Ovarian cancer: patterns of care in Victoria during 1993-1995

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Developing an Australian multi-module clinical quality registry for gynaecological cancers: a protocol paper

INTRODUCTION

Gynaecological cancers collectively account for almost 10% of cancer diagnoses made in Australian women. The extent of variation in gynaecological cancer survival rates and treatment outcomes across Australia is not well documented. The purpose of the clinical quality registry described in this paper is to systematically monitor and improve quality of care provided to these women, and facilitate clinical process improvements to ensure better patient outcomes and greater adherence to best practice care. The registry infrastructure has been developed in conjunction alongside the inaugural ovarian, tubal and peritoneal (OTP) module, allowing for concurrent piloting of the methodology and one module. Additional tumour modules will be developed in time to cover the other gynaecological tumour types.

METHOD AND ANALYSIS

The National Gynae-Oncology Registry (NGOR) aims to capture clinical data on all newly diagnosed cancers of the uterus, ovary, fallopian tubes, peritoneum, cervix, vulva and vagina in Australia with a view to using these data to support improved clinical care and increased adherence to 'best practice'. Data are sourced from existing clinical databases maintained by clinicians and/or hospital gynaecological cancer units. A pilot phase incorporating only OTP cancers has recently been conducted to assess the feasibility of the registry methodology and assess the support of a quality initiative of this nature among clinicians and other key stakeholders.

ETHICS AND DISSEMINATION

The NGOR has received National Mutual Acceptance (NMA) ethics approval from Monash Health Human Research Ethics Committee (HREC), NMA HREC Reference Number: HREC/17/MonH/198. We also have approval from Mercy Health HREC and University of Tasmania HREC. Data will be routinely reported back to participating sites illustrating their performance against measures of agreed best practice. It is through this feedback system that the registry will support changes to quality of care and improved patient outcomes.

Cytoreductive surgery for ovarian cancer: quality assessment

Surgery is the cornerstone of treatment of ovarian cancer. Given the importance of achieving no or minimal macroscopic residual disease at primary surgery, performing an assessment of the quality of ovarian cancer surgery is crucial. Assessing the quality of care and surgical outcome allows us to establish baseline information, set standards of care and clear priorities, enable benchmarking against peers, and sustain quality improvement. We know that suboptimal care exists and variation in outcomes results. One way to monitor variation in outcomes is through a clinical quality registry (CQR). A CQR collects a defined minimum dataset to measure performance of an individual or center against a range of clinical quality indicators and provides risk-adjusted, benchmarked data to participating institutions. CQR's are an excellent quality assurance measure as they capture all cases (an opt out system). They permit detection and analysis of unwarranted variations in care. This can provide indications of a systems or process problem, thereby motivating health care providers to improve services and care. Several groups have either developed quality indicators for advanced ovarian cancer surgery (The Scottish Cancer Taskforce and the European Society of Gynecological Oncology) or are in the process of doing so (Australian Society of Gynaecological Oncologists). Indicators should be evidence-based and determined by extensive discussion with experts and stakeholders to ensure appropriateness and buy-in. The Scottish Cancer Taskforce and European Society of Gynecological Oncology have set targets for their quality performance measures, which should provide a quantitative framework for improving care in the surgical management of ovarian cancer.

The Relevance of Gynecologic Oncologists to Provide High-Quality of Care to Women with Gynecological Cancer

Gynecologic oncologists have an essential role to treat women with gynecological cancer. It has been demonstrated that specialized physicians who work in multidisciplinary teams to treat women with gynecological cancers are able to obtain the best clinical and oncological outcomes. However, the access to gynecologic oncologists for women with suspected gynecological cancer is scarce. Therefore, this review analyzes the importance of specialized care of women with ovarian, cervical, and endometrial cancer. In addition, the role of gynecologic oncologists who offer fertility-sparing treatment as well as their role in assisting general gynecologists and obstetricians is also reviewed.

Patterns of chemotherapy treatment for women with invasive epithelial ovarian cancer--a population-based study

OBJECTIVE

Ovarian cancer five-year survival is poor at <40%. In the absence of effective screening or new treatments, ensuring all women receive optimal treatment is one avenue to improve survival. There is little population-based information regarding the primary chemotherapy treatment that women with epithelial ovarian cancer receive. This information is essential to identify potential gaps in care.

