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Can international standards in ovarian cancer treatment be attained by low- and middle-income countries?
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  1. Daniel Sanabria1,
  2. Laura Gómez1,
  3. Juliana Rodriguez1,2,
  4. Javier Mauricio Segovia3 and
  5. Adriana Ramos1
    1. 1Ginecología y Obstetricia, Hospital Universitario de la Fundación Santa Fe de Bogotá, Bogotá, Colombia
    2. 2Universidad Nacional de Colombia, Bogota, Colombia
    3. 3Oncology, Hospital Universitario de la Fundacion Santa Fe de Bogota, Bogota, Colombia
    1. Correspondence to Dr Laura Gómez, Ginecología y Obstetricia, Hospital Universitario de la Fundación Santa Fe de Bogotá, Bogotá, Bogotá, Colombia; lauragomez98{at}gmail.com

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    Ovarian cancer is the third most deadly cancer in females from low- and middle-income countries after breast and cervical cancer. Late diagnosis is a contributing factor, as serous high grade carcinomas are mostly diagnosed in advanced stages (stage III 51%, stage IV 29%), affecting overall and disease-free survival. Patients with ovarian cancer require a multidisciplinary assessment from various specialties such as gynecologic oncology, clinical oncology, radiology, pathology, genetics, nutrition, intensive care, palliative care, and psychology among others. In Colombia and Latin America, most institutions cannot provide all these areas of expertise. As a result, patient care is often fragmented, delayed, and lacks shared decision-making.

    One remarkable barrier to high quality care is surgical expertise in ovarian cancer debulking. Complete debulking is a cornerstone for management and a strong predictor of outcomes. Nevertheless, not all gynecologic oncology centers have enough expertise in upper abdominal or ultraradical surgery. In response to these challenges, the first project Epithelial Ovarian Cancer Clinical Care Center in Latin America was established in 2018 in Fundación Santa Fe de Bogotá, Colombia. Efforts were made to assemble a multidisciplinary team of caregivers and create a management protocol based on international guidelines. This care plan is divided into four stages: (1) correct diagnosis and risk mitigation; (2) cytoreductive surgery; (3) adjuvant chemotherapy; and (4) strict follow-up. Every step goes beyond treatment guidelines by performing risk identification, mitigation, and adjusting the treatment plan to the patient’s needs.

    Following the recommendations from the European Society of Gynecologic Oncology (ESGO), quality indicators were designed to assess the center’s procedures and results. These allowed the team to identify opportunities of improvement regarding safety, timely care, therapeutic approaches, and patient well-being. As the amount of treated patients grew, we sought to be accredited by the Joint Commission International. This organization is recognized as a leader in healthcare, quality of care, and patient safety in over 70 countries. The accreditation as a clinical care center certifies our commitment to improve the quality of patient care, management of the disease under evidenced-based protocols, and engagement with patients to improve awareness of disease. During this process, quality indicators were analyzed, clinical records were reviewed in the outpatient and surgical settings, and the compliance of all Joint Commission International standards were assessed. The institution was recognized for providing integral care, having adequate infrastructure and technology that facilitates adherence to guidelines, and an excellent rate of patient satisfaction.

    One of our most important quality indicators is the rate of optimal (no visible disease) cytoreductive surgeries. The established goal is to maintain our rate above 65% as suggested by ESGO’s quality standards. To achieve this, our care protocol dictates that all patients undergo radiologic and laparoscopic evaluation, as well as assessment of comorbidities, to establish if patients will benefit from neoadjuvant chemotherapy. Timely care is another pillar of the center. We included time from surgery to chemotherapy as a quality indicator to avoid delays undermining the benefits of debulking surgery. Also, our multidisciplinary tumor board along with strict follow ups improved our capacity to identify relapses and make group decisions before there is further deterioration of a patient’s health and life quality.

    In conclusion, there are various learning points from this process. First, every patient with ovarian cancer should be individualized and assessed by a multidisciplinary tumor board in order to find the best timing for debulking surgery. Communication within the team is necessary to assure timely management and improved outcomes. Lastly, despite structural barriers in low- and middle-income countries, we strongly believe that quality standards can be attained in the treatment of patients with ovarian cancer.

    Figure 1

    Accreditation visit for the Ovarian Cancer Clinical Care Center at Fundación Santa Fe de Bogotá, Colombia.

    Figure 2

    Ovarian Cancer Patients′ II annual meeting.

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    Footnotes

    • X @danielsanabrias, @_lauragomez98, @julianalrc

    • Contributors All authors mentioned were involved in the planning, writing and editing of this 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; internally peer reviewed.