The effect of hospital operative volume, residual tumor and first-line chemotherapy on survival of ovarian cancer — A prospective nation-wide study in Finland
Introduction
Ovarian cancer is the sixth most common cancer among women, accounting for 4% of all female malignancies [1]. Survival has improved due to new chemotherapeutic agents and improved surgical treatment [2], [3], [4], but ovarian cancer is still the most common cause of death from gynaecologic cancers in developed countries [4], [5].
The standard treatment for ovarian cancer consists of primary surgery aiming at adequate staging and maximal cytoreduction, and chemotherapy with a platinum–taxane combination [6], [7], [8], [9]. The generally accepted prognostic factors for ovarian cancer are age, FIGO stage, grade, and residual tumor [4], [10]. The need and justification of centralization of the primary surgical treatment of ovarian cancer has been widely discussed [11], [12], [13], [14], [15]. Most published data indicate that patient outcome is associated with the surgical volume of the hospital [11], [16], [17], but also contradictory results have been reported. A recently published population-based cohort study from the US did not show a statistically significant association between hospital operative volume and patient survival [15].
Our retrospective, population-based analysis suggested a survival benefit for ovarian cancer patients treated in hospitals with the largest operative volumes [13]. Data obtained from retrospective studies or cancer registries do not allow detailed evaluation of operative data and association of the results to surgical outcome or postoperative therapy. To obtain more detailed data we performed a prospective, nation-wide survey on primary operative treatment of ovarian cancer in different hospital categories. The estimated odds ratio for optimal cytoreduction was clearly better for patients operated at university hospitals [18]. Now we report the 5-year disease-free survival (DFS) and cancer-specific survival (CSS) for these patients. The study population covered 79% of patients operated for ovarian cancer in 1999, in Finland. Special emphasis was put on the impact of hospital operative volume, residual tumor, and first-line chemotherapy.
Section snippets
Hospital categories
In Finland, five university hospitals are the tertiary referral centres for the total population of 5.3 million people. In addition, there are 16 central hospitals, which do not necessarily have all specialist services and have the services of gynaecologic oncologists only occasionally. The third hospital category consists of smaller city and district hospitals and other miscellaneous units. Some of the central hospitals serve as primary referral units for these smaller hospitals. The site of
Results
The results are based on 275 patients treated for epithelial ovarian cancer. The demographic characteristics, residual disease status and the frequency of lymphadenectomy performed in different hospital categories are presented in Table 1. In university hospitals, pelvic lymphadenectomy was performed for 86%, and para-aortic lymphadenectomy for 71%, of the patients with stage I disease. The corresponding figures in central and district hospitals were 23% and 13%, respectively. In stage II
Discussion
The results of this prospective follow-up study indicate that FIGO stage, residual tumor, and primary chemotherapy are significant prognostic factors for 5-year cancer-specific survival of epithelial ovarian cancer. In addition, hospital operative volume was associated with residual tumor. The strengths of our study are prospective design and high coverage. The study population covered 90% of the patients operated for epithelial ovarian cancer in 1999 in Finland. These factors increase the
Conflict of interest statement
The authors have no conflicts of interest to declare.
Acknowledgments
The study was supported by the Cancer Society of Finland, EVO Grant of Turku University Central Hospital, The Finnish Medical Society Duodecim, and The Finnish Society for Obstetrics and Gynecology. The health care professionals in the participating hospitals are gratefully acknowledged.
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