Improved survival with clinical guidelines? Evaluation of a quality register linked to clinical guidelines for ovarian cancer in the western health care region in Sweden between 1 September 1993 and 1 June 1998

Survival of women with cancers of breast and genital organs in Europe 1999-2007: Results of the EUROCARE-5 study

BACKGROUND

Survival differences across Europe for patients with cancers of breast, uterus, cervix, ovary, vagina and vulva have been documented by previous EUROCARE studies. In the present EUROCARE-5 study we update survival estimates and investigate changes in country-specific and over time survival, discussing their relationship with incidence and mortality dynamics for cancers for which organised screening programs are ongoing.

METHODS

We analysed cases archived in over 80 population-based cancer registries in 29 countries grouped into five European regions. We used the cohort approach to estimate 5-year relative survival (RS) for adult (⩾15years) women diagnosed 2000-2007, by age, country and region; and the period approach to estimate time trends (1999-2007) in RS for breast and cervical cancers.

RESULTS

In 2000-2007, 5-year RS was 57% overall, 82% for women diagnosed with breast, 76% with corpus uteri, 62% with cervical, 38% with ovarian, 40% with vaginal and 62% with vulvar cancer. Survival was low for patients resident in Eastern Europe (34% ovary-74% breast) and Ireland and the United Kingdom [Ireland/UK] (31-79%) and high for those resident in Northern Europe (41-85%) except Denmark. Survival decreased with advancing age: markedly for women with ovarian (71% 15-44years; 20% ⩾75years) and breast (86%; 72%) cancers. Survival for patients with breast and cervical cancers increased from 1999-2001 to 2005-2007, remarkably for those resident in countries with initially low survival.

CONCLUSIONS

Despite increases over time, survival for women's cancers remained poor in Eastern Europe, likely due to advanced stage at diagnosis and/or suboptimum access to adequate care. Low survival for women living in Ireland/UK and Denmark could indicate late detection, possibly related also to referral delay. Poor survival for ovarian cancer across the continent and over time suggests the need for a major research effort to improve prognosis for this common cancer.

Survival for ovarian cancer in Europe: the across-country variation did not shrink in the past decade

BACKGROUND

Survival for ovarian cancer is the poorest of all gynaecological cancer sites. Our aim was to present the most up-to-date survival estimate for ovarian cancer by age and morphology and to answer the question whether survival for ovarian cancer improved in Europe during the 1990s.

MATERIAL AND METHODS

This analysis was performed with data from the EUROCARE database. We considered all adult women diagnosed with ovarian cancer between 1995 and 2002 and life status followed up until the end of 2003. A total of 97 691 cases were contributed by 72 European cancer registries in 24 countries. We estimated the most up-to-date relative survival for a mean of 23 661 patients followed up in 2000-2003 using the period hybrid approach and described the relative survival trends from the beginning of 1990s.

RESULTS AND CONCLUSION

Overall, the European age-standardised one-year, five-year and five-year conditional on surviving one-year relative survival were 67.2% (95% CI 66.6-67.8), 36.1% (95% CI 35.4-36.8) and 53.7% (95% CI 52.8-54.7), respectively. Five-year relative survival was 58.6% (95% CI 57.4-59.8), 37.1% (95% CI 36.1-38.1) and 20.5% (95% CI 19.1-21.9) in women aged 15-54, 55-74 and 75-99 years, respectively. The age-standardised five-year relative survival was 38.1% (95% CI 36.9-39.3) for serous tumours and 51.9% (95% CI 49.0-54.9) for mucinous cancers and the crude five-year relative survival was 85.6% (95% CI 81.2-90.0) for germ cell cancers. Overall, the age-standardised five-year relative survival increased from 32.4% (95% CI 31.7-33.2) in 1991-1993 to 36.3% (95% CI 35.5-37.0) in 2000-2003. There is a need to better understand the reasons for the wide variation in survival of ovarian cancer in Europe. Actions aiming to harmonise the protocols for therapy should contribute to narrowing the wide gap in survival and research on screening and early detection of ovarian cancer should be enforced.

