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Exploring international differences in ovarian cancer treatment: a comparison of clinical practice guidelines and patterns of care
  1. Charles H Norell1,
  2. John Butler1,2,
  3. Rhonda Farrell3,
  4. Alon Altman4,
  5. James Bentley5,
  6. Citadel J Cabasag6,
  7. Paul A Cohen7,
  8. Scott Fegan8,
  9. Michael Fung-Kee-Fung9,
  10. Charlie Gourley10,
  11. Neville F Hacker11,12,
  12. Louise Hanna13,
  13. Claus Kim Høgdall14,
  14. Gunnar Kristensen15,
  15. Janice Kwon16,
  16. Orla McNally17,
  17. Gregg Nelson18,
  18. Andy Nordin19,
  19. Dearbhaile O'Donnell20,
  20. Tine Schnack21,
  21. Peter H Sykes22,
  22. Ewa Zotow23 and
  23. Samantha Harrison23
  1. 1 International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London, UK
  2. 2 Gynaecology Department, Royal Marsden NHS Foundation Trust, London, UK
  3. 3 Gynaecological Oncology Department, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
  4. 4 Department of Gynecologic Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
  5. 5 Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
  6. 6 Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
  7. 7 Department of Gynaecological Oncology, St John of God Health Care, West Perth, Ontario, Australia
  8. 8 Department of Obstetrics and Gynaecology, NHS Lothian, Edinburgh, UK
  9. 9 Department of Obstetrics, Gynaecology and Surgery, University of Ottawa, Ottawa, Ontario, Canada
  10. 10 Cancer Research UK Edinburgh Centre, The University of Edinburgh, Edinburgh, Scotland, UK
  11. 11 Gynaecological Cancer Centre, Royal Hospital for Women, Randwick, New South Wales, Australia
  12. 12 School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
  13. 13 Department of Oncology, Velindre Cancer Centre, Cardiff, Wales, UK
  14. 14 Gynecologic Department, The Juliane Marie Centre, Copenhagen, Denmark
  15. 15 Department of Gynecologic Oncology and Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
  16. 16 Department of Obstetrics and Gynaecology, Vancouver General Hospital, Vancouver, British Columbia, Canada
  17. 17 Oncology and Dysplasia Service, Royal Women's Hospital, Parkville, Victoria, Australia
  18. 18 Department of Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
  19. 19 Department of Gynaecological Oncology, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
  20. 20 Department of Medical Oncology, St. James's Hospital, Dublin, Ireland
  21. 21 Department of Gynaecology, Copenhagen University Hospital, Copenhagen, Denmark
  22. 22 Department of Obstetrics and Gynaecology, University of Otago, Dunedin, New Zealand
  23. 23 Policy & Information, Cancer Research UK, London, UK
  1. Correspondence to Charles H Norell, International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London EC1V 4AD, UK; ICBP{at}


Introduction The International Cancer Benchmarking Partnership demonstrated international differences in ovarian cancer survival, particularly for women aged 65–74 with advanced disease. These findings suggest differences in treatment could be contributing to survival disparities.

Objective To compare clinical practice guidelines and patterns of care across seven high-income countries.

Methods A comparison of guidelines was performed and validated by a clinical working group. To explore clinical practice, a patterns of care survey was developed. A questionnaire regarding management and potential health system-related barriers to providing treatment was emailed to gynecological specialists. Guideline and survey results were crudely compared with 3-year survival by ‘distant’ stage using Spearman’s rho.

Results Twenty-seven guidelines were compared, and 119 clinicians completed the survey. Guideline-related measures varied between countries but did not correlate with survival internationally. Guidelines were consistent for surgical recommendations of either primary debulking surgery or neoadjuvant chemotherapy followed by interval debulking surgery with the aim of complete cytoreduction. Reported patterns of surgical care varied internationally, including for rates of primary versus interval debulking, extensive/‘ultra-radical’ surgery, and perceived barriers to optimal cytoreduction. Comparison showed that willingness to undertake extensive surgery correlated with survival across countries (rs=0.94, p=0.017). For systemic/radiation therapies, guideline differences were more pronounced, particularly for bevacizumab and PARP (poly (ADP-ribose) polymerase) inhibitors. Reported health system-related barriers also varied internationally and included a lack of adequate hospital staffing and treatment monitoring via local and national audits.

Discussion Findings suggest international variations in ovarian cancer treatment. Characteristics relating to countries with higher stage-specific survival included higher reported rates of primary surgery; willingness to undertake extensive/ultra-radical procedures; greater access to high-cost drugs; and auditing.

  • ovarian cancer
  • surgery
  • surgical oncology
  • medical oncology

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, an indication of whether changes were made, and the use is non-commercial. See:

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  • Contributors CHN, JBu, RF, andSH: methodology, validation, data collection, analysis, writing - original draft and editing. AA, JBe, SF, MF-K-F, CG, NFH, LH, CKH, GK, JK, OM, GN, AN, DO, TS, and PHS: validation, data collection, analysis, writing - review & editing. CJC: methodolgy, writing - review and editing. PAC: methodology, validation, data collection, analysis, writing - review and editing. EZ: methodology, analysis.

  • Funding This study was funded by the Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Institute New South Wales; Cancer Research UK; Danish Cancer Society; National Cancer Registry Ireland; The Cancer Society of New Zealand; National Health Service England; Norwegian Cancer Society; Public Health Agency Northern Ireland, on behalf of the Northern Ireland Cancer Registry; The Scottish Government; Western Australia Department of Health; and Wales Cancer Network.

  • Disclaimer The findings and interpretations in this article are those of the authors and do not necessarily represent the views of any government agency or funder. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. This manuscript includes anonymous survey data at country level. Survey data at states/provinces/nation level are available on request from

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