Abstract
Arguments for centralization of EOC treatment: There is considerable debate about whether specialized care has an effect on with the outcome of advanced (stages III–IV) epithelial ovarian cancer (EOC). It is known that the quality of surgery is one of the most important factors affecting the outcome of women with advanced EOC. We have reviewed the European population-based literature, focusing especially on studies published in the last 10 years, and have found that the evidence shows advantages for patients who undergo surgery performed by gynecologic oncologists over general gynecologists and general surgeons in terms of quality of life, morbidity, and survival. Despite this, population-based studies in Europe show that less than 50 % of patients with advanced EOC have their surgery performed by a gynecologic oncologist, and the debate about the benefits of advanced EOC centralization has continued. It is of great importance that EOC be centralized to centers with sufficiently skilled surgeons and the necessary organization to appropriately handle advanced EOC patients. This requires national health systems to secure sufficient education and training for all medical staff involved. Gynecologic cancers make up the second most common cancer among women. Five major gynecologic malignancies include cervical, ovarian, uterine vaginal, and vulvar cancers. All would agree that their management requires a multidisciplinary approach encompassing combinations of surgery, chemotherapy, and radiation treatment and also needing the help of psychologists, social workers, specialized nurses, and others. It has been claimed that centralization of gynecologic cancer improves outcome, but robust evidence is lacking. Most of the available evidence addresses ovarian cancer in developed countries and contains no information on the role of satellite centers or of other care models which can match the outcomes of centralized services. In fact for all gynecologic malignancy, the treatment site does not affect overall survival. All agree that accurate and complete surgical staging is associated with prolonged survival rates in women with early ovarian cancer and that optimal debulking improves progression-free and overall survival rates in advanced disease. But ovarian cancer is but one part of the spectrum of gynecologic malignancy and, indeed, given the epidemic of endometrial cancer due to obesity, which could engulf specialized units, a relatively less common one than previously. The data on surgical outcomes and their importance are still controversial and relate only to ovarian cancers. There are very few studies addressing outcomes in the other more common gynecologic malignancies including cervical and endometrial. It is impossible to prove that centralization is necessary as most of the published evidence is based on retrospective observational studies and therefore is at high risk of bias. To date no randomized trials have been undertaken to confirm this hypothesis
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Verleye L, Vergote I, van der Zee AG. Patterns of care in surgery for ovarian cancer in Europe. Eur J Surg Oncol. 2010;36 Suppl 1:S108–14.
Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer. 2010;46(4):765–81.
Sant M, Aareleid T, Berrino F, Bielska Lasota M, Carli PM, Faivre J, et al. EUROCARE-3: survival of cancer patients diagnosed 1990–94 – results and commentary. Ann Oncol. 2003;14 Suppl 5:v61–118.
Bray F, Loos AH, Tognazzo S, La Vecchia C. Ovarian cancer in Europe: cross-sectional trends in incidence and mortality in 28 countries, 1953–2000. Int J Cancer. 2005;113(6):977–90.
Paulsen T, Kjaerheim K, Kaern J, Tretli S, Tropé C. Improved short-term survival for advanced ovarian, tubal, and peritoneal cancer patients operated at teaching hospitals. Int J Gynecol Cancer. 2006;16 Suppl 1:11–7.
Bjørge T, Engeland A, Sundfør K, Tropé CG. Prognosis of 2,800 patients with epithelial ovarian cancer diagnosed during 1975–94 and treated at the Norwegian Radium Hospital. Acta Obstet Gynecol Scand. 1998;77(7):777–81.
Larsen IK, Grimsrud TK, Haldorsen T, Johannesen TB, Johansen A, Langseth H, et al., editors. Cancer in Norway 2009 – cancer incidence, mortality, survival and prevalence in Norway. Oslo: Cancer Registry of Norway; 2011.
Vernooij F, Heintz P, Witteveen E, van der Graaf Y. The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol. 2007;105(3):801–12.
Meigs JV. Tumors of the female pelvic organs. New York: Macmillan; 1934.
Griffiths CT. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma. Natl Cancer Inst Monogr. 1975;42:101–4.
Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol. 2002;20(5):1248–59.
Chi DS, Eisenhauer EL, Lang J, Huh J, Haddad L, Abu-Rustum NR, et al. What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol. 2006;103(2):559–64.
Hoskins WJ, Bundy BN, Thigpen JT, Omura GA. The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume stage III epithelial ovarian cancer: a Gynecologic Oncology Group study. Gynecol Oncol. 1992;47(2):159–66.
du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d’Investigateurs Nationaux Pour les Etudes des Cancers de l’Ovaire (GINECO). Cancer. 2009;115(6):1234–44.