Patterns of care in surgery for ovarian cancer in Europe

Quality of surgery is one of the most important determinants of the outcome in ovarian cancer patients. Surgery by a gynaecological oncologist in a specialised, high-volume environment and removal of all visible tumours are associated with a higher likelihood of favourable outcome for patients with advanced-stage ovarian cancer. Population-based studies in Europe however show that a substantial number of patients do not receive optimal surgical care. Less than half of the patients suffering from advanced-stage ovarian cancer are operated by a gynaecological oncologists. Also the proportion of patients operated in a high-volume or specialised hospital is lower than 50%. In a substantial number of patients, minimum standard procedures are not performed and optimal tumor debulking is not achieved. To improve the quality of care, efforts are needed to develop and implement robust evidence-based European guidelines, provide surgical training for gynaecological oncologists and establish comprehensive cancer networks with sufficient resources.

A population-based 5-year cohort study including all cases of epithelial ovarian cancer in western Sweden: 10-year survival and prognostic factors

Epithelial ovarian cancer (EOC) is the major gynecologic cancer mortality cause in Sweden. The aim of the present study was to investigate the long-term survival and prognostic factors of a complete population-based 5-year cohort of 682 patients with invasive EOC in western Sweden (population around 1.6 million). Data relating to residual tumor after surgery, FIGO stage, grade, histopathologic subtype, ploidy status, adjuvant chemotherapy (the prepaclitaxel period), and disease state (recurrence and death) were reported to a quality register in a prospectively kept database and were controlled against the Swedish National Cancer Registry for completeness. The median follow-up durations for the prospectively collected data in the Cox analysis and for the survival analysis that was made for all patients were 81 months (range, 52-109 months) and 11.7 years (range, 8.7-14.1 years), respectively. No patient was lost to follow-up. The relative 10-year survival rate was 38.4% (95% confidence interval, 34.5%-42.8%). The median relative survival time was 4.3 years (95% confidence interval, 3.6%-5.2%). In the univariate Cox regression analysis, prognostic significances for age, stage, residual tumor, histopathologic subtype of serous cystadenocarcinoma, grade, CA-125, and ploidy status were seen. In the multivariate analysis, age, stage, residual tumor after surgery, and postoperative CA-125 were of prognostic significance. In conclusion, 4 major prognostic factors were found for EOC in this population-based cohort study that also presents nearly accurate long-term survival owing to the nonselective nature and completeness regarding patients and follow-up of the study.

Population-based cohort follow-up study of all patients operated for borderline ovarian tumor in western Sweden during an 11-year period

Borderline ovarian tumors (BOTs) make up around 10–20% of all epithelial ovarian tumors. The aim of the present study was to investigate the outcome of a complete large population-based cohort of patients treated for BOT. All patients (n= 399) treated for BOT in the western part of Sweden (population around 1.6 million) between 1993 and 2004 were followed. The treatment consisted of primary staging surgery with addition of platinum-based adjuvant chemotherapy for the majority of aneuploid tumors. Data relating to the surgical procedure, FIGO stage, histopathology, ploidy status, adjuvant chemotherapy, and disease state (recurrence or death) at follow-up visits were continuously entered into a cancer quality registry. Data concerning cases and deaths were also controlled against the Swedish National Cancer Registry. The median age of the BOT patients was 55 years (range 16–90). The relative 5- and 10-year survivals were 99.9% (95% CI 96.3–102.4) and 103.5% (95% CI 97.2–108.2), respectively. Aneuploidy was found in 63 (17%) patients, with significantly more aneuploid tumors found among patients of older (>60 years) age. Out of the 399 patients, 8 had recurrence of the disease. Three of the eight patients died from the disease. Five patients with recurrence are alive, three of these patients with no signs of disease after additional treatment. This complete long-term follow-up of a large population-based cohort of BOT patients shows that there is a good overall survival in this patient group.

