Elsevier

Gynecologic Oncology

Volume 115, Issue 2, November 2009, Pages 199-203
Gynecologic Oncology

The effect of hospital operative volume, residual tumor and first-line chemotherapy on survival of ovarian cancer — A prospective nation-wide study in Finland

https://doi.org/10.1016/j.ygyno.2009.07.011Get rights and content

Abstract

Objective

Our recent prospective, nation-wide study indicated better surgical outcome in ovarian cancer patients operated at university hospitals compared to other hospitals. Here we report how this is reflected in 5-year cancer-specific survival (CSS).

Methods

Detailed 5-year follow-up data were obtained on 275 patients by using a special questionnaire, and the data were verified from the Finnish Cancer Registry data. The hospitals were categorized to university and other hospitals and by the number of operations performed in 1999 (< 10, 10–20, or > 20 operations). Data were analyzed using the Cox's proportional hazards regression analysis.

Results

The study population covered 90% of the epithelial ovarian cancer patients operated in 1999, in Finland. Eighty-two percent of the patients received platinum-based chemotherapy. The percentage of patients treated with a platinum–taxane combination was higher in university hospitals (63% vs. 49%, P = 0.037). The 5-year CSS was 56% and the median disease-free survival (DFS) was 33 months. In multivariate analysis prognostic factors for CSS were stage (P = 0.0027), residual tumor (P = 0.0001), and primary chemotherapy (P < 0.0001). Hospital operative volume was associated with residual tumor (P = 0.027). When hospital operative volume increased with ten patients per year, the odds ratio for no residual disease was 1.203 (95% CI 1.022–1.417).

Conclusion

FIGO stage, residual tumor, and primary chemotherapy are significant prognostic factors for ovarian cancer. Hospital volume is associated with residual tumor. The results favor performance of ovarian cancer surgery in hospitals with higher operative volumes.

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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