Harter P, Hilpert F, Mahner S, Kommoss S, Heitz F, Pfisterer J, et al. Prognostic factors for complete debulking in first- and second-line ovarian cancer. Int J Gynecol Cancer. 2009;19 Suppl 2:S14–7.
Killeen SD, O’Sullivan MJ, Coffey JC, Kirwan WO, Redmond HP. Provider volume and outcomes for oncological procedures. Br J Surg. 2005;92(4):389–402.
Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol. 2000;18(11):2327–40.
Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137(6):511–20.
Bentrem DJ, Brennan MF. Outcomes in oncologic surgery: does volume make a difference? World J Surg. 2005;29(10):1210–6.
Olaitan A, Weeks J, Mocroft A, Smith J, Howe K, Murdoch J. The surgical management of women with ovarian cancer in the south west of England. Br J Cancer. 2001;85(12):1824–30.
Kehoe S, Powell J, Wilson S, Woodman C. The influence of the operating surgeon’s specialisation on patient survival in ovarian carcinoma. Br J Cancer. 1994;70(5):1014–7.
Junor EJ, Hole DJ, McNulty L, Mason M, Young J. Specialist gynaecologists and survival outcome in ovarian cancer: a Scottish national study of 1866 patients. Br J Obstet Gynaecol. 1999;106(11):1130–6.
Covens AL. A critique of surgical cytoreduction in advanced ovarian cancer. Gynecol Oncol. 2000;78(3 Pt 1):269–74.
Engelen MJ, Kos HE, Willemse PH, Aalders JG, de Vries EG, Schaapveld M, et al. Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma. Cancer. 2006;106(3):589–98.
Oberaigner W, Stühlinger W. Influence of department volume on cancer survival for gynaecological cancers – a population-based study in Tyrol, Austria. Gynecol Oncol. 2006;103(2):527–34.
Harlan LC, Clegg LX, Trimble EL. Trends in surgery and chemotherapy for women diagnosed with ovarian cancer in the United States. J Clin Oncol. 2003;21(18):3488–94.
Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson N, et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med. 2010;363(10):943–53.
Tsolakidis D, Amant F, Van Gorp T, Leunen K, Neven P, Vergote I. Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB-IV epithelial ovarian cancer. Gynecol Oncol. 2010;116(3):489–96.
Yildirim Y, Sanci M. The feasibility and morbidity of distal pancreatectomy in extensive cytoreductive surgery for advanced epithelial ovarian cancer. Arch Gynecol Obstet. 2005;272(1):31–4.
Crawford SC, Vasey PA, Paul J, Hay A, Davis JA, Kaye SB. Does aggressive surgery only benefit patients with less advanced ovarian cancer? Results from an international comparison within the SCOTROC-1 Trial. J Clin Oncol. 2005;23(34):8802–11.
du Bois A, Rochon J, Pfisterer J, Hoskins WJ. Variations in institutional infrastructure, physician specialization and experience, and outcome in ovarian cancer: a systematic review. Gynecol Oncol. 2009;112(2):422–36.
Bristow RE, Zahurak ML, Diaz-Montes TP, Giuntoli RL, Armstrong DK. Impact of surgeon and hospital ovarian cancer surgical case volume on in-hospital mortality and related short-term outcomes. Gynecol Oncol. 2009;115(3):334–8.
Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol. 2005;99(2):447–61.
Eisenkop SM, Spirtos NM, Montag TW, Nalick RH, Wang HJ. The impact of subspecialty training on the management of advanced ovarian cancer. Gynecol Oncol. 1992;47(2):203–9.
Earle CC, Schrag D, Neville BA, Yabroff KR, Topor M, Fahey A, et al. Effect of surgeon specialty on processes of care and outcomes for ovarian cancer patients. J Natl Cancer Inst. 2006;98(3):172–80.
Tingulstad S, Skjeldestad FE, Hagen B. The effect of centralization of primary surgery on survival in ovarian cancer patients. Obstet Gynecol. 2003;102(3):499–505.
Wolfe CD, Tilling K, Raju KS. Management and survival of ovarian cancer patients in south east England. Eur J Cancer. 1997;33(11):1835–40.
Stockton D, Davis T. Multiple cancer site comparison of adjusted survival by hospital of treatment: an East Anglican study. Br J Cancer. 2000;82:208–12.
Münstedt K, von Georgi R, Misselwitz B, Zygmunt M, Stillger R, Künzel W. Centralizing surgery for gynecologic oncology – a strategy assuring better quality treatment? Gynecol Oncol. 2003;89(1):4–8.