METHODS

Cancer registries identified all women diagnosed with invasive epithelial ovarian cancer in Australia in 2005 (n=1192). Histopathology, chemotherapy and comorbidity information was abstracted from medical records. Multivariable logistic regression was used to identify factors associated with chemotherapy commencement, regimen, and completion.

RESULTS

Women >70 years (p<0.0001), those with high-grade, stage IA/IB cancers (vs. stages IC-IV, p=0.003) and those with mucinous cancers (p=0.0002) were less likely to start chemotherapy. Most treated women received platinum-based drugs (97%), but only 68% received combination carboplatin-paclitaxel and only half completed six cycles without treatment modification/delay. Approximately 19% received single-agent carboplatin: mostly those aged >70 (p<0.0001) and/or with co-morbidities (p<0.0001). Age was the strongest predictor of completing six cycles of combination therapy.

CONCLUSIONS

For specific patient groups, particularly older women, there is notable variation from standard treatment. Understanding how treatment variations affect survival and determining optimal regimens for these groups are research priorities.

Ovarian malignancy risk stratification of the adnexal mass using a multivariate index assay

OBJECTIVE

To validate the effectiveness of a multivariate index assay in identifying ovarian malignancy compared to clinical assessment and CA125-II, among women undergoing surgery for an adnexal mass after enrollment by non-gynecologic oncology providers.

METHODS

A prospective, multi-institutional trial enrolled female patients scheduled to undergo surgery for an adnexal mass from 27 non-gynecologic oncology practices. Pre-operative serum samples and physician assessment of ovarian cancer risk were correlated with final surgical pathology.

RESULTS

A total of 494 subjects were evaluable for multivariate index assay, CA125-II, and clinical impression. Overall, 92 patients (18.6%) had a pelvic malignancy. Primary ovarian cancer was diagnosed in 65 patients (13.2%), with 43.1% having FIGO stage I disease. For all ovarian malignancies, the sensitivity of the multivariate index assay was 95.7% (95%CI=89.3-98.3) when combined with clinical impression. The multivariate index assay correctly predicted ovarian malignancy in 91.4% (95%CI=77.6-97.0) of cases of early-stage disease, compared to 65.7% (95%CI=49.2-79.2) for CA125-II. The multivariate index assay correctly identified 83.3% malignancies missed by clinical impression and 70.8% cases missed by CA125-II. Multivariate index assay was superior in predicting the absence of an ovarian malignancy, with a negative predictive value of 98.1% (95%CI=95.2-99.2). Both clinical impression and CA125-II were more accurate at identifying benign disease. The multivariate index assay correctly predicted benign pathology in 204 patients (50.7%, 95%CI=45.9-55.6) when combined with clinical impression.

CONCLUSION

The multivariate index assay demonstrated higher sensitivity and negative predictive value for ovarian malignancy compared to clinical impression and CA125-II in an intended-use population of non-gynecologic oncology practices.

Ten years' experience with centralized surgery of ovarian cancer in one health region in Norway

BACKGROUND

Better outcome of advanced ovarian cancer after centralized surgery has led to the recommendation for centralized surgery in a Norwegian health region. Whether the practice pattern has changed according to this recommendation has not been examined.

OBJECTIVE

The objective of this study was to evaluate the referral practice and treatment of ovarian cancer in a Norwegian health region after the introduction of centralized surgery.

METHODS

This was a retrospective, population-based study, including all women undergoing surgery for primary ovarian, tubal, and peritoneal cancer between 2000 and 2005, in Health Region IV of Norway. Clinical data and data regarding treatment and 5-year follow-up were analyzed.

RESULTS

In total, 279 cases of ovarian, peritoneal, and tubal cancer were included. Eighty-four percent underwent primary surgery at the teaching hospital and 16% at the nonteaching hospitals. After an immediate rise in the number of cases undergoing primary surgery at the teaching hospital after the introduction of centralization in 1995, the percentage distribution between the teaching and nonteaching hospitals was stable during the study period. The women who underwent surgery at the nonteaching hospitals had a higher percentage of early-stage disease and were at higher risk of reoperation for comprehensive staging.

CONCLUSIONS

Centralization of ovarian cancer surgery has been successfully accomplished in a health region in Norway. The referral practice of assumed advanced ovarian cancer cases shows satisfactory compliance with centralization at 10 years after the implementation of centralized surgery.

Centralisation of services for gynaecological cancer

BACKGROUND

Gynaecological cancers are the second most common cancers among women. It has been suggested that centralised care improves outcomes but consensus is lacking.

