Background
Gynecologic cancer (of the ovaries, uterus, cervix, vulva, vagina, and placenta) is a common cause of mortality worldwide. It accounts for 25% of cancer diagnoses in women younger than 65 years in developing countries and 16% in developed regions. While traditionally cancer therapy was provided in general local hospitals, in many developed countries cancer care can now be offered in specialist tertiary treatment centers, which may impact patient outcomes through improved resources, expertise, and integrated team access. Nonetheless, we have not determined if specialist support improves gynecologic cancer outcomes, and because such care is more costly secondary to possible traveling and social costs for patients, a systematic review of available evidence was undertaken.
Objective/s
To determine the effectiveness of centralized specialist versus local nonspecialist care for patients with gynecologic cancer.
Intervention/Methods
A Cochrane systematic review with meta-analyses1 was undertaken; to be included in this review, studies needed to have recruited women older than 18 years with any gynecologic cancer and compared treatment in a regional/tertiary care center with care elsewhere. The primary outcome was survival (nondeath from any cause); progression-free survival and adverse event data were also considered. The reviewers sought information from randomized controlled trials, cohort studies, and quasi-experimental designs; the results of nonrandomized research designs needed to have been statistically adjusted for multiple participant differences (such as type or severity of cancer) across study arms before the intervention was applied.
Results
Five studies met the review criteria; all were observational studies deemed to have a high risk of bias; 4 studies collected data only on ovarian cancer patients.
* A meta-analysis of 3 studies with n = 9041 patients suggested that on-site gynecologic oncologists may prolong survival in women with ovarian cancer in comparison to community or general hospitals (hazard ratio of death [HR], 0.9; 95% confidence interval [CI], 0.82-0.99).
* Pooled data from 3 studies with n = 51 283 women found that teaching hospitals or regional cancer centers may increase survival in patients with any gynecologic cancer versus community or general hospitals (HR, 0.91; 95% CI, 0.84-0.99).
* Only 1 study measured progression-free survival and found no statistical evidence of any difference in patients treated in a teaching/regional cancer center versus a community/general hospital (HR, 0.91; 95% CI, 0.54-1.55; n = 233 participants). No study reported adverse event data.
Conclusions
Two meta-analyses suggest a positive effect of specialist care on gynecologic cancer survival rates. As survival rates for gynecologic cancer vary, research is also needed about patients who do not have ovarian cancer or are treated in developing countries. In addition, more robust studies are needed that consider "quality of life" outcomes from specialist cancer services.
Implications for Practice
There is currently some consistent, although low-quality, evidence that specialist treatment centers may increase survival times for women with gynecologic cancer (particularly ovarian cancer) in comparison to care elsewhere.
Reference