Shylasree TS, Howells RE, Lim K, Jones PW, Fiander A, Adams M, et al. Survival in ovarian cancer in Wales: prior to introduction of all Wales guidelines. Int J Gynecol Cancer. 2006;16(5):1770–6.
Kumpulainen S, Kuoppala T, Leminen A, Penttinen J, Puistola U, Pukkala E, et al. Surgical treatment of ovarian cancer in different hospital categories – a prospective nation-wide study in Finland. Eur J Cancer. 2006;42(3):388–95.
Weide R, Arndt M, Pandorf A, Heymanns J, Thomalla J, Köppler H. Ovarian cancer treatment reality in northern Rheinland-Pfalz (Germany). Suboptimal surgical treatment as a possible cause for inferior survival. Onkologie. 2007;30(12):611–7.
Skírnisdóttir I, Sorbe B. Prognostic factors for surgical outcome and survival in 447 women treated for advanced (FIGO-stages III-IV) epithelial ovarian carcinoma. Int J Oncol. 2007;30(3):727–34.
Aune G, Torp SH, Syversen U, Hagen B, Tingulstad S. Ten years’ experience with centralized surgery of ovarian cancer in one health region in Norway. Int J Gynecol Cancer. 2012;22(2):226–31.
Fagö-Olsen CL, Høgdall C, Kehlet H, Christensen IJ, Ottesen B. Centralized treatment of advanced stages of ovarian cancer improves survival: a nationwide Danish survey. Acta Obstet Gynecol Scand. 2011;90:273–9.
Goff BA, Matthews BJ, Wynn M, Muntz HG, Lishner DM, Baldwin LM. Ovarian cancer: patterns of surgical care across the United States. Gynecol Oncol. 2006;103(2):383–90.
Marth C, Hiebl S, Oberaigner W, Winter R, Leodolter S, Sevelda P. Influence of department volume on survival for ovarian cancer: results from a prospective quality assurance program of the Austrian Association for Gynecologic Oncology. Int J Gynecol Cancer. 2009;19(1):94–102.
Soegaard Andersen E, Knudsen A, Svarrer T, Lund B, Nielsen K, Grove A, et al. The results of treatment of epithelial ovarian cancer after centralisation of primary surgery. Results from North Jutland, Denmark. Gynecol Oncol. 2005;99(3):552–6.
Bailey J, Murdoch J, Anderson R, Weeks J, Foy C. Stage III and IV ovarian cancer in the South West of England: five-year outcome analysis for cases treated in 1998. Int J Gynecol Cancer. 2006;16 Suppl 1:25–9.
Petignat P, Vlastos G. Why do ovarian cancer patients not consult a gynecologic oncologist? Gynecol Oncol. 2002;87(1):157.
du Bois A, Rochon J, Lamparter C, Pfisterer J, AGO Organkommission OVAR PFisterer. Pattern of care and impact of participation in clinical studies on the outcome in ovarian cancer. Int J Gynecol Cancer. 2005;15(2):183–91.
Vergote I. VWOG-oncologieregistratie 1998–2002. Deel 5: Ovariumcarcinoom. Tijdschrift Voor Geneeskunde. 2006;62(11):853–8.
Marx C, Bendixen A, Høgdall C, Ottosen C, Kehlet H, Ottesen B. Organisation and quality of primary surgical intervention for ovarian cancer in Denmark. Acta Obstet Gynecol Scand. 2007;86(12): 1496–502.
Akeson M, Jakobsen AM, Zetterqvist BM, Holmberg E, Brännström M, Horvath G. A population-based 5-year cohort study including all cases of epithelial ovarian cancer in western Sweden: 10-year survival and prognostic factors. Int J Gynecol Cancer. 2009;19(1):116–23.
Bristow RE, Palis BE, Chi DS, Cliby WA. The National Cancer Database report on advanced-stage epithelial ovarian cancer: impact of hospital surgical case volume on overall survival and surgical treatment paradigm. Gynecol Oncol. 2010;118(3):262–7.
Kumpulainen S, Sankila R, Leminen A, Kuoppala T, Komulainen M, Puistola U, et al. The effect of hospital operative volume, residual tumor and first-line chemotherapy on survival of ovarian cancer – a prospective nation-wide study in Finland. Gynecol Oncol. 2009;115(2):199–203.
Schrag D, Earle C, Xu F, Panageas KS, Yabroff KR, Bristow RE, et al. Associations between hospital and surgeon procedure volumes and patient outcomes after ovarian cancer resection. J Natl Cancer Inst. 2006;98(3):163–71.
