Journal of the National Cancer Institute Advance Access published online on March 11, 2008
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djn033
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Specialized Care and Survival of Ovarian Cancer Patients in The Netherlands: Nationwide Cohort Study
Affiliations of authors: Departments of Gynecologic Surgery and Oncology (FV, APMH) and Medical Oncology (POW) and Julius Center for Health Sciences and Primary Care (YvdG), University Medical Center Utrecht, Utrecht, The Netherlands; Comprehensive Cancer Center Middle Netherlands, Utrecht, The Netherlands (MvdHvdL); Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands (JWC)
Correspondence to: Flora Vernooij, MD, Department of Gynecologic Surgery and Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands (e-mail: f.vernooij{at}umcutrecht.nl).
Background: There is much debate on the necessity of regionalization of ovarian cancer care. We investigated the association between hospital type and survival of patients with ovarian cancer in The Netherlands.
Methods: A retrospective, population-based cohort study was performed on all Dutch patients diagnosed with ovarian cancer from January 1, 1996, through December 31, 2003. We used data from the Netherlands Cancer Registry that were linked to mortality data from the Statistics Netherlands database to obtain the date and cause of death. Five-year relative survival ratios, defined as the ratio of the observed survival in the patient population to the expected survival of women in the general population with the same age, were determined for the total population and for groups stratified by tumor stage and/or hospital type. The association between hospital type and disease-specific survival was analyzed by use of multivariable Cox regression analyses.
Results: We analyzed data from 8621 women with epithelial ovarian cancer, of whom 3482 (40%) were treated in general hospitals, 3510 (41%) were treated in semispecialized hospitals, and 1557 (18%) were treated in specialized hospitals. Five-year relative overall survival ratios of patients treated in general, semispecialized, and specialized hospitals were 38.0% (95% confidence interval [CI] = 36.0% to 39.9%), 39.4% (95% CI = 37.5% to 41.4%), and 40.3% (95% CI = 37.4% to 43.1%), respectively; median survival of patients aged 50–75 years was 36 months (interquartile range [IQR] = 13 to >54 months), 37 months (IQR = 14 to >54 months), and 38 months (IQR = 15 to >55 months), respectively. Age and cancer stage were associated with the relationship between hospital type and ovarian cancer–specific survival but histologic tumor type, grade, year of diagnosis, and socioeconomic status were not. Among patients with early-stage ovarian cancer, treatment in semispecialized and specialized hospitals was associated with lower risks of ovarian cancer–specific mortality than treatment in general hospitals. Among patients with stage I–IIA disease who were aged 50–75 years, risk of ovarian cancer–specific mortality was 30% and 42% lower after treatment in semispecialized and specialized hospitals, respectively, than in general hospitals (for semispecialized hospitals, hazard ratio [HR] = 0.70, 95% CI = 0.53 to 0.93; for specialized hospitals, HR = 0.58, 95% CI = 0.38 to 0.87). Among patients with advanced ovarian cancer, hospital type was not associated with survival.
Conclusion: Hospital type was statistically significantly associated with survival among Dutch ovarian cancer patients with early-stage ovarian cancer: Patients who were treated in specialized and semispecialized hospitals survived longer than patients treated in general hospitals.
| CONTEXT AND CAVEATS Prior knowledge Some countries have developed referral guidelines that recommend that ovarian cancer patients be treated in specialized centers because treatment in such hospitals has been shown to result in better survival. Study design Retrospective, population-based cohort study performed on all Dutch patients diagnosed with ovarian cancer from January 1, 1996, through December 31, 2003, investigating the association between hospital type (general, semispecialized, and specialized) and disease-specific survival. Contribution Hospital type was statistically significantly associated with survival among patients with early-stage ovarian cancer in The Netherlands. Ovarian cancer patients with early-stage cancer who were treated in specialized or semispecialized hospitals survived longer than patients treated in general hospitals. Among patients with advanced ovarian cancer, no association was found between hospital type and survival. Implications The level of collaboration between general hospitals and semispecialized or specialized hospitals during the study period was not sufficient to deliver optimal care to all Dutch patients with ovarian cancer. Regionalized care thus seems necessary. Limitations Adjustment for comorbidity could not be done, so it is possible that more patients without severe comorbid conditions were referred to specialized hospitals than patients with comorbid conditions.
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Manuscript received July 13, 2007; revised January 3, 2008; accepted January 23, 2008.
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J Natl Cancer Inst 2008 100: 378-379.
J Natl Cancer Inst 2008 100: 375.
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