OBJECTIVES

To assess the effectiveness of centralisation of care for patients with gynaecological cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL (The Cochrane Library, Issue 4, 2010), MEDLINE, and EMBASE up to November 2010. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, controlled before-and-after studies, interrupted time series studies, and observational studies that examined centralisation of services for gynaecological cancer, and used multivariable analysis to adjust for baseline case mix.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data, and two assessed risk of bias. Where possible, we synthesised the data on survival in a meta-analysis.

MAIN RESULTS

Five studies met our inclusion criteria; all were retrospective observational studies and therefore at high risk of bias.Meta-analysis of three studies assessing over 9000 women suggested that institutions with gynaecologic oncologists on site may prolong survival in women with ovarian cancer, compared to community or general hospitals: hazard ratio (HR) of death was 0.90 (95% confidence interval (CI) 0.82 to 0.99). Similarly, another meta-analysis of three studies assessing over 50,000 women, found that teaching centres or regional cancer centres may prolong survival in women with any gynaecological cancer compared to community or general hospitals (HR 0.91; 95% CI 0.84 to 0.99). The largest of these studies included all gynaecological malignancies and assessed 48,981 women, so the findings extend beyond ovarian cancer. One study compared community hospitals with semi-specialised gynaecologists versus general hospitals and reported non-significantly better disease-specific survival in women with ovarian cancer (HR 0.89; 95% CI 0.78 to 1.01). The findings of included studies were highly consistent. Adverse event data were not reported in any of the studies.

AUTHORS' CONCLUSIONS

We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.

Second-line treatment of first relapse recurrent ovarian cancer

First-line therapy of advanced ovarian cancer involves primary cytoreductive surgery and adjuvant systemic chemotherapy. Progression of incompletely resected disease or recurrence after cytoreduction is inevitable. The approach to second-line treatment is ill-defined and chemotherapy remains the conventional approach, with surgery being reserved in some patients to debulk or palliate symptoms. Increasing evidence suggests that secondary cytoreduction improves progression-free and overall survival. This approach may be appropriate in selected patients. Intraperitoneal chemotherapy delivered in the adjuvant setting postoperatively has been shown to be more effective than systemic chemotherapy in advanced ovarian cancer after primary surgery. However, its use has not been well accepted and has not been adopted in secondary surgery. Hyperthermic intraperitoneal chemotherapy delivered intraoperatively during surgery has been of clinical interest and may prove to be efficacious and advantageous. The support of the gynaecological cancer medical and surgical community to embrace the efforts and assist in the recruitment of appropriate patients into randomised trials of first relapse recurrent ovarian cancer will provide answers to questions and establish evidence that would impact the care of ovarian cancer patients.

Evaluation of the Risk of Malignancy Index in daily clinical management of adnexal masses

OBJECTIVE

To verify the effectiveness of the Risk of Malignancy Index in the discrimination between non-invasive (benign and borderline) lesions and invasive malignant adnexal masses in daily clinical practice.

METHODS

This prospective observational study was conducted in a multicentre cooperation of 11 hospitals. A total of 548 women with adnexal masses were included. Ultrasound characteristics, menopausal status and serum CA 125 level were registered preoperatively, and combined into the RMI afterwards. Final diagnosis was based on routine histopathologic examination. The decision to have patients operated by or with a gynecologic oncologist was based on the clinical impression of the gynecologist in the local hospital, based on physical examination, testing of serum samples, and ultrasound examination. This was compared with the hypothetical situation in which the RMI would have been applied as method of selection.

RESULTS

An RMI of 200 achieved a sensitivity of 81% and specificity of 85% in the detection of ovarian cancer. Positive and negative predictive values were 48% and 96% respectively. In current practice, 64% of ovarian cancer patients were operated by a gynecologic oncologist. This percentage would have increased to 80% if the RMI with a cutoff value of 200 would have been used as method of selection.

CONCLUSIONS

In our study population, introduction of the RMI would improve the management of adnexal masses, with a higher percentage of ovarian cancer patients that are operated by a gynecologic oncologist. At the same time, referral of patients with non-invasive (benign and borderline) lesions would be reduced.

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

OBJECTIVE

Ovarian cancer outcome varies among different institutions, regions, and countries. This systematic review summarizes the available data evaluating the impact of different physician and hospital characteristics on outcome in ovarian cancer patients.

