Treatment Guidelines For Ovarian Cancer Research Articles

Barriers of Care to Ovarian Cancer: A Scoping Review.

Ovarian cancer is a leading cause of female cancer-related deaths, but patients continue to be diagnosed late. This subjects them to disease progression and possible death due to lack of early detection, despite earlier stage detection improving survival rates by significant percentages. Early detection and access to care are closely related. However, many barriers to high-quality care exist for patients and the majority of patients do not receive recommended care according to ovarian cancer treatment guidelines. In order to improve care for ovarian cancer patients and decrease healthcare disparities in accessing equitable care, it is important to acknowledge the current gaps in patient knowledge, healthcare availability, and physician practice. This scoping review explores the available evidence on ovarian cancer to identify these barriers to care in the effective treatment of ovarian cancer. Using both inclusion and exclusion criteria, results from the initial literature search were screened by the authors. After quality assessment and screening for relevance, 10 articles were included in the final review. The following themes emerged as barriers to care: hospital and physician-patient volumes, geographic distance from care facilities, patient and physician education, and demographic factors. Many patients were found to not receive guideline adherent care due to various barriers to care, whereas guideline adherent care was independently associated with factors such as patient proximity to a high-volume hospital, White race, and higher socioeconomic status. Several areas were identified as potential for increased patient and physician education, including treatment complications and patient resources. The evidence found that certain socioeconomic groups and racial minorities are often at higher risk for guideline non-adherent care. Additionally, the evidence showed a further need for physicians and healthcare providers to be provided with resources for post-cancer treatment, follow-up, and patient education. The findings of this review will provide health experts and patients with better insight into what barriers may exist so that guideline-adherent care can be better advocated for and met.

A Risk-Adjusted Model for Ovarian Cancer Care and Disparities in Access to High-Performing Hospitals.

To validate the observed/expected ratio for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care, and to identify patient characteristics associated with disparities in access to high-performing hospitals. This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to the California Cancer Registry between 1996 and 2014. A fit logistic regression model, which was risk-adjusted for patient and disease characteristics, was used to calculate the observed/expected ratio for each hospital, stratified by hospital annual case volume. A Cox proportional hazards model was used for survival analyses, and a multivariable logistic regression model was used to identify independent predictors of access to high-performing hospitals. The study population included 30,051 patients who were treated at 426 hospitals: low observed/expected ratio (n=304) 23.5% of cases; intermediate observed/expected ratio (n=92) 57.8% of cases; and high observed/expected ratio (n=30) 18.7% of cases. Hospitals with high observed/expected ratios were significantly more likely to deliver guideline-adherent care (53.3%), compared with hospitals with intermediate (37.8%) and low (27.5%) observed/expected ratios (P<.001). Median disease-specific survival time ranged from 73.0 months for hospitals with high observed/expected ratios to 48.1 months for hospitals with low observed/expected ratios (P<.001). Treatment at a hospital with a high observed/expected ratio was an independent predictor of superior survival compared with hospitals with intermediate (hazard ratio [HR] 1.06, 95% CI 1.01-1.11, P<.05) and low (HR 1.10, 95% CI 1.04-1.16, P<.001) observed/expected ratios. Being of Hispanic ethnicity (odds ratio [OR] 0.85, 95% CI 0.78-0.93, P<.001, compared with white), having Medicare insurance (OR 0.74, 95% CI 0.68-0.81 P<.001, compared with managed care), having a Charlson Comorbidity Index score of 2 or greater (OR 0.91, 95% CI 0.83-0.99, P<.05), and being of lower socioeconomic status (lowest quintile OR 0.41, 95% CI 0.36-0.46, P<.001, compared with highest quintile) were independent negative predictors of access to a hospital with a high observed/expected ratio. Ovarian cancer care at a hospital with a high observed/expected ratio is an independent predictor of improved survival. Barriers to high-performing hospitals disproportionately affect patients according to sociodemographic characteristics. Triage of patients with suspected ovarian cancer according to a performance-based observed/expected ratio hospital classification is a potential mechanism for expanded access to expert care.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for ovarian cancer

