by Dr. C.H. Weaver M.D. updated 5/1/2020
Research shows that experience, expertise, and specialization improve outcomes for women with ovarian, endometrial and cervical cancers. As a patient or caregiver affected by a gynecologic cancer diagnosis make sure you are treated by a gynecologic oncologist to ensure that you or your loved one receive the best possible care. This is crucial, whether you are the patient or a caregiver of a patient who is primarily dependent upon you for support.
Gynecologic oncologists are physicians who specialize in cancers of the female reproductive system. General gynecologists are physicians who specialize in all medical concerns of the female reproductive system. The Gynecologic Oncology Group (GOG), established in 1970 by a group of gynecologic surgeons interested in promoting a “collaborative research effort, not only among institutions but also among the various disciplines involved in the treatment of women with gynecologic cancers,” conducts research that has set the standard of care for many gynecologic cancers and has also addressed issues of quality of life and cancer prevention. The work of the GOG encompasses all gynecologic cancers, including cancers of the ovary, cervix, and uterus.
What does the research show?
Women with ovarian cancer whose surgery is performed by a gynecologic oncologist have improved survival compared to women whose surgery is performed by a general gynecologist. and women who are treated by a gynecologic oncologist who performs many surgeries for ovarian cancer have a higher survival rate than patients not treated by an experienced specialist in the specified surgical procedures.
Specifically, women who have no residual cancer mass larger than 1 centimeter in diameter, referred to as “optimal cytoreduction”, following surgery tend to have better survival than those with a larger mass of residual cancer.Recent research has indicated that surgeon tendency and more aggressive surgery in eligible women leads to improved survival in ovarian cancer.
Research continues into whether more practiced surgeons achieve greater survival among this group of patients. Researchers from the Netherlands recently conducted a study including patients with all stages of ovarian cancer who were diagnosed between 1994 and 1997. Outcomes of gynecologic oncologists were compared to those of general gynecologists. Initial surgery was performed on 184 patients by gynecologic oncologists and on 328 patients by general gynecologists. Women whose surgery was performed by a gynecologic oncologist had improved outcomes:
- Gynecologic oncologists removed more cancer during surgery in twice the number of patients with stage III ovarian cancer as general gynecologists (24% vs. 12%, respectively).
- Gynecologic oncologists followed surgical guidelines more strictly than general gynecologists in all stages of ovarian cancer (55% vs. 33%, respectively for stages I-II; 60% vs. 40%, respectively for stages III-IV).
- At 5 years, survival was 86% for patients who underwent surgery by a gynecologic oncologist, compared with only 70% for those who underwent initial surgery by a general gynecologist.
The researchers concluded that initial surgery for women with ovarian cancer performed by a gynecologic oncologist improves survival over surgery performed by a general gynecologist. Patients diagnosed with ovarian cancer should seek a gynecologic oncologist to perform their surgery. (2)
Specialized hospitals make a difference.
Hospitals that specialize in care for ovarian cancer are associated with significantly improved survival for women with early ovarian cancer. These results were recently reported in the Journal of the National Cancer Institute.
Researchers from the Netherlands recently conducted study to evaluate the relationship between hospital experience and outcomes among women with early ovarian cancer. This study included 8,621 women; 40% of participants were treated in general hospitals, 41% were treated in semispecialized hospitals, and 18% were treated in specialized hospitals. Specialized hospitals had gynecologic oncologists on staff and were regional hospitals for treating gynecologic cancers, whereas semispecialized hospitals were community hospitals that had physicians on staff with subspecialty training in gynecologic oncology.
- Among women with Stage I-IIA ovarian cancer who were aged 50-75 years of age, the risk of death from ovarian cancer was reduced by 42% among women treated at specialized hospitals and by 30% among those treated at semispecialized hospitals compared with those treated at general hospitals.
- Among patients with advanced ovarian cancer, hospital type was not associated with survival.
The researchers concluded: “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.” Women with early ovarian cancer may wish to speak with their physician regarding the degree of expertise of the hospital where they will be undergoing surgery. (4)
According to an early online publication in the journal Cancer, women with ovarian cancer receive optimal therapy if treated by a gynecologic oncologist who performs a high volume of surgeries for ovarian cancer either in a hospital in which a high volume of these procedures are performed or in a teaching hospital. These results provide further evidence that women with this deadly disease should seek treatment from specialists to improve their chances for survival.
Researchers from the University of Washington, Centers for Disease Control and Prevention (CDC), and the National Cancer Institute (NCI) recently conducted a clinical study to evaluate factors associated with outcomes of surgical treatment among women with ovarian cancer. This study included over 10,000 admissions of women with ovarian cancer who had undergone the surgical removal of cancer. Data was collected from the Healthcare Cost and Utilization Project hospital discharge data from nine states from 1999 to 2002. The surgeries were categorized as comprehensive according to the National Institutes of Health Consensus Panel recommendations.
- Overall, nearly 67% of women received comprehensive surgery.
