Elsevier

Gynecologic Oncology

Volume 136, Issue 1, January 2015, Pages 11-17
Gynecologic Oncology

Ovarian cancer in the United States: Contemporary patterns of care associated with improved survival,☆☆,

https://doi.org/10.1016/j.ygyno.2014.10.023Get rights and content

Highlights

  • In the United States, 56% of ovarian cancer cases do not receive NCCN guideline care.

  • Delivery of non-guideline care for ovarian cancer is correlated with facility case volume and survival.

  • 65% of U.S. cancer centers treat fewer than 8 cases of ovarian cancer annually.

Abstract

Background

Ovarian cancer (OC) requires complex multidisciplinary care with wide variations in outcome. We sought to determine the impact of institutional and process of care factors on overall survival (OS) and delivery of guideline care nationally.

Methods

This was a retrospective cohort study of primary OC diagnosed from 1998 to 2007 using the National Cancer Data Base (NCDB) capturing 80% of all U.S. cases. Patient- (demographics, comorbidities, stage/grade), process of care (adherence to guidelines) and institutional- (facility type, case volume) factors were evaluated. Primary outcomes were OS and delivery of guideline therapy. Multivariable logistic regression and Cox proportional hazards models were used for analysis.

Results

We analyzed 96,802 consecutive cases. Five-year OS was 84%, 66.3%, 32% and 15.7% for stages I, II, III and IV, respectively. The annual mean facility case volumes varied by cancer center type (range: 5.7 to 26.7), with 25% of cases spread over 65% of centers — all treating fewer than 8 cases. Overall, 56% of cases received non-guideline care. Low facility case volume and higher comorbidity index independently predicted non-guideline care; high volume centers were less likely to deliver non-guideline care (OR: 0.44, 95% CI: 0.41–0.47). Delivery of non-guideline care (OR: 1.4, 95% CI: 1.36–1.44), and higher facility case volume (OR: 0.91, 95% CI: 0.86–0.96) were both independent predictors of OS.

Conclusions

Delivery of guideline care and facility case volume are important drivers of overall survival. Most cancer centers treat very few women with OC. National efforts should focus on improved access to centers with expertise in OC and ensuring delivery of guideline care.

Introduction

Epithelial ovarian cancer (OC) is the 5th cause of cancer death in women [1]. Advances have improved survival rates including, development of subspecialty care; improved surgical staging and adjuvant chemotherapy; improved rates of cytoreduction and use of intraperitoneal chemotherapy [2].

National Comprehensive Cancer Network (NCCN) guidelines were established to establish stage-specific standards of care [3]. Applying these guidelines is a crucial cost-effective strategy to improve outcomes, but evidence suggests poor compliance with these standards. For example, using medicare data, only 30% of ovarian cancer cases received standard therapy for advanced stage OC (defined as receiving primary surgery and 6 cycles of adjuvant chemotherapy) [4]. The Health Care Cost and Utilization Project demonstrated that 50% of women received inadequate staging: rates of debulking procedures were dependent upon physician specialty and hospital volume [5]. Harlan et al. reported similar findings for early stage disease [6]. Hospital and surgeon volume have remained consistent predictors of oncologic surgical outcomes since the pivotal report by Begg et al. [7], [8] including OC [9].

The National Cancer Database (NCDB) was developed by the American College of Surgeons' (ACoS) Commission on Cancer (CoC) and the American Cancer Society (ACS) [10] to track outcomes from more than 1500 U.S. CoC-accredited programs. In the US, nearly 80% of all OC cases are captured, allowing a broad analysis to examine current care and foster recommendations for improved access, delivery and quality of care.

We sought to evaluate the patterns of OC care in the US to specifically define the influence of patient and institutional factors on overall survival (OS) including the independent relationship between volume and outcomes. We limited this analysis to invasive epithelial OC to allow more focused conclusions.

Section snippets

Case ascertainment and definitions

This study received exempt status from the Institutional Review Board of Washington University. Invasive epithelial OC diagnosed between January 1, 1998 and December 31, 2008 was identified from the NCDB by topography code C56.9; subjects and facilities were de-identified in the public use file (PUF). Records were included if malignant, or the first of two or more independent malignant primary tumors, and if either pathological or clinical staging was known. Histology was classified as serous,

Results

We identified 144,449 eligible cases and a total of 96,802 cases met study inclusion criteria, with cases evenly distributed between the two intervals of analysis (n = 49,160, 1998–2002; n = 47,642, 2003–2007). (Supplemental Fig. 1)

Overall characteristics and trends are shown in Table 1. There were minimal changes observed in the mean age or income categories between time periods. We observed shifts in payer mix: most significantly privately insured patients decreased from 19.4% to 12.9%, while

Discussion

The strengths of this study, one of the largest patterns of care study in OC, include the use of the most comprehensive dataset reporting long-term, stage-specific cancer outcomes available. Our findings identify several opportunities for improvements that can be used to inform policy makers, payors and health-care systems. Our data also provide important insights into the design of relevant and controllable quality measures that can be used by such groups to track quality.

First, survival has

Conflict of interest

The authors have no conflict of interests to report.

Acknowledgment

This project was written in conjunction with the Society of Gynecologic Oncology Outcomes Research Institute and Outcomes Committee. William Cliby received support from NIH grant number: P50 CA136393.

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    Financial Disclosures: none.

    ☆☆

    Funding Sources: William Cliby — NIH Grant Number: P50 CA136393.

    Precis: Nationally, most cancer centers treat fewer than 8 ovarian cancers annually. Case volume appears to be an important independent predictor of both delivery of guideline care and overall survival.

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