Will patients benefit from regionalization of gynecologic cancer care?

Abstract

Objective: Patient chances for cure and palliation for a variety of malignancies may be greatly affected by the care provided by a treating hospital. We sought to determine the effect of volume and teaching status on patient outcomes for five gynecologic malignancies: endometrial, cervical, ovarian and vulvar carcinoma and uterine sarcoma.

Methods: The Florida Cancer Data System dataset was queried for all patients undergoing treatment for gynecologic cancers from 1990-2000.

Results: Overall, 48,981 patients with gynecologic malignancies were identified. Endometrial tumors were the most common, representing 43.2% of the entire cohort, followed by ovarian cancer (30.9%), cervical cancer (20.8%), vulvar cancer (4.6%), and uterine sarcoma (0.5%). By univariate analysis, although patients treated at high volume centers (HVC) were significantly younger, they benefited from an improved short-term (30-day and/or 90-day) survival for cervical, ovarian and endometrial cancers. Multivariate analysis (MVA), however, failed to demonstrate significant survival benefit for gynecologic cancer patients treated at teaching facilities (TF) or HVC. Significant prognostic factors at presentation by MVA were age over 65 (HR = 2.6, p<0.01), African-American race (HR = 1.36, p<0.01), and advanced stage (regional HR = 2.08, p<0.01; advanced HR = 3.82, p<0.01, respectively). Surgery and use of chemotherapy were each significantly associated with improved survival.

Conclusion: No difference in patient survival was observed for any gynecologic malignancy based upon treating hospital teaching or volume status. Although instances of improved outcomes may occur, overall further regionalization would not appear to significantly improve patient survival.

Figure 1. Flow diagram depicting number of incident gynecologic malignancies diagnosed in the state of Florida from 1990–2000.

Figure 2. Kaplan-Meier survival curves comparing cumulative survival at teaching facilities (TF) and non-teaching facilities (NTF) for (a) cervical cancer, (b) ovarian cancer, (c) endometrial cancer, (d) uterine sarcoma, and (e) vulvar cancer and at high-volume centers (HVC), intermediate-volume centers (IVC), and low-volume centers (LVC) for (f) cervical cancer, (g) ovarian cancer, (h) endometrial cancer, (i) uterine sarcoma, and (j) vulvar cancer.