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The Optimal Organization of Gynecologic Oncology Services: a Systematic Review

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The Optimal Organization of Gynecologic Oncology Services: a Systematic Review GYNECOLOGIC ONCOLOGY ORGANIZATION: SYSTEMATIC REVIEW, Fung-Kee-Fung et al. REVIEW ARTICLE The optimal organization of gynecologic oncology services: a systematic review † ‡ § || M. Fung-Kee-Fung MBBS MBA,* E.B. Kennedy MHSc, J. Biagi MD, T. Colgan MD, D. D’Souza MD, L.M. Elit MD,# A. Hunter MBA,** J. Irish MD,** R. McLeod MD,** and B. Rosen MD†† ABSTRACT Background A system-level organizational guideline for gynecologic oncology was identified by a provincial cancer agency as a key priority based on input from stakeholders, data showing more limited availability of multidisciplinary or specialist care in lower-volume than in higher-volume hospitals in the relevant jurisdiction, and variable rates of staging for ovarian and endometrial cancer patients. Methods A systematic review assessed the relationship of the organization of gynecologic oncology services with patient survival and surgical outcomes. The electronic databases medline and embase (ovid: 1996 through 9 January 2015) were searched using terms related to gynecologic malignancies combined with organization of services, patterns of care, and various facility and physician characteristics. Outcomes of interest included overall or disease-specific survival, short-term survival, adequate staging, and degree of cytoreduction or optimal cytoreduction (or both) for ovarian cancer patients by hospital or physician type, and rate of discrepancy in initial diagnoses and intraoperative consultation between non-specialist pathologists and gyne-oncology–specialist pathologists. Results One systematic review and sixteen additional primary studies met the inclusion criteria. The evidence base as a whole was judged to be of lower quality; however, a trend toward improved outcomes with centralization of gynecologic oncology was found, particularly with respect to the gynecologic oncology care of patients with advanced-stage ovarian cancer. Conclusions Improvements in outcomes with centralization of gynecologic oncology services can be attributed to a number of factors, including access to specialist care and multidisciplinary team management. Findings of this systematic review should be used with caution because of the limitations of the evidence base; however, an expert consensus process made it possible to create recommendations for implementation. Key Words Organization, gynecologic oncology, systematic reviews Curr Oncol. 2015 Aug;22(4):e282-e293 www.current-oncology.com INTRODUCTION The present systematic review was designed to assess the relationship of the organization of gynecologic oncol- The annual incidence of gynecologic cancers exceeds ogy services with patient survival, surgical outcomes, the a million cases worldwide, with half a million deaths delivery of chemotherapy, and some aspects of the role annually1. In some jurisdictions, gynecologic oncology of specialist pathologists in gynecologic oncology. This services have been centralized2 in one or more centres choice of topic was based on perceived issues, including with higher patient volumes and interdisciplinary collab- the absence of a health care system–wide network of care oration3. Those centres receive referrals from less-spe- and a lack of collaboration, even in a setting in which most cialized hospitals within a network, region, or defined gynecologic oncologists are practicing in major centres catchment area. The effectiveness of that model of service with teaching hospitals and using a multidisciplinary team delivery has been shown for other cancer disease sites4, approach. Specific areas of potential concern for patient but its benefits have historically not been as clear for care included low rates of appropriate disease staging8,9, gynecologic oncology5–7. geographic variations in treatment8, and variations in Correspondence to: Stephen Chia, Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia V5Z 4E6. E-mail: [email protected] n DOI: http://dx.doi.org/10.3747/co.22.2482 e282 Current Oncology, Vol. 22, No. 4, August 2015 © 2015 Multimed Inc. GYNECOLOGIC ONCOLOGY ORGANIZATION: SYSTEMATIC REVIEW, Fung-Kee-Fung et al. treatment delivered by subspecialists relative to other sur- TABLE I Search strategy geons9. Our systematic review provides the basis for recom- mendations that are intended to promote evidence-based Initial search for articles (to 12 December 2011) practice and to improve patient access to timely, consistent, 1. ((endometr* or uter* or cervi* or ovar* or vulva* or gynae* high-quality care in a higher-resource location. or gyne*) adj (cancer* or neoplas* or carcinom* or malignan* or tumor* or tumour*)).ti,ab. RESEARCH QUESTIONS 2. Organizational Policy/ or Efficiency, Organizational/ or Models, Organizational/ n Are outcomes better for patients with gynecologic cancer treated in designated centres (“centralized 3. *health facilities/ care”) compared with non-designated centres (“de- centralized care”)? 