Elsevier

Gynecologic Oncology

Volume 112, Issue 2, February 2009, Pages 422-436
Gynecologic Oncology

Review
Variations in institutional infrastructure, physician specialization and experience, and outcome in ovarian cancer: A systematic review

https://doi.org/10.1016/j.ygyno.2008.09.036Get rights and content

Abstract

Objective

Ovarian cancer outcome varies among different institutions, regions, and countries. This systematic review summarizes the available data evaluating the impact of different physician and hospital characteristics on outcome in ovarian cancer patients.

Methods

A MEDLINE database search for pertinent publications was conducted and reference lists of each relevant article were screened. Experts in the field were contacted. Selected studies assessed the relationship between physician and/or hospital specialty or volume and at least one of the outcomes of interest. The primary outcome was survival. Additional parameters included surgical outcome (debulking), completeness of staging, and quality of chemotherapy. The authors independently reviewed each article and applied the inclusion/exclusion criteria. The quality of each study was assessed by focusing on strategies to control for important prognostic factors.

Results

Forty-four articles met inclusion criteria. Discipline and sub-specialization of the primary treating physician were identified as the most important variable associated with superior outcome. Evidence showing a beneficial impact of institutional factors was weaker, but followed the same trend. Hospital volume was hardly related to any outcome parameter.

Conclusions

The limited evidence available showed considerable heterogeneity and has to be interpreted cautiously. Better utilization of knowledge about institutional factors and well-established board certifications may improve outcome in ovarian cancer. Patients and primary-care physicians should select gynecologic oncologists for primary treatment in countries with established sub-specialty training. Policymakers, insurance companies, and lay organizations should support development of respective programs.

Introduction

Ovarian cancer is the leading cause of death among all gynecologic cancers. The lifetime risk varies between 1.1 and 1.6 in Europe and the United States [1]. The majority of affected women die from this disease, and overall 5-year-survival rates are still only 48.4% for Federation Internationale de Gynecologie et d'Obstetrique (FIGO) stages I–IV [2]. Five-year-survival rates differ substantially, however, among European countries, ranging from 25.6% in Estonia to 51.4% in Iceland for patients diagnosed between 1990 and 1994 [3].

The chance of surviving ovarian cancer mainly depends on three variables: (1) patient characteristics, (2) tumor biology, and (3) quality of treatment (e.g., surgical outcome, chemotherapy selection). The first two reflect the unchangeable reality of the patient, but the latter is amenable for direct influence, and therefore, seems to be of utmost importance when considering efforts aiming at improvement in the outcome of this disease. The diversity of treatment results might be related to variations in institutional infrastructure, national training and education programs, and physician's specialization and experience. However, only sporadic information about the relationship between the above-mentioned factors and treatment outcome is available. The first review published in 1998 reported a positive impact of specialization on survival in ovarian cancer [4]; however, this review included only seven rather heterogeneous studies available at that time. Since then, more data are available and, therefore, we performed a systematic review to evaluate whether different institutional and physician-related variables have any impact on outcome in ovarian cancer patients. The following hierarchical questions were defined upfront: Are there any institution or physician characteristics that are associated with

  • 1.

    Superior survival?

  • 2.

    Superior surgical outcome with respect to tumor debulking?

  • 3.

    Superior surgical outcome with respect to completeness of staging?

  • 4.

    Superior compliance with guidelines regarding selection of chemotherapy regimens?

Section snippets

Data sources

We searched MEDLINE for literature published between 1 January 1980 and 31 July 2007, using the following algorithm: “ovarian neoplasms” [MeSH Terms] AND (patterns of care [Text Word = TW] OR quality of health care [TW] OR audit [TW] OR centralization [TW] OR centralisation [TW] OR centralized treatment [TW] OR centralised treatment [TW] OR specialization [TW] OR specialisation [TW] OR specialty [TW] OR specialties [TW] OR specialist [TW] OR gynecologic oncologist [TW] OR gynecological oncologist

Literature review and inclusion criteria

One hundred ninety-eight publications were identified in MEDLINE through our search algorithm. Of the identified publications, 38 were considered relevant according to the inclusion criteria [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42]. The screening of the bibliographies of the articles retrieved from the electronic

Discussion

Surgery and chemotherapy are the mainstays in the treatment of both early and advanced ovarian cancer. Several guidelines and consensus statements outlining detailed surgical, as well as chemotherapeutical procedures, have been published in the US and worldwide [53], [54], [55]. However, adherence to these treatment recommendations is poor even in countries with established training programs in gynecologic oncology [15], [28]. Completeness of tumor resection and comprehensive staging are of

Conflict of interest statement

The authors have no conflicts of interest to declare.

Acknowledgments

The authors want to thank all authors and co-workers of the articles included; and especially those who provided original data, further details and analysis or explanations regarding their published articles: K. Bertelsen and R. dePont Christensen, C. Earle and B. Neville, L. Elit, B. M. Engelen, Goff, D. Hole, A. Ioka, S. Kumpulainen and R. Sankila, A. Olaitan and A. Mocroft, T. Paulsen, M. Quinn and V. Thursfield, I. Skirnisdottir and B. Sorbe, D. Stockton, S. Tingulstad and F. Skjeldestad,

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