Review: The optimal organization of gynecologic oncology services: a systematic review

open access - Current Oncology

Abstract

Background

A system-level organizational guideline for gynecologic oncology was identified by a provincial cancer agency's (Ontario, Canada) 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.

RESEARCH QUESTIONS

• □ Are outcomes better for patients with gynecologic cancer treated in designated centres (“centralized care”) compared with non-designated centres (“decentralized care”)?
• □ Are outcomes better for patients treated by gynecologic oncologists than by non-subspecialist physicians?

CONCLUSIONS

The evidence found in the present review is consistent with previous research showing a likely benefit from the delivery of gynecologic oncology care in specialized centres with subspecialists working as part of a multidisciplinary team—particularly for patients with more advanced ovarian cancer. It should be cautioned, however, that unlike other disease sites such as pancreas and esophagus4, the evidence for this finding is far from strong.

Because of the lower-quality nature of the evidence base, an expert consensus process was used to create an organizational guideline, the results of which are published separately40.

Briefly, the consensus process led to recommendations for the performance of definitive surgery for most invasive cancers by subspecialist gynecologic oncologists within designated gynecologic oncology centres. The recommendations indicate that some services, such as radiation therapy, could be provided in other affiliated centres. Multidisciplinary team management is also endorsed, and recommendations are provided for human and physical resource needs and some aspects of pathology. The recommendations are intended to minimize provincial variations in practice and to make best use of limited resources.

Our review also found that, even when practice and outcomes appeared to have improved under a centralized model, heterogeneity of technique remained, even among groups of subspecialists. That finding suggests that a plan to implement care in centralized or specialized facilities featuring subspecialists and multidisciplinary care should also include the adoption of appropriate guidelines across the care continuum and of the necessary system processes and evaluation plans. It will be a challenge to implement those changes across a health care system spanning a large and variable geographic area with a range of independent hospitals.