Specialized care and survival of ovarian cancer patients in The Netherlands: nationwide cohort study

BACKGROUND

There is much debate on the necessity of regionalization of ovarian cancer care. We investigated the association between hospital type and survival of patients with ovarian cancer in The Netherlands.

METHODS

A retrospective, population-based cohort study was performed on all Dutch patients diagnosed with ovarian cancer from January 1, 1996, through December 31, 2003. We used data from the Netherlands Cancer Registry that were linked to mortality data from the Statistics Netherlands database to obtain the date and cause of death. Five-year relative survival ratios, defined as the ratio of the observed survival in the patient population to the expected survival of women in the general population with the same age, were determined for the total population and for groups stratified by tumor stage and/or hospital type. The association between hospital type and disease-specific survival was analyzed by use of multivariable Cox regression analyses.

RESULTS

We analyzed data from 8621 women with epithelial ovarian cancer, of whom 3482 (40%) were treated in general hospitals, 3510 (41%) were treated in semispecialized hospitals, and 1557 (18%) were treated in specialized hospitals. Five-year relative overall survival ratios of patients treated in general, semispecialized, and specialized hospitals were 38.0% (95% confidence interval [CI] = 36.0% to 39.9%), 39.4% (95% CI = 37.5% to 41.4%), and 40.3% (95% CI = 37.4% to 43.1%), respectively; median survival of patients aged 50-75 years was 36 months (interquartile range [IQR] = 13 to >54 months), 37 months (IQR = 14 to >54 months), and 38 months (IQR = 15 to >55 months), respectively. Age and cancer stage were associated with the relationship between hospital type and ovarian cancer-specific survival but histologic tumor type, grade, year of diagnosis, and socioeconomic status were not. Among patients with early-stage ovarian cancer, treatment in semispecialized and specialized hospitals was associated with lower risks of ovarian cancer-specific mortality than treatment in general hospitals. Among patients with stage I-IIA disease who were aged 50-75 years, risk of ovarian cancer-specific mortality was 30% and 42% lower after treatment in semispecialized and specialized hospitals, respectively, than in general hospitals (for semispecialized hospitals, hazard ratio [HR] = 0.70, 95% CI = 0.53 to 0.93; for specialized hospitals, HR = 0.58, 95% CI = 0.38 to 0.87). Among patients with advanced ovarian cancer, hospital type was not associated with survival.

CONCLUSION

Hospital type was statistically significantly associated with survival among Dutch ovarian cancer patients with early-stage ovarian cancer: Patients who were treated in specialized and semispecialized hospitals survived longer than patients treated in general hospitals.

The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review

OBJECTIVE

There is much debate on the effect of specialized care for ovarian cancer patients. In this review we present an overview and summary of the recent literature on this subject.

METHODS

The Pubmed database was searched for studies on the relationship between care setting (type of gynecologist or hospital) and care outcomes which were published between January 1991 and November 2006. Studies were included if they were of sufficient quality and included patients treated from 1990 onwards.

RESULTS

Nineteen articles were retrieved. There were no randomized controlled trials on this subject. Staging and debulking were consistently found to be performed more adequately by gynecologic oncologists (pooled relative risk of optimal debulking by a gynecologic oncologist to <2 cm residual disease 1.4 (95%CI 1.2-1.5) and to no macroscopic disease 2.3 (95%CI 1.5-3.5)) and in specialized hospitals (odds ratios for optimal debulking varied between 1.9 and 6.0). There were no differences in postoperative complication rates between different providers. Chemotherapy was given 1-15% more often in specialized settings. Differences in chemotherapy did not lead to differences in survival of patients treated by gynecologic oncologists, but did influence the effect of hospital on survival. Long-term survival was better after treatment in a specialized hospital. Surgery by a gynecologic oncologist resulted in longer survival in subgroups of patients, leading to a 5- to 8-month median survival benefit for patients with advanced stage disease.

CONCLUSIONS

The outcome of ovarian cancer is better when treatment is provided by a gynecologic oncologist or in a specialized hospital.