The survival of ovarian cancer patients has been reported to be superior at hospitals with a high volume of operations. A population-based study was carried out to assess whether this is true in Japan, where the incidence rate is relatively low as compared with other developed countries. The Osaka Cancer Registry's data were used to investigate associations between hospital procedure volume and survival of ovarian cancer patients. Hospitals were ranked according to the number of operations for ovarian cancer performed per year (high/medium/low/very low varian cancer is the leading cause of death among gynecologic malignancies in the developed countries, and fewer than half of women diagnosed with ovarian cancer survive 5 years after diagnosis. In Japan, the incidence rate of ovarian cancer is relatively low as compared with other developed countries (i.e., Nordic nations, the United Kingdom, and North America), 1) while the relative 5-year survival for ovarian cancer is less than that in the US (36.4% vs. 43.5%).2)The standard treatment of ovarian cancer is cytoreductive surgery followed by combination chemotherapy. Initial surgery is important for accurate staging of the disease and for removing as much of the tumor as possible. Former reports suggest that one of the prognostic factors predicting survival is the diameter of the residual tumor mass after operation, 3,4) so it has been suggested that the initial operation provides the most important opportunity to improve survival.5) The question arises, are lower survival rates in Japan, where the incidence rate of ovarian cancer is low, associated with poor technical expertise of physicians and of the teams performing primary surgery?Relative 5-year survival for malignant ovarian germ cell tumors in Japan is also much lower than that in the US (58.6% vs. 83.7%).2) Similar differences were observed between Japan and the US in survival for malignant testicular germ cell tumors.6) Malignant ovarian germ cell tumors are rare compared with testicular germ cell tumors. Most of the advances in the management of the former have been extrapolations from experience with the latter, and developments in surgery and of effective chemotherapy regimens have markedly improved the outcome of treatment of ovarian germ cell tumors.7, 8) Lower availability of medical oncologists than in the US might have adversely influenced the 5-year survival of both types of germ cell tumor patients in Japan.In this paper, using the Osaka Cancer Registry's data, we have tried to clarify whether increased hospital procedure volume (i.e., the number of operations performed for ovarian cancer) is associated with increased survival in Japan, and whether centralizing operative treatment for ovarian cancer might improve survival. The quality of this data, therefore, can be assumed to have met the standards set by the International Association of Cancer Registries during the last 3 decades. In 1993-1997, the proportion of death certificate only (DCO) cases was 16%, the mortality to incidence (M/I) rat...