Will Patients Benefit from Regionalization of Gynecologic Cancer Care?

Abstract

ObjectivePatient chances for cure and palliation for a variety of malignancies may be greatly affected by the care provided by a treating hospital. We sought to determine the effect of volume and teaching status on patient outcomes for five gynecologic malignancies: endometrial, cervical, ovarian and vulvar carcinoma and uterine sarcoma.MethodsThe Florida Cancer Data System dataset was queried for all patients undergoing treatment for gynecologic cancers from 1990–2000.ResultsOverall, 48,981 patients with gynecologic malignancies were identified. Endometrial tumors were the most common, representing 43.2% of the entire cohort, followed by ovarian cancer (30.9%), cervical cancer (20.8%), vulvar cancer (4.6%), and uterine sarcoma (0.5%). By univariate analysis, although patients treated at high volume centers (HVC) were significantly younger, they benefited from an improved short-term (30-day and/or 90-day) survival for cervical, ovarian and endometrial cancers. Multivariate analysis (MVA), however, failed to demonstrate significant survival benefit for gynecologic cancer patients treated at teaching facilities (TF) or HVC. Significant prognostic factors at presentation by MVA were age over 65 (HR = 2.6, p<0.01), African-American race (HR = 1.36, p<0.01), and advanced stage (regional HR = 2.08, p<0.01; advanced HR = 3.82, p<0.01, respectively). Surgery and use of chemotherapy were each significantly associated with improved survival.ConclusionNo difference in patient survival was observed for any gynecologic malignancy based upon treating hospital teaching or volume status. Although instances of improved outcomes may occur, overall further regionalization would not appear to significantly improve patient survival.

The Optimal Organization of Gynecologic Oncology Services: A Systematic Review

“…The research method used was systematic and comprehensive, but the resulting evidence base was of limited quality and largely comprised nonrandomized retrospective studies with inconsistent definitions of comparison groups and outcomes. A significant limitation of the literature in this area is the failure account for the "clustering" phenomenon: the fact that patients treated within the same facility are not entirely independent, and that the outcomes of patients treated in a single facility tend to be similar 23 . Most of the studies included in the evidence base did not account for clustering, and the effect of hospital type might therefore have been exaggerated.…”

“…In one of the few studies to control for the tendency of outcomes to be clustered within facilities 23 , no significant differences in overall survival by hospital type over a 10-year period were found. A study of ovarian cancer found no difference in survival for centres with a gynecologic oncologist compared with other centres 21 .…”

Do all patients with carcinoma of the esophagus benefit from treatment at teaching facilities?

“…Medical facilities were grouped into tertiles based on number of surgeries with curative intent performed during the study period. The upper one-third of institutions was classified as HVC and the lower two third as low volume centers (LVC), as described elsewhere [10,13,[29][30][31][32]. We observed that of the 11 TF, 8 met criteria to be classified as HVC for esophageal resection in the State of Florida.…”

“…For example, Cheung et al showed that for patients with lung cancer, those treated at teaching facilities (TF) and high-volume centers (HVC) had improved medial survival and that TF or HVC were independent predictors of improved survival on multivariate analysis [9]. On the other hand, in patients with gynecologic cancers, it has been demonstrated that no difference in survival was observed for TF or HVC and that further regionalization of care would not improve survival in these patients [10]. Therefore, while it is clear that outcomes at regionalized centers are superior to those at low volume or non-teaching institutions for certain patients, whether all patients, or only certain subsets, derive such benefits is less well-defined.…”

Trends in the receipt of guideline care and survival for women with ovarian cancer: A population-based study

“…This is consistent with other studies using population-based data that have reported that for women with ovarian cancer, hospital volume was not significantly associated with survival after adjusting for other factors, including surgeon volume. 20,21 Other prior studies that have reported that hospital volume and SES were significantly associated with guideline care did not have available information about consultation with a GO, which we had available for our analysis.…”