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Guideline adherence in ovarian cancer for surgical staging in the Netherlands
  1. Nishita M S Baldewpersad Tewarie1,2,
  2. Maaike van Ham1,
  3. Michel Wouters2,3,
  4. Roy Kruitwagen4 and
  5. Willemien van Driel5
  6. on behalf of the participants of the Dutch Gynecological Oncology Collaborator Group
  7. On behalf of the participants of the Dutch Gynecological Oncology Collaborator Group
    1. 1Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
    2. 2Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, The Netherlands
    3. 3Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
    4. 4Department of Obstetrics and Gynecology, and GROW- School for Oncology and Reproduction, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
    5. 5Department of Gynecology, Amsterdam, Center of Gynecological Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
    1. Correspondence to Nishita M S Baldewpersad Tewarie, Obstetrics and Gynecology, Radboudumc, Nijmegen, 6525 GA, The Netherlands; nishita.tewarie{at}


    Objective Previous studies have shown low adherence to surgical staging guidelines in patients with clinical early-stage ovarian carcinoma. The aim of this study was to identify guideline adherence for surgical staging and to show the distribution of each surgical item within the study population. In addition, we examined whether regional variation in the Netherlands exists for complete surgical staging.

    Methods Patients with ovarian cancer and surgical staging registered in the Dutch Gynecological Oncology Audit between January 1, 2015 and December 31, 2019 in the Netherlands were included. Complete surgical staging was defined according to the Dutch evidence-based guideline. Surgical items were ranked and illustrated. Variation in complete surgical staging for eight regional cancer networks was shown in funnel plots. Manual validation of registered data was performed in three gynecological oncology centers.

    Results 604 patients underwent surgical staging, 365 (60%) underwent an incomplete staging procedure, 295 (81%) were registered with early-stage disease (International Federation of Gynecology and Obstetrics I–IIA) and, of these patients, 115 (39%) received adjuvant chemotherapy. Patients with incomplete surgical staging were operated more often with minimal invasive techniques (laparoscopy or robot) compared with patients in the complete staging group (p<0.001). Sampling of cytology/ascites was the most frequently lacking factor (29%). Manual validation of data in three gynecological oncology centers identified reasons for incomplete staging, the most common being ‘perioperative findings’ such as dense adhesions between tumor and peritoneum, consistent with advanced stage disease (≥IIA). Regional variation for complete surgical staging showed two regions performing outside the confidence intervals (12.5% and 25.5%, mean 40%).

    Conclusion Guideline adherence for staging was lower than expected and validation of data gave additional insights into the reasons that were contributing to incomplete surgical staging. Moreover, this analysis showed that regional variation for surgical staging exists, which forms a starting point to improve and harmonize staging procedures for these patients nationwide.

    • Ovarian Cancer
    • Surgical Oncology

    Data availability statement

    Data are available upon reasonable request.

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    • Collaborators Dutch Gynecological Oncology Collaborator Group: AJ Kruse, gynecologist, Isala Klinieken, Zwolle; R Yigit, gynecologist, University Medical Centre Groningen, Groningen; M van der Aa, Senior investigator National Cancer Care Network (NCCN); JW Mens, radiation oncologist, Erasmus Medical Centre, Rotterdam; TC Stam, radiation oncologist, Haaglanden Medical Center, The Hague; J Diepstraten, patient advocate, Stichting Olijf; A van der Kolk, board member quality of care Stichting Olijf; H Verhoeve, gynecologist, OLVG, Amsterdam; HPM Smedts, gynecologist, Amphia Ziekenhuis, Breda; AMLD van Haaften-de Jong, gynecologist, HagaZiekenhuis, The Hague; N Reesink, gynecologist, Medisch Centrum Twente, Enschede; MC Vos, gynecologist, Elisabeth-TweeSteden Ziekenhuis, Tilburg; AD ten Cate, gynecologist, Spaarne Gasthuis Hoofdorp; BFM Slangen, gynecologist, Maastricht University Medical Centre, Maastricht; PJ Timmers, gynecologist, Maasstad Ziekenhuis, Rotterdam; RA Smit, gynecologist, Jeroen Bosch Ziekenhuis, s-Hertogenbosch; KN Gaarenstroom, gynecologist, Leids Universitair Medisch Centrum, Leiden; PMLH Vencken, gynecologist, Bravis Ziekenhuis, Roosendaal; MJA Engelen, gynecologist, Zuyderland Medisch Centrum, Heerlen; MB Verbruggen, gynecologist, Zaans Medisch Centrum, Zaandam; D Boll, gynecologist, Catharina Ziekenhuis, Eindhoven; G Fons, gynecologist, Academic Medical Centre, Amsterdam; SFPJ Coppus, gynecologist, Maxima Medisch Centrum, Veldhoven; A Baalbergen, gynecologist, Reinier de Graaf Groep, Delft; EBL van Dorst, gynecologist, University Medical Centre Utrecht, Utrecht; MY Tjiong, gynecologist, Vrije Universiteit Medisch Centrum, Amsterdam; EM Roes, gynecologist, Erasmus MC Cancer Institute, Rotterdam; BAJT Visschers, gynecologist, Stichting Zorgsaam Zeeuws Vlaanderen, Terneuzen; CG Gerestein, gynecologist, Meander Medisch Centrum, Amersfoort; HTC Nagel, gynecologist, Haaglanden Medical Centre Bronovo, The Hague; AL Aalders, gynecologist, Rijnstate Ziekenhuis, Arnhem; L Hofman, gynecologist, Albert Schweitzer Ziekenhuis, Dordrecht; J Lange, gynecologist, Sint Antonius Ziekenhuis, Nieuwengein; I Ebisch, gynecologist, Cansius Wilhelmina Ziekenhuis, Nijmegen; J de Waard, gynecologist, Fransiscus Gasthuis & Vlietland, Rotterdam; YWCM van der Plas- Koning. gynecologist, Admiraal de Ruyter, Vlissingen; M Huisman, gynecologist, Gelre Ziekenhuis, Apeldoorn; M Kleppe, gynecologist, Martini Ziekenhuis, Groningen; TK Schukken, gynecologist, Antonius Ziekenhuis, Sneek; J Kaijser, gynecologist, Ikazia Ziekenhuis, Rotterdam; JA Louwers, gynecologist, Diakonessenhuis, Utrecht; LC De Vries, gynecologist, Treant Zorggroep, Hoogeveen; AMG Van de Swaluw, gynecologist, Dijklander Ziekenhuis, Hoorn; DH Ngo, gynecologist, Elkerliek, Helmond.

    • Contributors NMSBT: First author, writing, data collection, revision, final version, guarantor. RK, MW, WJvD, MvH: Active participation in reviewing the manuscript from the first to the last version. The Dutch Gynecology Oncology Collaborator Group: collecting data for the Dutch Gynecological Oncology Audit and reviewing and aproving the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

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

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