Ovarian cancer in the United States: Contemporary patterns of care associated with improved survival☆,☆☆,★
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.
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Funding Sources: William Cliby — NIH Grant Number: P50 CA136393.
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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.