Large Study Supports Regionalization of Gynecologic Cancer Care

Charles Bankhead

May 2014, Vol 5, No 4 - Society of Gynecologic Oncology


Tampa, FL—Women with gynecologic cancers had significantly better survival when treated at high-volume centers, according to a review of 863,000 cases reported at the 2014 Society of Gynecologic Oncology meeting.

Patients treated at the highest-volume centers had a median survival of more than 1 year longer than that of patients treated at centers with the lowest annual procedural volume (122.7 vs 110.0 months, respectively).

An analysis of individual types of gynecologic cancers yielded significantly better survival at high-volume centers for all but uterine cancer.

“Regionalization of care is already ongoing,” Jeff F. Lin, MD, Gynecologic Oncology Fellow, Magee-Womens Hospital of the University of Pittsburgh Medical Center, PA, and colleagues, concluded in a poster presentation. “Treatment at high-volume centers is associated with improved outcomes even when controlled for age, stage, and comorbidities,” noted Dr Lin and colleagues.

“These data support regionalization of gynecologic cancer care and identify patients who may benefit from transfer to high-volume centers.”

The findings add to existing evidence supporting favorable associations between procedural volume and clinical outcomes. The associations have added implications in light of policy discussions about potential regionalization of healthcare services at specialized centers.

Dr Lin and colleagues sought to determine the characteristics and outcomes of centers that provide care for high volumes of patients with gynecologic cancers. The investigators queried the National Cancer Data Base to identify patients treated for cervical, uterine, ovarian, vaginal, and vulvar cancer from 1998 through 2011. Case volumes were calculated for centers, which were divided into quartiles according to volume.

The principal outcome of interest was estimated overall survival (OS). Univariate and multivariate analyses were performed to identify charac­teristics associated with procedural volume.

A Large Sample
The analysis comprised 863,156 patients and 1666 centers. Uterine cancer accounted for 427,473 cases, followed by ovarian cancer (215,877), cervical cancer (142,518), vulvar cancer (63,641), and vaginal cancer (13,647).

Dr Lin reported that 64 centers accounted for the highest-volume quartile, followed by 120 in the second quartile, 235 in the third, and 1247 centers in the lowest-volume quartile.

Results
Overall, patients treated at the lowest-volume centers had a 10% greater mortality risk compared with patients treated at the highest-volume centers (odds ratio [OR], 1.10; P <.005). Centers in the second and third quartiles also had a higher mortality risk compared with the centers that cared for the most gynecologic oncology patients (OR, 1.02, P = .039; OR, 1.3, P = .009).

In absolute terms, the difference in median OS between the highest and lowest quartiles ranged from 2.3 months for vulvar cancer (136.4 vs 134.1 months) to 34.1 months for vaginal cancer (72.2 vs 38.1 months).

Median OS for patients with cervical cancer was 117.8 months for the highest-volume centers, followed by 114.1, 111.5, and 102.4 months for quartiles 2 through 4 (P <.005).

Patients with ovarian cancer had a median OS of 49.4 months at centers in the top quartile, decreasing to 45.4, 42.7, and 32.5 months as centers’ volume decreased (P <.005).

Survival for patients with uterine cancer varied the least, ranging from 159.7 months in the first quartile to 157.9, 156.0, and 156.2 months in the other quartiles.

For vaginal cancer, the median survival values were 72.2, 69.8, 60.7, and 38.1 months (P <.005). Median survival in patients with vulvar cancer was 136.4 months in the first quartile, 125.6 months in the second, 130.4 months in the third, and 134.1 months in the fourth (P <.005).

Analysis of factors associated with high volume showed that centers in the top quartile were more likely to be academic or research centers. No community oncology program reached the top 2 volume-based quartiles. Higher volume was also associated with patient residence in metropolitan areas, location in the South, and location more than 30 miles from patients.

Patients at the lowest-volume centers were older, lived in higher-income areas, and were more likely to have advanced disease.