Vernooij F, Witteveen PO, Verweij E, van der Graaf Y, Heintz AP. The impact of hospital type on the efficacy of chemotherapy treatment in ovarian cancer patients. Gynecol Oncol. 2009;115(3):343–8.
Elit L, Bondy SJ, Paszat L, Przybysz R, Levine M. Outcomes in surgery for ovarian cancer. Gynecol Oncol. 2002;87:260–7.
Kumpulainen S, Grénman S, Kyyrönen P, Pukkala E, Sankila R. Evidence of benefit from centralised treatment of ovarian cancer: a nationwide population-based survival analysis in Finland. Int J Cancer. 2002;102(5):541–4.
du Bois A, Rochon J, Lamparter C, Pfisterer J. Impact of center characteristics on outcome in ovarian cancer in Germany. Zentralbl Gynakol. 2005;127(1):18–30. German.
Szczesny W, Paulsen T, Tropé C. Improved 8-years survival for ovarian cancer patients FIGO stage IIIc operated at teaching hospitals in Norway. Abstract presented at the 17th international meeting of the European Society of Gynaecological Oncology (ESGO). Milan; 11–14 Sept 2011.
Carney ME, Lancaster JM, Ford C, Tsodikov A, Wiggins CL. A population-based study of patterns of care for ovarian cancer: who is seen by a gynecologic oncologist and who is not? Gynecol Oncol. 2002;84(1):36–42.
Woodman C, Baghdady A, Collins S, Clyma JA. What changes in the organisation of cancer services will improve the outcome for women with ovarian cancer? Br J Obstet Gynaecol. 1997;104(2):135–9.
NIH consensus conference. Ovarian cancer. Screening, treatment, and follow-up. NIH Consensus Development Panel on Ovarian Cancer. JAMA. 1995;273(6):491–7.
Bristow RE, Berek JS. Surgery for ovarian cancer: how to improve survival. Lancet. 2006;367(9522):1558–60.
Oksefjell H, Sandstad B, Trope C. Ovarian cancer stage IIIC. Consequences of treatment level on overall and progression-free survival. Eur J Gynaecol Oncol. 2006;27(3):209–14.
Powell M, Cliby W, Bristow R, Al-Hammadi N, Chen L, Miller J, et al. Adherence with National Comprehensive Cancer Network (NCCN) Guidelines Associated with improved survival in ovarian cancer patients, a study of 144,449 patients from the National Cancer Data Base: a project from the Society of Gynecologic Oncologists (SGO) Quality and Outcomes Committee. Late-breaking abstracts presented at the 42nd annual meeting of the Society of Gynecologic Oncologists. Gynecol Oncol. 2011;121(2):S1–3.
Cancer treatment policies and their effects on survival – ovary. Key sites study 8. Leeds: Northern and Yorkshire Cancer Registry and Information Service; 2002. http://www.nycris.org.uk. Accessed 4 July 2007.
Crawford SM, Brunskill PJ. Centralisation of services for the management of ovarian cancer: arguments against. BJOG. 2007;114(10):1183–5.
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001;20(3 Suppl):21–35.
Vergote I, de Oliveira C, Dargent D. How to organize gynecologic oncology in the future: results of an international questionnaire. Int J Gynecol Cancer. 1997;7(5):368–75.
Cibula D, Kesic V. Surgical education and training in gynecologic oncology I: European perspective. Gynecol Oncol. 2009;114(2 Suppl):S52–5.
Kjaerbye-Thygesen A, Huusom LD, Frederiksen K, Kjaer SK. Trends in the incidence and mortality of ovarian cancer in Denmark 1978–2002. Comparison with other Nordic countries. Acta Obstet Gynecol Scand. 2005;84(10):1006–12.
Ottesen B, Iversen MG, Kehlet H. Surgical treatment for ovarian cancer in Denmark 2004–2007. Ugeskr Laeger. 2009;171(4):217–20. Danish.
Dobbs S. Commentary on “centralisation of ovarian cancer”. BJOG. 2007;114(10):1186–7.
Hackman N, Olaitan A, Mould T, Sherr L. Evaluating women’s experience of a centralized service for gynaecological malignancies. Abstract 740. Int J Gynecol Cancer. 2004;14 Suppl 1:205.
Olaitan A, Murdoch J, Weeks J, James J, Howe K. The management of women with apparent early ovarian cancer in the south-west region of England. J Obstet Gynaecol. 2002;22(4):394–8.
Olaitan A, McCormack M. Centralisation of services for the management of ovarian cancer: arguments for. BJOG. 2007;114(10):1188–90.