METHODS

A MEDLINE database search for pertinent publications was conducted and reference lists of each relevant article were screened. Experts in the field were contacted. Selected studies assessed the relationship between physician and/or hospital specialty or volume and at least one of the outcomes of interest. The primary outcome was survival. Additional parameters included surgical outcome (debulking), completeness of staging, and quality of chemotherapy. The authors independently reviewed each article and applied the inclusion/exclusion criteria. The quality of each study was assessed by focusing on strategies to control for important prognostic factors.

RESULTS

Forty-four articles met inclusion criteria. Discipline and sub-specialization of the primary treating physician were identified as the most important variable associated with superior outcome. Evidence showing a beneficial impact of institutional factors was weaker, but followed the same trend. Hospital volume was hardly related to any outcome parameter.

CONCLUSIONS

The limited evidence available showed considerable heterogeneity and has to be interpreted cautiously. Better utilization of knowledge about institutional factors and well-established board certifications may improve outcome in ovarian cancer. Patients and primary-care physicians should select gynecologic oncologists for primary treatment in countries with established sub-specialty training. Policymakers, insurance companies, and lay organizations should support development of respective programs.

Influence of the gynecologic oncologist on the survival of ovarian cancer patients

OBJECTIVE

To estimate the influence of gynecologic oncologists on the treatment and outcome of patients with ovarian cancer.

METHODS

Data were obtained from California Cancer Registry from 1994 to 1996. Kaplan-Meier and Cox proportional hazard methods were used for analyses.

RESULTS

Of 1,491 patients, the median age was 65 years (range: 13-100). Only 34.1% received care by gynecologic oncologists (group A) while 65.9% were treated by others (group B). Women in group A were more affluent (P<.001), were more educated (P=.036), were classified as white-collar employees (P=.128), and lived in urban regions (P<.001) compared with group B. Patients who saw gynecologic oncologists were more likely to have surgery as their initial treatment (91.9% versus 69.1%; P<.001), present with advanced (stage III-IV) cancers (78.2% versus 70.5%; P<.001), have more grade 3 tumors (61.7% versus 39.9%; P=.048), and receive chemotherapy (90.0% versus 70.1%; P<.001). Women in group B had a fourfold higher risk of having unstaged cancers (8.0% versus 2.1%; P<.001). The 5-year disease-specific survival of group A patients was 38.6% compared with 30.3% in group B (P<.001). On multivariable analysis, early stage, lower grade, and treatment by gynecologic oncologists were independent prognostic factors for improved survival. After adjusting for surgery and chemotherapy, there was no improvement in survival associated with care by gynecologic oncologists (hazard ratio=0.90, 95% confidence interval 0.78-1.03; P=.133).

CONCLUSION

In this study of 1,491 women, those who were treated by gynecologic oncologists were more likely to undergo primary staging surgery and receive chemotherapy. Stage, grade of disease, and treatment by gynecologic oncologists were important prognosticators.

Centralization of care for patients with advanced-stage ovarian cancer: a cost-effectiveness analysis

BACKGROUND

The objective of this study was to evaluate the cost-effectiveness of centralized referral of patients with advanced-stage epithelial ovarian cancer who underwent primary cytoreductive surgery and adjuvant chemotherapy.

METHODS

A decision-analysis model was used to compare 2 referral strategies for patients with advanced-stage ovarian cancer: 1) referral to an expert center, with a rate of optimal primary cytoreduction of 75% and utilization of combined intraperitoneal and intravenous adjuvant chemotherapy, and 2) referral to a less experienced center, with a rate of optimal primary cytoreduction of 25% and adjuvant treatment that consisted predominantly of intravenous chemotherapy alone. The cost-effectiveness of each strategy was evaluated from the perspective of society.

RESULTS

A cost-effectiveness analysis revealed that the strategy of expert center referral had an overall cost per patient of $50,652 and had an effectiveness of 5.12 quality-adjusted life years (QALYs). The strategy of referral to a less experienced center carried an overall cost of $39,957 and had an effectiveness of 2.33 QALYs. The expert center strategy was associated with an additional 2.78 QALYs at an incremental cost of $10,695 but was more cost-effective, with a cost-effective ratio of $9893 per QALY compared with $17,149 per QALY for the less experienced center referral strategy. Sensitivity analyses and a Monte Carlo simulation confirmed the robustness of the model.

