (high volume to low volume, or low volume to high volume), and high volume-none (low volume to low volume). In all, 36% (n = 104/290) received chemotherapy at a low-volume center, the majority (68%, n = 71/104) of whom were referred from high-volume centers after surgery. Crude, unadjusted mortality risk of chemotherapy recipients differed by referral pattern (surgery to chemotherapy): high volume-all patients (hazard ratio, 1.0; referent), followed by high volume-hybrid (hazard ratio, 1.33; 95% confidence interval, 0.93-1.91) then high volume-none patients (RR, 1.95; 95% confidence interval, 1.24-3.08). CONCLUSION Most women with uterine cancer treated at high-volume centers arrive through referral, which is affected by age and type of insurance, in addition to histology. For high-risk women who require chemotherapy, survival may be related to the extent of treatment received at high-volume centers.
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Affiliation(s)
- Kemi M Doll
- Division of Gynecologic Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC; Division of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC.
| | - Ke Meng
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Paola A Gehrig
- Division of Gynecologic Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Wendy R Brewster
- Division of Gynecologic Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Anne-Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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Rim SH, Hirsch S, Thomas CC, Brewster WR, Cooney D, Thompson TD, Stewart SL. Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival. World J Obstet Gynecol 2016; 5:187-196. [PMID: 29520338 PMCID: PMC5839163 DOI: 10.5317/wjog.v5.i2.187] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/04/2016] [Accepted: 03/16/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To examine the influence of gynecologic oncologists (GO) in the United States on surgical/chemotherapeutic standard of care (SOC), and how this translates into improved survival among women with ovarian cancer (OC).
METHODS: Surveillance, Epidemiology, and End Result (SEER)-Medicare data were used to identify 11688 OC patients (1992-2006). Only Medicare recipients with an initial surgical procedure code (n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOC and proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival.
RESULTS: About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC (P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22 (95%CI: 1.12-1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs (for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC.
CONCLUSION: A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.
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Forde GK, Hornberger J, Michalopoulos S, Bristow RE. Cost-effectiveness analysis of a multivariate index assay compared to modified American College of Obstetricians and Gynecologists criteria and CA-125 in the triage of women with adnexal masses. Curr Med Res Opin 2016; 32:321-9. [PMID: 26588255 DOI: 10.1185/03007995.2015.1123679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of the multivariate index assay (MIA) for use in triaging women with an adnexal mass relative to modified American College of Obstetricians and Gynecologists (mACOG) referral guidelines and CA-125 testing alone. METHODS The MIA triage algorithm was based on qualitative serum testing of five biomarkers: transthyretin, apolipoprotein, A-1, 2-microglobulin, transferrin, and CA-125. An economic analysis was developed to evaluate the clinical and cost implications of adopting MIA in clinical practice versus the mACOG referral guidelines and CA-125 alone, over a lifetime horizon, from the perspective of the public payer. Clinical parameters used to characterize patients' disease status, quality of life, and treatment decisions were estimated using the results of published studies; costs were approximated using reimbursement rates from CMS fee schedules. Model endpoints included overall survival (OS), costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). The cost-effectiveness threshold was set to $50,000 per QALY. One-way sensitivity analysis was performed to assess uncertainty of individual parameters included in the analysis. All costs were reported in 2014 US dollars. RESULTS Use of MIA was cost-effective, resulting in fewer re-operations and pre-treatment CT scans. Overall MIA resulted in an ICER of $35,094/QALY gained. MIA was also cost-saving and QALY-increasing compared to use of CA-125 alone with an ICER of $12,189/QALY gained. One-way sensitivity analysis showed the ICER was most affected by the following parameters: (1) sensitivity of MIA; (2) sensitivity of mACOG; and (3) percentage of patients, not referred to a gynecologic oncologist, who were correctly diagnosed with advanced epithelial ovarian cancer (EOC). CONCLUSION Use of MIA is a more cost-effective triage strategy than mACOG or CA-125. It is expected to increase the percentage of women with ovarian cancer that are referred to gynecologic oncologists, which is shown to improve clinical outcomes. Limitations include the use of assumptions when published data was unavailable, and the use of multiple sources for survival data.
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Affiliation(s)
- G K Forde
- a a Division of Gynecologic Oncology , Department of Obstetrics and Gynecology, University of California, Irvine Medical Center , Orange , CA , USA
| | - J Hornberger
- b b Stanford University School of Medicine , Stanford , CA , USA
- c c Cedar Associates LLC , Menlo Park , CA , USA
| | | | - R E Bristow
- a a Division of Gynecologic Oncology , Department of Obstetrics and Gynecology, University of California, Irvine Medical Center , Orange , CA , USA
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Alvero AB, Montagna MK, Sumi NJ, Joo WD, Graham E, Mor G. Multiple blocks in the engagement of oxidative phosphorylation in putative ovarian cancer stem cells: implication for maintenance therapy with glycolysis inhibitors. Oncotarget 2015; 5:8703-15. [PMID: 25237928 PMCID: PMC4226715 DOI: 10.18632/oncotarget.2367] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Survival rate in ovarian cancer has not improved since chemotherapy was introduced a few decades ago. The dismal prognosis is mostly due to disease recurrence where majority of the patients succumb to the disease. The demonstration that tumors are comprised of subfractions of cancer cells displaying heterogeneity in stemness potential, chemoresistance, and tumor repair capacity suggests that recurrence may be driven by the chemoresistant cancer stem cells. Thus to improve patient survival, novel therapies should eradicate this cancer cell population. We show that in contrast to the more differentiated ovarian cancer cells, the putative CD44+/MyD88+ ovarian cancer stem cells express lower levels of pyruvate dehydrogenase, Cox–I, Cox-II, and Cox–IV, and higher levels of UCP2. Together, this molecular phenotype establishes a bioenergetic profile that prefers the use of glycolysis over oxidative phosphorylation to generate ATP. This bioenergetic profile is conserved in vivo and therefore a maintenance regimen of 2-deoxyglucose administered after Paclitaxel treatment is able to delay the progression of recurrent tumors and decrease tumor burden in mice. Our findings strongly suggest the value of maintenance with glycolysis inhibitors with the goal of improving survival in ovarian cancer patients.
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Affiliation(s)
- Ayesha B Alvero
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Michele K Montagna
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Natalia J Sumi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Won Duk Joo
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Emma Graham
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Gil Mor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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Trends in hospital volume and patterns of referral for women with gynecologic cancers: adherence to treatment guidelines for ovarian cancer as a measure of quality care. Obstet Gynecol 2013; 122:905-906. [PMID: 24084554 DOI: 10.1097/aog.0b013e3182a79fd0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wright JD, Hershman DL. In reply. Obstet Gynecol 2013; 122:906-907. [PMID: 24084555 DOI: 10.1097/aog.0b013e3182a7b774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jason D Wright
- Department of Obstetrics and Gynecology and, Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, New York Department of Medicine and, Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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In reply. Obstet Gynecol 2013; 122:907. [PMID: 24084556 DOI: 10.1097/aog.0b013e3182a7bbac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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