Cochrane Review: abstract/plain text summary - Centralisation of services for gynaecological cancer - The Cochrane Library - Woo - Wiley Online Library

Centralisation of services for gynaecological cancer - The Cochrane Library 

Authors' conclusions

We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.
Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.

 

Plain language summary

Gynaecological cancers are cancers affecting the ovaries, uterus, cervix, vulva, and vagina.  They are the second most common cancers among women, after breast cancer. It is often suggested that outcomes are improved by centralising care within highly specialised services that include expert surgeons, radiologists, pathologists, oncologists who specialise in chemotherapy and radiotherapy, specialist nurses and other health professionals. However, consensus is lacking on whether centralisation of care for gynaecological cancer helps patients to live longer. This review investigated this issue by comparing the survival of women diagnosed with gynaecological cancer who received care from specialised and unspecialised centres.

We used a set of tests to ensure that the evidence the five studies identified reached the quality standard for our analysis.The analysis of three studies combined (meta-analysis), assessing over 9000 women, suggested that institutions with gynaecologic oncologists (specialists in the field of gynaecological cancer treatment) on site may prolong the lives of women with ovarian cancer compared to community or general hospitals. Similarly, another meta-analysis of three studies which assessed well over 50,000 women, found evidence to suggest that teaching centres or regional cancer centres (specialised centres) (Blogger's Note: do the specialized/regional centre have gynecologic oncologists/clinical trial access....) may prolong the lives of women with gynaecological cancer compared to community or general hospitals. The largest study in this meta-analysis assessed all gynaecological cancers in 48,981 women, so it had major influence on the final result; this means that our findings are likely to be relevant to other gynaecological cancers, besides ovarian cancer.

Overall, the findings suggest that centralisation of care may prolong the lives of women with gynaecological cancer, and in particular ovarian cancer. However, the results should be interpreted with caution as all of the studies included in the review could be biased. For example, it is possible that the patients who were treated in specialised centres were less ill to begin with. Another weakness of the review is that only one of the studies included women with gynaecological cancers other than ovarian cancer. (Blogger's opinion: any studies of this nature should differentiate and isolate/categorize the gynecologic cancers as treatments, side effects, survival rates, genetics....vary greatly)

Ideally, further studies in this area are needed.  New studies should be designed to avoid the possibility of bias due to the treatment of women at specialist and non-specialist centres being systematically different.

Additionally, studies should assess the impact of centralisation of care on the quality of life of patients.

Most of the available evidence was about ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers and to less developed countries.

open access: paper/Editorial - Improvements in survival of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of multidisciplinary management?

Blogger's Note:  search blog for additional information on centralization of ovarian cancer surgery (eg. Norway...)

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Setting 
In 1999 the DH (Department of Health) in England introduced the Improving Outcomes in Gynaecological Cancer guidance, advising case management by multidisciplinary teams with surgical concentration in specialist hospitals.

In conclusion, there was a highly significant step-change increase in survival in gynaecological cancers associated with the adoption of the 1999 national policy change. ......... These changes have been most marked within endometrial and ovarian cancers.

Editorial: 

"Finally, Crawford and Greenberg on page 160 present their detailed population-based analyses of the effects of centralisation of care on survival outcomes in endometrial and ovarian cancer. Introduced in the UK in the late 1990s, the development of Cancer Networks (the ‘hub and spoke’ model) met with considerable resistance. Although it seemed intuitively right, the evidence to support such health care re-organisations was best described as weak, and they not only needed a significant investment of resources, but also required people to travel away from their immediate locality, making it difficult for friends and families to visit. Now, a number of years on, data are beginning to emerge reassuring all of the interested parties, patients in particular, that the energies and efforts required to implement the principles of centralisation of cancer services appear to have been justified."