CONCLUSIONS

According to results from the decision-analysis model, centralized referral of patients with ovarian cancer to an expert center was a cost-effective healthcare strategy and represents a paradigm for quality cancer care, delivering superior patient outcomes at an economically affordable cost. Increased efforts to align current patterns of care with a universal strategy of centralized expert referral are warranted.

The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review

OBJECTIVE

There is much debate on the effect of specialized care for ovarian cancer patients. In this review we present an overview and summary of the recent literature on this subject.

METHODS

The Pubmed database was searched for studies on the relationship between care setting (type of gynecologist or hospital) and care outcomes which were published between January 1991 and November 2006. Studies were included if they were of sufficient quality and included patients treated from 1990 onwards.

RESULTS

Nineteen articles were retrieved. There were no randomized controlled trials on this subject. Staging and debulking were consistently found to be performed more adequately by gynecologic oncologists (pooled relative risk of optimal debulking by a gynecologic oncologist to <2 cm residual disease 1.4 (95%CI 1.2-1.5) and to no macroscopic disease 2.3 (95%CI 1.5-3.5)) and in specialized hospitals (odds ratios for optimal debulking varied between 1.9 and 6.0). There were no differences in postoperative complication rates between different providers. Chemotherapy was given 1-15% more often in specialized settings. Differences in chemotherapy did not lead to differences in survival of patients treated by gynecologic oncologists, but did influence the effect of hospital on survival. Long-term survival was better after treatment in a specialized hospital. Surgery by a gynecologic oncologist resulted in longer survival in subgroups of patients, leading to a 5- to 8-month median survival benefit for patients with advanced stage disease.

CONCLUSIONS

The outcome of ovarian cancer is better when treatment is provided by a gynecologic oncologist or in a specialized hospital.

Prognostic factors for complete debulking in advanced ovarian cancer and its impact on survival. An exploratory analysis of a prospectively randomized phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR)

BACKGROUND

No residual tumor as result of primary surgery in advanced ovarian cancer is known as one of the most important prognostic factors.

PURPOSE

To evaluate the impact of different prognostic factors for surgical outcome and to evaluate the impact of surgical outcome on survival.

METHODS

Surgical data as well as survival data were documented throughout the multi-center prospective randomized phase III trial (OVAR-3) of the AGO-OVAR and were used for this exploratory analysis. In this study 798 patients with FIGO IIB-IV were first operated then randomized and homogenously treated with cisplatin/paclitaxel or carboplatin/paclitaxel. Only patients with complete surgical data (n=761) entered this analysis.

RESULTS

Multivariable logistic regression analysis showed a significant decrease of probability for complete debulking without any macroscopic residual tumor for higher pre-operative tumor load (OR 0.32; 95% CI 0.17-0.61), higher FIGO stage (OR 0.22; 95% CI 0.13-0.39), worse performance status (OR 0.57; 95% CI 0.38-0.86), advanced age (OR 0.78; 95% CI 0.65-0.94) and presence of peritoneal carcinomatosis (OR 0.17; 95% CI 0.10-0.28). Surgery in centers with surgeons who performed comprehensive surgical debulking including retroperitoneal lymphadenectomy and peritoneal stripping was associated with higher rates of complete debulking compared to surgery in other centers (32.8% vs. 22.9%, p=0.007). This resulted in a markedly improved overall survival (p=0.045). This effect was held true after adjustment for prognostic factors (HR 0.77, 95% CI 0.63-0.94, p=0.012).

CONCLUSION

Post-operative residual tumor is one of the most important independent prognostic factor for survival. Our results suggest an advantage for aggressive primary surgery and complete debulking. This surgical goal was achieved more often in experienced centers.

MANAGEMENT OF MUSCLE-INVASIVE BLADDER CANCER IN VICTORIA, 1990-1995

BACKGROUND

The management and outcomes of muscle-invasive bladder cancer are described in this article.

METHODS

A retrospective survey of medical practitioners involved in the management of bladder cancer was conducted. The survey obtained at least 5 years of follow-up data on all patients. The sample was taken from the public and private health sectors in Victoria. All were cases of muscle-invasive bladder cancer diagnosed between 1990 and 1995. The main outcome measures included reported management by staging, treatment and survival.

