SummaryThe surgical management of epithelial ovarian cancer in the South West of England was studied in the two years 1997-1998 in order to determine the factors that influence the outcome of surgery and to provide a baseline from which to assess the effect of centralisation of cancer services. All hospitals in the South West region of England participating in the Regional Cancer Organisation's longitudinal study of outcomes in gynaecological malignancies are included. Six hundred and eighty-two patients with epithelial ovarian cancer were registered with the RCO in the two-year study period. Five hundred and ninety-five women were offered primary cytoreductive surgery of which 438 were said to be optimally cytoreduced. Applying multivariate models to analyse the outcome of surgery, older patients (OR = 0.82 per 5-year increase in age, P = 0.0003), patients treated in hospitals managing fewer than ten cases of ovarian cancer per year (OR = 1.92, P = 0.02) and patients with FIGO stage 3 (OR = 0.02, P < 0.0001) or 4 (OR = 0.002, P < 0.0001) disease were less likely to be optimally cytoreduced. Gynaecological oncologists were 2.06 times more likely to attain optimal cytoreduction when compared to general gynaecologists and this was statistically significant (P = 0.01). The results from this study support the argument that limiting surgery for ovarian malignancy to specialised surgeons improves the extent of cytoreductive surgery. prior to the re-organisation of gynaecological cancer services, looking particularly at factors influencing the completeness of surgery at each stage of disease. This study, as well as providing a base-line against which future performance can be measured, enables us to estimate the increase in work load and the resource implications for the regional cancer centre if centralisation of ovarian cancer management is fully implemented. MATERIALS AND METHODSThe South and West Regional Cancer Organisation (RCO) Gynaecology Tumour Panel is constituted of a multidisciplinary team of experts involved in the management of gynaecological malignancies. In 1997, the RCO initiated a prospective longitudinal study of the management of gynaecological cancer to establish current patterns of care and facilitate development of services in the region (Jackson et al, 1997). A one-page minimum data-set for each major gynaecological cancer site was designed (Figure 1). After obtaining approval from all units managing gynaecological malignancies, copies of the minimum data set pro forma were circulated along with guidance notes that included outlines of American Society of Anesthesiologists (ASA) grading, FIGO staging, and histopathology information required. Treatment policies detailing accepted pre-operative and operative management of epithelial ovarian cancer were produced and circulated by the RCO to all participating hospitals (Appendix 1). To ensure uniform histopathological reporting, the RCO also circulated guidelines for participating histopathologists (Appendix 2). The clinician managing the case is re...

Objective 1, To audit the management of cervical carcinoma in the South West Region with the aim of identifying and addressing deficiencies. 2. To determine whether recent NHS restructuring has affected the provision of cancer care.Design Retrospective review of hospital case notes.Setting All hospitals in the South West Region of England.Population Three hundred and twenty-four women with a diagnosis of cervical carcinoma: 191 wereMain outcome measures Documentation of patient assessment and management.Results There was a mean delay of 17 days (range 0-66) from cervical smear to cytology report and 34 days (range 1-380) from general practitioner referral to attendance at a hospital clinic. Overall, 175 women (54%) had evidence of cytological assessment prior to treatment and 137 (42%) had a colposcopic assessment; 49% had cytological assessment and 37% had colposcopy in 1989, compared with 60% and 50%, respectively, in 1993. Excluding 49 cases of micro-invasive carcinoma, 238 case notes (86%) contained evidence of clinical examination; 195 women (71%) had had an examination under anaesthesia, 1 15 (42%) a chest radiograph, 123 (45%) an intravenous urogram or renal ultrasound, and 92 (33%) cystoscopy. One hundred and forty-seven women (53%) had FIG0 staging recorded in the notes. As first line treatment, 69 had conservative surgery (39 for Stage IA), 138 had radiotherapy, and 107 had radical surgery. Ten had radical surgery for Stage IA but eight had a > 3 mm invasion or lymphatichascular spread. Thirty-one had Stage IB treated with radiotherapy of whom 14 were younger than 50 years of age. Following radical surgery 30% had evidence of sampling 2 10 nodes, and 9% had tumour extending to the resection margins.Conclusions Record keeping was inadequate but appeared to indicate inconsistent cytological, clinical, colposcopic and radiological assessment, leading to inappropriate clinical delays and conservative surgery. Radical surgery often appeared inadequate, but poor node sampling rates may also reflect insufficient histopathological preparation or reporting. There was a reduction in the number of new cases of cervical carcinoma diagnosed in 1993, perhaps reflecting an observed increase in cytological surveillance. No other alterations in clinical practice were observed over the four-year period. We feel it is imperative to standardise assessment throughout the region with a minimum clinical and histopathological dataset.diagnosed in I989 and 133 in 1993.

Objective To define and use a minimum clinical dataset for prospective data collection in order to audit the surgical management of cervical cancer in the South West of England. To compare this data set with a retrospective audit allowing assessment of the quality of care offered to patients.Design Prospective collection of a defined dataset on paper forms which were put into a computerised database for analysis. Registrations validated against histopathology databases and hospital coding.Setting All 13 hospitals in the South West of England which participated in the retrospective audit.Participants One hundred and sixty-five women with cervical cancer diagnosed in 1997.Main outcome measures Distribution of cases by hospital and surgeon; workload of individual surgeons; adequacy and accuracy of FIGO staging; adequacy of histological information; and adequacy of surgery.There is a trend to centralisation of cancer care and radical surgery in the region. Prospective collection of data has dramatically improved FIGO staging with 92% of all cases staged. For cases greater than Stage Ia, 98% were staged suggesting that a target of 100% staging is feasible. The histological dimensions of tumours were not measured in a high proportion of cases (20% of tumour diameters and 28% of tumour thicknesses). Apparent inadequacies in surgical management are explored. In 10/165 cases (6%) inappropriate conservative surgery may have been unavoidable, suggesting that a quality standard of 95% for appropriate radical surgical management of cervical cancer can be achieved. An anatomically complete removal of pelvic node-bearing tissue, yielding greater than 10 nodes in more than 95% cases, should be achievable with each surgeodpathologist achieving a mean of more than 20 nodes. ConclusionRegional audit of cervical cancer management is feasible. It can be used to improve the quality of information on management and guide improved service provision. Results INTRODUCTION

This study investigated the management of women with apparent early ovarian cancer in the South West region of England. This was retrospective review of prospectively collected data supplement by case note review. All women registered with stage 1 ovarian cancer in the 2 years from January 1997 to December 1998 were identified from the database of the Regional Cancer Organisation (RCO). Data on staging and subsequent management were obtained from the RCO database. Additional information was collected from the patients' casenotes. We considered the accuracy of staging, consideration of fertility-sparing surgery, evidence of multidisciplinary approach to management, appropriateness of oncological referral and adjuvant therapy. Of 222 cases of stage 1 ovarian cancer identified from the RCO database, 168 casenotes were available for inspection. Eighty-seven cases were confirmed as FIGO stage 1 but the substage was amended in 21 cases. There were insufficient data available in 75 cases to confirm the stage assigned. Six cases were re-staged to FIGO stage 3a. Fertility-sparing surgery was considered in four of 10 nulliparous patients of reproductive age. Thirty-nine patients with disease more advanced than FIGO stage 1b were not referred for onco1 logical opinion. Even after Calmine-Hine guidelines are implemented, women with early ovarian cancer may still be treated in general hospitals. There is an urgent need to provide clear local guidelines for the management of these patients.