Brookfield KF, et al. Will patients benefit from regionalization of gynecologic cancer care? PLoS One. 2009;4(1):e4049.
Parkin DE, et al. An audit of the quality of endometrial cancer in specialised unit. Scott Med J. 2006;51(2):22–4.
Hoekstra A, et al. Participation of the general gynecologist in surgical staging of endometrial cancer: analysis of cost and perioperative outcomes. Gynecol Oncol. 2006;103:897–901.
Underhill C, et al. Mapping oncology services in regional and rural Australia. Aust J Rural Health. 2009;17:321–9.
Junor EJ, Hole DHS, Gill CR. Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer. 1994;70:363–70.
Crawford R, Greenberg D. Improvements in survival of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of multidisciplinary management? BJOG. 2012;119(2):160–5.
Jong KE, Vale PJ, Armstrong BK. Rural inequalities in cancer care and outcome. Med J Aust. 2005;182:13–4.
Butow PN, Phillips F, Schweder J, White K, Underhill C, Goldstein D. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer. 2012;20(1):1–22.
Grimison P, Phillips F, Butow P, White K, Yip D, Sardelic F, Underhill C, Tse R, Simes R, Turley K, Raymond C, Goldstein D. Are visiting oncologists enough? A qualitative study of the needs of Australian rural and regional cancer patients, carers and health professionals. Asia Pac J Clin Oncol. 2012. doi:10.1111/ajco.12014 [Epub ahead of print].
Ke KM, Hollingworth W, Ness AR. The costs of centralisation: a systematic review of the economic impact of the centralisation of cancer services. Eur J Cancer Care (Engl). 2012;21(2):158–68.
Underhill CR, Goldstein D, Grogan PB. Inequity in rural cancer survival in Australia is not an insurmountable problem. Med J Aust. 2006;185(9):479–80.
Campbell NC, Ritchie LD, Cassidy J, Little J. Systematic review of cancer treatment programmes in remote and rural areas. Br J Cancer. 1999;80:1275–80.
Underhill C, Koschel A, Szer J, Steer C, Clarke K, Grigg A, Juneja S, Stella D, Francis H, Josselyn K. Mentoring in the management of hematological malignancies. Asia Pac J Clin Oncol. 2010;6(1):28–34.
Available from: http://10thnrhc.ruralhealth.org.au/papers/docs/Phillips_Jane_C2.pdf.
McConigley R, Platt V, Holloway K, Smith J. Developing a sustainable model of rural cancer care: the Western Australian Cancer Network project. Aust J Rural Health. 2011;19(6):324–8.
Vernooij F, et al. Specialized care and survival of ovarian cancer patients in Netherlands; nation wide cohort study [see comment]. J Natl Cancer Inst. 2008;100:399–406.
Tingulstad S, Skjldestad FE, Halvorsen TB, Hagen B. Survival and prognostic factors in patients with ovarian cancer. Obstet Gynecol. 2003;101:885–91.
Nguyen H, Averette HE, Hoskins W, Penlaver M, Bernd-Uwe S, Steren A. National survey of ovarian carcinoma part V. The impact of physician’s specialty on patient’s survival. Cancer. 1993;72: 3663–70.
Woo YL, Kyrgio M, Bryant A, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev. 2012;(3):CD007945.
Jong KE, Smith DP, Yu XQ, et al. Remoteness of residence and survival from cancer in New South Wales. Med J Aust. 2004;b180: 618–22.
Elatter A. Bryant A, Winter-Roach BA. Optimal primary surgical treatment for advanced epithelial ovarian cancer. Cochrane Database Syst Rev. 2011;(8):CD007565.
Acknowledgments
We wish to thank Ms. Trudy Perdrix-Thoma for her assistance in editing the chapter and Mrs. Gry Seppola for technical assistance. We also gratefully acknowledge the financial support from the Inger and John Fredriksen Foundation for Ovarian Cancer Research.
Author information
Authors and Affiliations
Corresponding authors
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2014 Springer-Verlag London
About this chapter
Cite this chapter
Tropé, C.G., Paulsen, T., Saqib, A., Underhill, C. (2014). What Is the Best Treatment Model for Gynecologic Cancers? Does Centralization Help?. In: Ledermann, J., Creutzberg, C., Quinn, M. (eds) Controversies in the Management of Gynecological Cancers. Springer, London. https://doi.org/10.1007/978-0-85729-910-9_12
Download citation
DOI: https://doi.org/10.1007/978-0-85729-910-9_12
Published:
Publisher Name: Springer, London
Print ISBN: 978-0-85729-909-3
Online ISBN: 978-0-85729-910-9
eBook Packages: MedicineMedicine (R0)