RESULTS

Completed questionnaires were returned for 743 (89.6%) of 829 cases. Of these, 523 (70.4%) were men, and the mean age was 72.7 years. More than 75% of the cases (560) presented with macroscopic haematuria. The majority (696, 94%) had transitional cell carcinoma. A variety of treatments were given in various sequences, with 231 cases (31.1%) having initial surveillance. Eventually, 303 cases (40.8%) proceeded to 'definitive' management with either radiotherapy (132, 17.8%) or cystectomy (171, 23.0%). In addition, chemotherapy was given to 254 patients (34.2%) at some time. Most patients (613, 82.5%) have subsequently died; 402 (54%) died from bladder cancer. Crude 5-year survival was 13.0%, and disease-specific survival was 27.7%. Multivariate analysis identified the following predictors of greater disease-specific survival: grade 1 or 2 histopathology (P = 0.0003), T2 primary (P < 0.0001), N0 disease (P = 0.04), M0 disease (P < 0.0001), radiation dose in BED(10) >70 Gy and cystectomy (P < 0.0001).

CONCLUSION

Muscle-invasive bladder cancer in Victoria typically occurs in elderly patients, and a notable proportion of these patients do not proceed onto 'definitive' treatment. Disease stage, cystectomy and the use of high doses of radiation are associated with better outcomes. Chemotherapy was given to approximately one-third of patients at some point in their disease management. Our data are similar to population-based data from North America, and provide a baseline against which potential changes in management of bladder cancer can be compared.

Treatment decisions: A qualitative study with women with gynaecological cancer

This qualitative study investigated women's participation in decisions regarding treatment of gynaecological cancer. Thirty women, receiving health care in two tertiary hospitals in Australia, were interviewed face-to-face. For women with gynaecological cancer, the most influential factors in treatment decisions are still the surgeon's recommendation and fear of dying from cancer.

Who should operate on patients with ovarian cancer? An evidence-based review

OBJECTIVE

To evaluate the relationship between surgical specialty and survival in patients receiving initial surgical management for ovarian epithelial cancer.

STUDY METHODS

An analytic framework was constructed to address the principle question 'does the type of surgeon operating on patients with newly diagnosed ovarian epithelial cancer influence survival?' A literature search addressing the components of this analytic framework was carried out using the Cochrane Library, Medline, EMBASE, and HealthSTAR databases. Relevant articles were selected and graded using U.S. Preventive Services Task Force and Canadian Task Force guidelines. Results were summarized by quality as well as level of evidence.

RESULTS

Eighteen studies were reviewed. The quality of evidence was good in 3, fair in 8, and poor in 7 of the studies. The most common study flaws encountered were 'failure to account for confounders' and 'incompleteness of data'. In studies focusing on advanced disease, there was good quality evidence to support a 6- to 9-month median survival benefit for patients operated on by gynecologic oncologists rather than general gynecologists and/or general surgeons (P values 0.009 to 0.01). Studies focusing on early stage disease found gynecologic oncologists more likely to carry out optimal staging (P values 0.001 to 0.01). Increased survival could be explained by improved identification of true stage I patients.

CONCLUSION

Patients receiving initial surgical management for ovarian epithelial cancer should be operated on by gynecologic oncologists.

Cancer statistics: everything you wanted to know about the cancer registry data but were too afraid to ask

Australia and New Zealand (ANZ) have had complete population cancer incidence registration for decades and are beginning to develop clinical data systems to collect details of staging and treatment. Sadly, this bounty of statistical data is often under utilized and occasionally abused. Many are unaware of the data and statistical services available from their local cancer registry. To promote the use of ANZ population cancer data, the following paper describes the principal statistics that are available and identifies common problems with their use.

Estimation of an optimal radiotherapy utilization rate for gynecologic carcinoma: part I--malignancies of the cervix, ovary, vagina and vulva

BACKGROUND

Radiotherapy usage rates exhibit wide variations both within and between countries. Current estimates of the proportion of cancer patients who should optimally receive radiotherapy are based either on expert opinion or on the measurement of actual usage rates rather than on the best available scientific evidence.

METHODS

With the goal of developing an evidence-based benchmark for radiotherapy use in the treatment of malignancies of the cervix, vagina, vulva, and ovary (endometrial malignancies are covered in a separate article), the authors reviewed international evidence-based treatment guidelines. Optimal radiotherapy usage trees were constructed, and proportions of patients with clinical indications for radiotherapy were obtained from epidemiologic data. These ideal usage rates were compared with actual radiotherapy utilization rates recorded in Australia and elsewhere.

