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Alternating 5-day chemotherapy with methotrexate and dactinomycin as primary therapy for nonmetastatic gestational trophoblastic disease was studied in nine patients. The complete response rate was 100% with follow-up of a median of 80 months. Stomatitis was universal but rarely prevented oral alimentation or delayed therapy. Overall, 94% of toxicity was mild or moderate in severity and all toxicity was reversible. This alternating non-cross resistant regimen, reported in a total of 40 patients in the literature, is the only regimen to result in a 100% response rate. This response rate is statistically improved when compared to historical controls receiving methotrexate/folinic acid or pulse dactinomycin. No patients required hysterectomy for disease control. Cooperative prospective phase III studies are needed to determine the efficacy and toxicity of current regimens.

Results: A total of 9933 patients were identified (Stage I = 22.8%, Stage II = 7.9%, Stage III = 45.1%, Stage IV = 24.2%), and 8.1% of patients were treated at NCI-CCCs. Overall, 35.7% of patients received NCCN guideline adherent care. NCI-CCC status (OR = 1.00) was an independent predictor of adherence to treatment guidelines compared to HVHs (OR = 0.83, 95% CI = 0.70-0.99) and LVHs (OR = 0.56, 95% CI = 0.47-0.67). The median ovarian cancer-specific survival according to hospital type was: NCI-CCC = 77.9 (95% CI = 61.4-92.9) months, HVH = 51.9 (95% CI = 49.2-55.7) months, and LVH = 43.4 (95% CI = 39.9-47.2) months (P b 0.0001). The survival advantage associated with NCI-CCC status was maintained across socioeconomic strata. NCI-CCC status (HR = 1.00) was a statistically significant and independent predictor of improved survival compared to HVH (HR = 1.18, 95% CI = 1.04-1.33) and LVH (HR = 1.30, 95% CI = 1.15-1.47). Conclusions: NCI-CCC status is an independent predictor of adherence to ovarian cancer treatment guidelines and improved ovarian cancerspecific survival. These data validate NCI-CCC status as a structural health care characteristic correlated with superior ovarian cancer quality measure performance. Increased access to NCI-CCCs through regional concentration of care may be a mechanism to improve clinical outcomes.