4. centralization.mp. or Centralized Hospital Services/ n Are outcomes better for patients treated by gynecologic 5. (patterns adj5 care).ti. oncologists than by non-subspecialist physicians? 6. clinical competence.mp. or Clinical Competence/ Outcomes of interest included overall or disease-spe- cific survival, short-term survival, adequate staging, degree 7. palliative care.mp. or Palliative Care/ of cytoreduction or optimal cytoreduction (or both) for 8. patient care.mp. or Patient Care/ ovarian cancer patients by hospital or physician type, and rate of discrepancy in initial diagnoses and intraoperative 9. cancer care facilities.mp. or Cancer Care Facilities/ consultation between non-specialist pathologists and 10. (training or competency or proficiency).ti. gyne-oncology–specialist pathologists. 11. Surgical Procedures, Operative/ or surgical volumes.mp. METHODS 12. volume*.ti. The electronic databases medline and embase (ovid: 13. (centrali?ation or speciali?ation or speciali?$).ti. 1996 through 12 December 2011) were searched using terms related to gynecologic malignancies combined 14. regional*.ti. with organization of services, patterns of care, and var- ious facility and physician characteristics (Table i). The 15. (subspecialty or specialty).ti. Cochrane Database of Systematic Reviews was searched 16. multidisciplinary.ti. for topic-specific reviews up to Issue 12 (December), 2011. Reference lists of included articles were scanned for ad- 17. multidisciplinary team management.mp. or Patient Care Team/ ditional citations. The search engine Google Scholar was 18. 1 and (2 or 3 or 4 or 6 or 8 or 9 or 10) used to identify articles using the terms “gynecological cancer” or “gynaecological cancer” and “centralisation” 19. 1 and 5 or “centralization” or “volumes.” Additional search terms were used to locate studies that addressed some aspect of 20. 1 and 7 quality in pathology diagnosis. 21. 1 and (11 or 12) Articles were selected by the project methodologist and were reviewed by all authors. To identify existing relevant 22. 1 and (13 or 14 or 15) guidelines published between 1995 and 2011, a search was conducted of the Web sites of major guideline developersa. 23. 1 and (16 or 17) 24. 18 or 19 or 20 or 21 or 22 or 23 25. limit 24 to (english language and yr=“1995 -Current”) a Standards and Guidelines Evidence directory (http://www. 26. 25 not screening.ti. cancerview.ca/cv/portal/Home/TreatmentAndSupport/ TSProfessionals/ClinicalGuidelines/GRCMain/GRCSAGE/ GRCSAGESearch), the U.S. National Guidelines Clearinghouse (http://www.guideline.gov), the U.K. National Institute for Health Additional search for pathology-related articles (to 1 February 2012) and Clinical Excellence (http://www.nice.org.uk/Guidance), the Scottish Intercollegiate Guidelines Network (http://www.sign. 1. ((endometr* or uter* or cervi* or ovar* or vulva* or gynae* or gyne*) adj (cancer* or neoplas* or carcinom* or ac.uk/guidelines/index.html), the American Society of Clinical malignan* or tumor* or tumour*)).ti,ab. Oncology (http://jco.ascopubs.org/site/misc/specialarticles. xhtml), the U.S. National Comprehensive Cancer Network (http:// 2. patholog*.ti. www.nccn.org/professionals/physician_gls/f_guidelines.asp), Cancer Australia Guidelines (http://canceraustralia.gov.au/ 3. 1 and 2 publications-and-resources/clinical-practice-guidelines), and the New Zealand Guidelines Group (http://www.health.govt.nz/ 4. limit 3 to yr=“1995 -Current” about-ministry/ministry-health-websites/new-zealand-guide lines-group) 5. limit 8 to english language Current Oncology, Vol. 22, No. 4, August 2015 © 2015 Multimed Inc. e283 GYNECOLOGIC ONCOLOGY ORGANIZATION: SYSTEMATIC REVIEW, Fung-Kee-Fung et al. The search was repeated on 9 January 2015 to improve citations for screening. Ninety of those articles were re- the currency of the evidence base. trieved for full-text review. Two additional articles for full- text review were identified from a scan of the reference lists Study Selection of included articles, Google key word searching, and files of Study designs eligible for inclusion were observational working group members. After review, fifteen articles that studies with a retrospective or prospective assessment of a met the inclusion criteria were retained. Of 3832 non-dupli- cohort of patients and systematic reviews of such study de- cate records identified in the update search in January 2015, signs. Case–control studies and case series were excluded one additional article18 met the inclusion criteria and was to develop an evidence base of the highest possible quality. added to
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