RESULTS

According to the best available evidence, radiotherapy is indicated at least once for 58% of patients with cervical carcinoma, 4% of patients with ovarian carcinoma, 100% of patients with vaginal carcinoma, and 34% of patients with vulvar carcinoma. A review of the limited data available suggests that actual radiotherapy usage rates for patients with gynecologic malignancies are comparable to optimal usage rates.

CONCLUSIONS

Actual practice appears to approximate the authors' model of optimal radiotherapy use. This finding reflects the high level of agreement among treatment guidelines as well as the existence of high-quality evidence related to the management of gynecologic malignancies, and it may also be indicative of the fact that a large proportion of patients are treated in specialist units. The management of gynecologic malignancies may serve as a good example in the development of management strategies for other types of cancer.

Survival of Californian women with epithelial ovarian cancer, 1994-1996: a population-based study

OBJECTIVE

The objective was to identify demographic, clinical, and provider characteristics that might influence cancer survival in a cohort of Northern California women using a population-based cancer registry.

METHODS

We used California Cancer Registry data to evaluate survival in 1051 Northern California women who were diagnosed with epithelial ovarian cancer between 1994 and 1996 and underwent a surgical procedure for their cancer. Chemotherapy data from the cancer registry were supplemented with a physician survey and medical record review. Database linkages with census and hospital discharge data provided socioeconomic and comorbidity measures. Kaplan-Meier method was used to generate survival curves and multivariate Cox proportional hazard models were used to evaluate the effect of different factors on survival.

RESULTS

Crude 5-year survival was 82, 57, 28, and 10% for women with FIGO stage IC, II, III, and IV disease, respectively. Adverse survival was most strongly influenced by advanced stages III and IV with a hazards ratio ranging from 8 to 11.8 compared to stage IC disease. Multivariate analysis also identified other adverse factors including high grade and other adverse histologies, age over 45, and rural location. Chemotherapy decreased the risk of death by 50% if the patient had advanced-stage disease. Medical comorbidity increased the risk of death by 40%. Survival was not influenced by race/ethnicity, socioeconomic status, physician specialty, or hospital characteristics.

CONCLUSION

Advanced age remains an adverse prognostic factor even after adjustment for treatment and comorbidity factors. These results also suggest that there may be important regional differences in ovarian cancer survival.

Ovarian cancer in Western Australia (1982-1998): trends in surgical intervention and relative survival

OBJECTIVES

We aimed to review the utilisation and trends in surgical procedures for the primary management of ovarian cancer and the survival outcomes of patients surgically treated in Western Australia.

METHODS

The population-based Western Australia Data Linkage System was used to link hospital morbidity and mortality data for all women diagnosed with malignant primary ovarian cancer in the State Cancer Registry in the period 1982-1998. Poisson regression was used to analyse trends in surgical procedure rates. Logistic regression examined the likelihood of having a surgical procedure in the periods 1988-1993 and 1994-1998 compared with 1982-1987. Relative survival was used to adjust survival estimates for other causes of death occurring in the general female population.

RESULTS

There were 1,126 women who underwent a primary surgical procedure for ovarian cancer in Western Australia in the period 1982-1998. Women were more likely to undergo surgery in 1994-1998 (87.8%) compared with 1988-1993 (76.8%), but there was no difference when compared to 1982-1987 (89.2%) (P = 0.62). The likelihood of using specific surgical procedures to treat ovarian cancer increased for all but total abdominal hysterectomy. Bilateral salpingo-oophorectomy was 3.7 times more likely to be performed and omentectomy 5 times more likely to be performed in 1994-1998 compared with 1982-1987. The median length of hospital stay decreased from 15 to 12 days and emergency admissions decreased from 26.5 to 15.4% over the three time periods. Thirty-two percent of women were readmitted within 30 days of separation from their primary surgery, 23% of which were for the same-day treatment with either chemotherapy or radiotherapy. A 15% increase in relative survival was observed between the periods 1982-1997 (38.8%) and 1994-1998 (53.5%).Conclusion.

CONCLUSION

Surgery remains a cornerstone in the primary management of ovarian cancer. There have been dramatic shifts in surgical practice in Western Australia, with more women undergoing certain surgical procedures today than they were 20 years ago. Coupling the increasing surgical trends are improved outcomes. Fewer women are presenting as an emergency, the length of hospital stay has been reduced, and survival outcomes have shown a significant improvement.