ObjectiveTo develop an observed-to-expected ratio (O/E) for adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines as a risk-adjusted hospital measure of quality care correlated with disease-specific survival. MethodsConsecutive patients with stages I–IV epithelial ovarian cancer were identified from the California Cancer Registry (1/1/96–12/31/06). Using a fit logistic regression model, O/E for guideline adherence was calculated for each hospital and distributed into quartiles stratified by hospital annual case volume: lowest O/E quartile or annual hospital case volume <5, middle two O/E quartiles and volume ≥5, and highest O/E quartile and volume ≥5. A multivariable logistic regression model was used to characterize the independent effect of hospital O/E on ovarian cancer-specific survival. ResultsOverall, 18,491 patients were treated at 405 hospitals; 37.3% received guideline adherent care. Lowest O/E hospitals (n=285) treated 4661 patients (25.2%), mean O/E=0.77±0.55 and median survival 38.9months (95%CI=36.2–42.0months). Intermediate O/E hospitals (n=85) treated 8715 patients (47.1%), mean O/E=0.87±0.17 and median survival of 50.5months (95% CI=48.4–52.8months). Highest O/E hospitals (n=35) treated 5115 patients (27.7%), mean O/E=1.34±0.14 and median survival of 53.8months (95% CI=50.2–58.2months). After controlling for other variables, treatment at highest O/E hospitals was associated with independent and statistically significant improvement in ovarian cancer-specific survival compared to intermediate O/E (HR=1.06, 95% CI=1.01–1.11) and lowest O/E (1.16, 95% CI=1.10–1.23) hospitals. ConclusionsCalculation of hospital-specific O/E for NCCN treatment guideline adherence, combined with minimum case volume criterion, as a measure of ovarian cancer quality of care is feasible and is an independent predictor of survival.

Socioeconomic status as a predictor of adherence to treatment guidelines for early-stage ovarian cancer

ObjectiveInvestigate the impact of socioeconomic status and other demographic variables on adherence to the National Comprehensive Cancer Network ovarian cancer treatment guidelines among patients with stage I/II disease. MethodsPatients diagnosed with stage I/II epithelial ovarian cancer between 1/1/96–12/31/06 were identified from the California Cancer Registry. Univariate analysis and multivariate logistic regression models were used to evaluate differences in surgical procedures, chemotherapy regimens, and overall adherence to the NCCN guidelines according to increasing SES quintiles (SES-1 to SES-5). ResultsA total of 5445 stage I and II patients were identified. The median age at diagnosis was 54.0years (range=18–99years); 72.5% of patients had stage I disease, while 27.5% had stage II disease. With a median follow-up time of 5years, the 5-year ovarian cancer-specific survival for all patients was 82.7% (SE=0.6%). Overall, 23.7% of patients received care that was adherent to the NCCN guidelines. Compared to patients in the highest SES quintile (SES-5), patients in the lowest SES quintile (SES-1) were significantly less likely to receive proper surgery (27.3% vs 47.9%, p<0.001) or chemotherapy (42.4% vs 53.6%, p<0.001). There were statistically significant trends between increasing SES and the likelihood of overall treatment plan adherence to the NCCN guidelines: SES-1=16.4%, SES-2=19.0%, SES-3=22.4%, SES-4=24.2% and SES-5=31.6% (p<0.001). Multivariate logistic regression analysis revealed that compared to SES-5, decreasing SES was independently predictive of a higher risk of non-standard overall care. ConclusionsFor patients with early-stage ovarian cancer, low SES is a significant and independent predictor of deviation from the NCCN guidelines for surgery, chemotherapy, and overall treatment.

Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for ovarian cancer

Objectives: To develop an observed-to-expected ratio (O/E) for adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines as a risk-adjusted hospital measure of quality care correlated with disease-specific survival.

Impact of National Cancer Institute Comprehensive Cancer Centers on Ovarian Cancer Treatment and Survival

The regional impact of care at a National Cancer Institute Comprehensive Cancer Center (NCI-CCC) on adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines and survival is unclear. We performed a retrospective population-based study of consecutive patients diagnosed with epithelial ovarian cancer between January 1, 1996 and December 31, 2006 in southern California. Patients were stratified according to care at an NCI-CCC (n = 5), non-NCI high-volume hospital (≥ 10 cases/year, HVH, n = 29), or low-volume hospital (<10 cases/year, LVH, n = 158). Multivariable logistic regression and Cox-proportional hazards models were used to examine the effect of NCI-CCC status on treatment guideline adherence and ovarian cancer-specific survival. A total of 9,933 patients were identified (stage I, 22.8%; stage II, 7.9%; stage III, 45.1%; stage IV, 24.2%), and 8.1% of patients were treated at NCI-CCCs. Overall, 35.7% of patients received NCCN guideline adherent care, and NCI-CCC status (odds ratio [OR] 1.00) was an independent predictor of adherence to treatment guidelines compared with HVHs (OR 0.83, 95% CI 0.70 to 0.99) and LVHs (OR 0.56, 95% CI 0.47 to 0.67). The median ovarian cancer-specific survivals according to hospital type were: NCI-CCC 77.9 (95% CI 61.4 to 92.9) months, HVH 51.9 (95% CI 49.2 to 55.7) months, and LVH 43.4 (95% CI 39.9 to 47.2) months (p < 0.0001). National Cancer Institute Comprehensive Cancer Center status (hazard ratio [HR] 1.00) was a statistically significant and independent predictor of improved survival compared with HVH (HR 1.18, 95% CI 1.04 to 1.33) and LVH (HR 1.30, 95% CI 1.15 to 1.47). National Cancer Institute Comprehensive Cancer Center status is an independent predictor of adherence to ovarian cancer treatment guidelines and improved ovarian cancer-specific survival. These data validate NCI-CCC status as a structural health care characteristic correlated with superior ovarian cancer quality measure performance. Increased access to NCI-CCCs through regional concentration of care may be a mechanism to improve clinical outcomes.

Role of lymphadenectomy for ovarian cancer

Japan Society of Gynecologic Oncology (JSGO) recently revised its Ovarian Cancer Treatment Guidelines and the 4th edition will be released next year. This Guidelines state that lymphadenectomy is essential to allow accurate assessment of the clinical stage in early ovarian cancer, but there is no randomized controlled trial that shows any therapeutic efficacy of lymphadenectomy. In patients with advanced stage tumors, lymphadenectomy should be considered if optimal debulking has been performed. I fully agree with this recommendation of the JSGO and I would like to discuss the role of lymphadenectomy in the management of ovarian cancer.

NCCN treatment guidelines for ovarian cancer: A population-based vali- dation study of structural and process quality measures

NCCN treatment guidelines for ovarian cancer: A population-based vali- dation study of structural and process quality measures

Adherence to Treatment Guidelines for Ovarian Cancer as a Measure of Quality Care

