Elsevier

Gynecologic Oncology

Volume 103, Issue 2, November 2006, Pages 383-390
Gynecologic Oncology

Ovarian cancer: Patterns of surgical care across the United States

https://doi.org/10.1016/j.ygyno.2006.08.010Get rights and content

Abstract

Objective.

To describe the primary surgical procedures and procedures for intraoperative and postoperative complications, and factors associated with these procedures, in women with ovarian cancer.

Methods.

Using hospital discharge data from nine states, obtained from the Heath Care Cost and Utilization Project from 1999 to 2002, we evaluated 10,432 women with a primary diagnosis of ovarian cancer who underwent at least an oophorectomy for additional procedural ICD-9 codes during their initial hospitalization.

Results.

Surgical procedures performed in addition to oophorectomy included: omentectomy/debulking 81.9%, hysterectomy 73.4%, lymph node dissection 41.4%, appendectomy 23.8%, bowel procedures 19.8%, laparoscopy 5.6%, diaphragmatic procedures 4.9%, colostomy 3.5%, and splenectomy 1.2%. Transfusions were given to 15.5% of patients. Intraoperative and postoperative procedures for complications were coded in 7.4% of patients, including repair of surgical injury 3.5%, procedures for cardiopulmonary complications 2.8%, reoperation 1.1%, and infection treatment 0.3%. In early stage disease 21.4% of women received no additional staging procedures and 46.8% did not have nodal sampling. In bivariate analysis of crude rates, factors associated with lymph node dissection were patient age, race, payer, teaching hospital status, hospital and surgeon volume, and surgeon specialty, p < .01. for all observations. Colostomies were performed by general surgeons in 23.1% of cases, by gynecologic oncologists in 2.7% of cases, and by obstetrician/gynecologists in no cases, p < .001. Complications were associated with age, payer, median household income, and stage, p < .001 for all observations. Complication rates were similar for low- and high-volume hospitals and surgeons. However, in higher volume settings, significantly more patients received debulking procedures, lymph node dissections, and additional surgical procedures, p < .001 for all observations.

Conclusions.

A significant percentage of women with ovarian cancer did not receive recommended surgical procedures. Almost 50% of women with early stage disease were not adequately staged and in women with advanced disease, the percentage who had additional surgical procedures such as bowel resections was much lower than in institutions that report high optimal cytoreduction rates.

Introduction

Surgery is an important component in the effective treatment of ovarian cancer. Surgery is required for diagnosis and staging [1]. While the majority of women with ovarian cancer will need chemotherapy in addition to surgery, some early stage cancers are cured with surgery alone. In women with advanced stage disease, optimal surgical cytoreduction is one of the most important prognostic factors [2], [3].

The surgical procedures required for optimal cytoreduction are quite diverse and often require significant surgical expertise. In a study from the University of Florida, 28% of patients with advanced disease who underwent cytoreduction required bowel resections [4]. Many studies report extensive bowel procedures, diaphragmatic stripping, splenectomy, partial liver resection, or partial resection of bladder or ureter as important procedures in performing cytoreduction [5], [6]. Many single institution reports have documented frequency of procedures needed to achieve the cytoreduction and complications, but few population-based studies have evaluated patterns of surgical care for ovarian cancer in the United States. Harlan et al. conducted a population-based study of patients from the Surveillance Epidemiology and End Results (SEER) registry and found that 25% of women with advanced disease were not receiving the surgical procedures recommended by the NIH Consensus Conference; however, the authors provided no specifics on what procedures actually were or were not performed [7].

The purpose of our current study is to describe the patterns of surgical care for women with ovarian cancer from nine states that are diverse in environmental factors. In addition, we have examined the rates of different surgical procedures and complications among women with varied sociodemographic and environmental characteristics as well as among women who received care from different types of physicians and hospitals.

Section snippets

Materials and methods

We identified hospitalizations for women aged 21 and older with primary surgical treatment for ovarian cancer in an acute care hospital in one of nine U.S. states (Colorado, Florida, Iowa, Maine, New Jersey, South Carolina, Washington, and Wisconsin) between 1999 and 2002. These were the most recent 3 years of hospital discharge data available nationally through the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project (HCUP) when our study was initiated. Primary

Results

During the study period, 10,432 women were hospitalized with a primary diagnosis of ovarian cancer and underwent at least an oophorectomy. The mean age of the study population was 60 years; of those for whom race was known 83.6% were Caucasian, 6.4% African American, and 5.3% Hispanic. Women from New York made up 28.1% of the population, Florida 25.6%, New Jersey 12.1%, Washington 9.2%, Wisconsin 8.2%, Colorado 6.1%, Iowa 4.5%, South Carolina 4.5%, and Maine 1.8%.

Table 1 lists the frequency of

Discussion

Inadequate surgery in ovarian cancer patients has been shown to decrease survival from this disease [10], [11]. In 1994 the NIH convened a consensus panel for ovarian cancer, which published guidelines for appropriate surgical treatment [12]. Recommendations for women with disease that appears to be confined to the pelvis is to undergo a comprehensive staging, which includes peritoneal cytology, omentectomy, pelvic and para-aortic lymph node dissection, and diaphragmatic and peritoneal

Acknowledgments

This publication was supported in part by the Centers for Disease Control and Prevention and the National Cancer Institute through the Cancer Prevention and Control Research Network, a network within the CDC's Prevention Research Centers Program (Grant I-U48-DP-000050).

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    1

    The findings and conclusions in the report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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