Advanced-Stage (FIGO III–IV) Epithelial Ovarian Cancer: Multivariate Analysis of Prognostic Factors in an Area without a Tertiary Referral Oncology Center. A Population-Based Study

Abstract

Background: Most of the time, prognostic factors of patients with epithelial ovarian cancer (EOC) have been evaluated in hospital-based populations, mostly in secondary or tertiary referral centers. The aim of the study was to analyze these factors in a well-defined and nonselected population with complete follow-up from a cantonal cancer registry and to assess the adequacy of treatment in an area which has no central institution for oncological treatment. Patients and Methods:From 1989 to 1995, the cantonal cancer registry of the Valais has registered 73 patients with ovarian epithelial cancers of stages III and IV; 72 patients have been evaluable. We have calculated survival rates and analyzed variables such as age (< 55 / 55–70 / >70 years), stage (III/IV), DNA ploidy (diploid/aneuploid), residual tumor after surgery (tumor ≤2 cm / >2 cm), histologic grading (G1/G2/G3) and chemotherapy treatment (curative/ palliative). The median follow-up was 25 (range 18–101) months. Multivariate analyses (Cox’s proportional hazard) were used to identify an independent effect of each variable on survival time. Survival rates were calculated according to the Kaplan and Meier method. Results: The Canton Valais has no tertiary center and no trained gynecological (surgical) oncologist. The patients have been operated in 7 regional hospitals and one private clinic by 16 different gynecologists and 8 general surgeons, chemotherapy regimens have been given by 5 medical oncologists. Both treatments were very heterogeneous. The median age was 63 years. The estimated 5-year survival rate was 30%. Multivariate analyses identified age and stage as the only significant prognostic factors associated with survival. DNA ploidy, size of residual disease after primary surgery, histologic grading and chemotherapy had no significant impact on survival. Conclusions:Variables such as primary treatment (surgical and chemotherapy) do not improve survival time, probably because patients had too heterogeneous surgical and chemotherapy treatments, the choice of which was influenced by the many treating physicians. Patients with ovarian cancer should be referred to central institutions where they are more likely to have standardized and optimal surgery and chemotherapy treatment.

Centralisation of services for gynaecological cancer

“…In twenty-three studies (Carney 2002; Chan 2007; Earle 2006; Eisenkop 1992; Engelen 2006; Ghaemmaghami 2010;Grant 1992; Grossi 2002; Ioka 2004; Ioka 2005; Junor 1999;Kehoe 1994; Kumpulainen 2002; Kwon 2008; Macdonald 2005; Mayer 1992; Nguyen 1993; O’Malley 2003; Petignat 2000; Tanner 2008; Tingulstad 2003; Van der Zee 2009;Woodman 1997), the interventions were not clearly defined. In addition, we excluded studies where only the effect of the surgeon was measured.Eight studies (Goff 2006; Goff 2007; Munstedt 2003;Paulsen 2006; Pearl 2002; Petignat 1999; Wolfe 1996; Wolfe 1997) did not report pertinent outcomes defined in this review.Fifteen studies (Bristow 2006; Brolmann 1992; Chan 1999;Du Bois 2009; Giede 2005; Grant 1999; Grant 2000; Lehtovirta 2000; Luesley 2000; Olaitan 2008a; Rich 1993; Savage 2008;Tangjitgamol 2009; Vernooij 2007; Williams 2008) were letters, commentaries, editorials, or reviews.Three studies (Bailey 2006; Crawford 2002; Diaz-Montes 2006) did not include a multivariate analysis or use any kind of statistical adjustment for survival outcomes.…”

“…Eight studies (Goff 2006; Goff 2007; Munstedt 2003;Paulsen 2006; Pearl 2002; Petignat 1999; Wolfe 1996; Wolfe 1997) did not report pertinent outcomes defined in this review.…”

“…It was excluded as the comparison included primary surgery operation by gynaecologic oncologist versus obstetrician-gynaecologists versus general surgeons O’Malley 2003 The study examined hospital characteristics which included provider (teaching Hospital, ACoS Hospital, gynaecologic oncologist) in multivariate analysis, but only the significant results were presented. This study has been discussed in more detail in Agreements and disagreements with other studies or reviews Olaitan 2008a This was a letter Paulsen 2006 Details on survival outcomes were not included Pearl 2002 Study compared university and community hospitals, but survival outcomes were not reported Petignat 1999 The primary outcomes were not reported Petignat 2000 No interventions were defined in this study Rich 1993 This was a letter Savage 2008 This was a commentary Tangjitgamol 2009 This was a Cochrane review Tanner 2008 Outcomes were defined based on age and surgical volume of surgeon Tingulstad 2003 Case control study. This was a historical prospective study, where cases were referred between 1995 and 1997 from community hospitals to a teaching hospital for primary surgery.…”

Centralisation of services for gynaecological cancer

“…• Eight studies (Goff 2006;Goff 2007;Munstedt 2003;Paulsen 2006;Pearl 2002;Petignat 1999;Wolfe 1996; Wolfe 1997) did not report pertinent outcomes defined in this review.…”