To validate National Comprehensive Cancer Network ovarian cancer guideline adherence as a quality process measure associated with improved survival, and to identify structural health care characteristics predictive of adherence to National Comprehensive Cancer Network guideline care. Consecutive patients with epithelial ovarian cancer diagnosed between 1 January 1999 and 31 December 2006 were identified from the California Cancer Registry. Adherence to National Comprehensive Cancer Network guideline care was defined by stage-appropriate surgical procedures and recommended chemotherapy. Multivariable logistic regression models were used to identify characteristics predictive of National Comprehensive Cancer Network guideline adherence and ovarian cancer-specific survival. A total of 13,321 patients were identified. Overall, 37.2% of patients received National Comprehensive Cancer Network guideline-adherent care. Guideline-adherent care was associated with high-volume hospitals (20 or more cases per year; 50.8% compared with 34.1%; P<.001) and high-volume physicians (10 or more cases per year; 47.6% compared with 34.5%; P<.001). After controlling for other factors, both low-volume hospitals (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.66-2.01) and low-volume physicians (OR 1.19, 95% CI 1.07-1.32) were independently associated with deviation from National Comprehensive Cancer Network guidelines. On multivariable survival analysis, nonadherence to National Comprehensive Cancer Network guideline care was associated with decreased disease-specific survival (hazard ratio [HR] 1.33, 95% CI 1.26-1.41). Both low-volume hospitals (HR 1.08, 95% CI 1.01-1.16) and low-volume physicians (HR 1.18, 95% CI 1.09-1.28) were associated with decreased disease-specific survival after adjusting for National Comprehensive Cancer Network guideline-adherent care. Adherence to National Comprehensive Cancer Network guidelines for treatment of ovarian cancer is correlated with improved survival and may be a useful process measure of quality cancer care. Ovarian cancer case volume correlates with a higher likelihood of recommended care and improved survival and may be a useful structural quality measure. Increased efforts to concentrate ovarian cancer care are warranted.

JSGO's 46th Biannual Meeting, July 10-12, 2009

The Japan Society of Gynecologic Oncology (JSGO) has its origins in the Japan Colposcopy Association, which was founded in 1975. The Association merged with the Japan Ovarian Tumor Pathology Research Society to form the JSGO in 1998. Three other academic societies have merged to form the new integrated JSGO - an equal partnership of gynecologic oncologists, radiation oncologists, medical oncologists, pathologists, and other scientists who devote their professional lives to the field of gynecologic oncology. At the present time the Society has over 2,300 memberships. The JSGO meeting has been held biannually in the spring and autumn. In principle, the spring conference focuses on the diagnosis of gynecologic tumors (pathology, colposcopy, genetic analysis, tumor markers, etc.), and the autumn conference focuses on the treatment of gynecologic tumors (operation, chemotherapy and radiation therapy). The 46th JSGO meeting was held in Niigata, July 10-12, 2009, and over 1,000 participants including medical students, junior residents, and JSGO members joined the meeting. Two hundred and ninety two abstracts, 120 in the Oral Abstract Session, 143 in the Poster Discussion Session, and 28 in the Pathological Session, were presented. We hosted 4 Workshops regarding the treatment of high-risk cervical cancer, topics in gynecologic cancer, advances in chemotherapy for gynecologic cancer, and video workshop for gynecologic surgery, inviting leaders of each field as speakers. Since December 2004, the JSGO has published guidelines for the diagnosis and treatment of gynecologic tumors to enlighten general physicians and to educate young doctors. The first printing of the Ovarian Cancer Treatment Guidelines was completed in 2004. Endometrial Cancer Guidelines and Cervical Cancer Guidelines were completed in 2006 and 2007, respectively. These guidelines are scheduled to be revised every 3 years. The Second Edition (2009 edition) of Endometrial Cancer Guidelines has been almost completed and the points of the new guideline were presented in the Educational Lecture Session in this meeting. In the International Symposium, Professor Soon-Beom Kang (Seoul National University College of Medicine, Korea), Dr. Yukio Sonoda (Memorial Sloan-Kettering Cancer Center, USA), and Dr. Thomas J. Herzog (Columbia University Medical Center, USA), were invited and gave impressive talks about Current Advances in Basic and Clinical Medicine with two Japanese speakers. The Society will try to be a forum for the worldwide exchange of scientific information. The 47th JSGO meeting is scheduled for November 21-22, 2009 in Tokyo, Japan, and the 48th meeting is scheduled for July 8-10, 2010 in Tsukuba, Japan.