- Women treated by gynecologic oncologists who performed larger numbers of surgeries for ovarian cancer had significantly improved rates of comprehensive surgical procedures compared to women whose physicians were either obstetrician gynecologists or general surgeons and/or those who performed lower volumes of the surgeries.
- Women treated at either hospitals in which a high volume of surgical procedures for ovarian cancer were performed or those treated at obstetrician or gynecologic teaching hospitals had a significantly higher rate of comprehensive surgical procedures compared to women treated at hospitals in which lower volumes of these surgical procedures were performed or those who were treated at non-teaching hospitals.
The researchers concluded, “Efforts should be made to ensure that all women with ovarian cancer, especially those in vulnerable populations, have the opportunity to receive care from centers or surgeons with higher comprehensive surgery rates.” Women diagnosed with ovarian cancer are encouraged to seek treatment from a gynecologic oncologist who performs a high volume of surgeries for ovarian cancer at either a hospital in which a high volume of these procedures are performed or at teaching hospital. (5)
A crucial component in achieving optimal survival among patients with ovarian cancer is surgical removal of all or the majority of visible cancer, referred to as optimal debulking. Optimal debulking means that only one centimeter or less of visible cancer is left in the body following surgery. Results from studies have indicated that more experienced surgeons provide greater rates of optimal debulking and ultimately improved survival among ovarian cancer patients.
Researchers from Germany rconducted a clinical trial to further evaluate different prognostic factors and their associated impact on survival among patients with ovarian cancer. This study included data from the OVAR-3 trial, in which 761 patients with advanced-stage ovarian cancer underwent surgery followed by chemotherapy. These patients were analyzed for factors that may have affected surgery as well as survival.
- Patients who underwent surgery in centers with surgeons who performed comprehensive surgical debulking had rates of nearly 33% of debulking surgery compared with only 23% among patients who were not treated in these types of centers.
- Patients whose surgeons performed comprehensive surgical debulking had significantly improved overall survival.
- Patients with a greater amount of cancer prior to surgery, more extensive cancer, more advanced age, worse performance status (ability to perform daily functions), and those whose cancer spread to the peritoneum (lining of the abdominal cavity) had worse rates of debulking during surgery.
The researchers concluded that these results provide further evidence that patients with ovarian cancer who are treated by surgeons who are more apt to perform complete debulking surgery have significantly improved survival. Patients diagnosed with ovarian cancer may wish to speak with their physician regarding their individual risks and benefits of debulking surgery. (6)
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According to another article published in Gynecologic Oncology, patients with ovarian cancer who undergo initial surgery at a medical center with expertise in surgery for their disease appear to achieve a significant survival benefit.Approximately 25,000 new cases of ovarian cancer are diagnosed in the U.S. each year. Standard treatment for ovarian cancer involves the surgical removal of as much cancer as possible (if the patient is eligible for surgery), as well as chemotherapy and/or radiation therapy. If ovarian cancer is detected and treated prior to spread from its site of origin, chances of a cure are promising. However, the vast majority of patients with ovarian cancer are diagnosed with advanced cancer, or cancer that has already spread from the ovary. Cure rates for women with advanced ovarian cancer remain dismal.Surgery is an integral component of treatment for all stages of ovarian cancer. Surgeons attempt to remove all of the cancer and sometimes perform a second surgery following chemotherapy and/or radiation to remove any remaining cancer.Results from previous studies have demonstrated that patients treated by surgeons, physicians, and other healthcare providers who perform high volumes of surgeries or care for high volumes of patients with very specific diseases tend to have improved outcomes. Unfortunately, patients who live in very rural areas may have a difficult time accessing specialized treatment centers.Researchers from Denmark recently conducted a clinical trial to evaluate possible differences in outcomes of patients with ovarian cancer who undergo initial surgery in a specialized, central medical center. The trial included 107 patients in the County of North Jutland who were treated with initial surgery from 1999 to 2002 at the Gynecologic Oncology Center. These 107 patients represented 95.5% of all women diagnosed with ovarian cancer in that county.Patients had been diagnosed with stages I (cancer not spread from ovary) to IV (cancer spread to distant sites in the body); all had initial surgery at the Gynecologic Oncology Center. Optimal debulking (no cancer remaining that is bigger than 2 cm in diameter) was achieved in at least 78% of patients. Patients then underwent standard chemotherapy. Results were as follows:
- Post-operative death (death within 30 days of surgery) occurred in only 3.7% of women.
- For all patients, median survival was nearly 4 years.
- Patients with stages IIIC and IV disease (the most advanced stages) had a median survival of 32 months.
- For patients with optimally debulked stages IIIC and IV disease (79.5%), median survival was 41 months.
- Overall median survival was improved by 15 months for all stages of ovarian cancer when compared to regional and national data.
The researchers concluded that specialized treatment centers that perform initial surgery for all stages of ovarian cancer appear to provide significantly improved survival for these patients. This trial included the centralization of a primary center for a specific county in Belgium; however, because the U.S. is much larger, bringing this concept into clinical practice may prove more difficult. Nonetheless, this study supports similar finding of previous studies: Specialized surgeons tend to provide improved outcomes for their patients.Patients diagnosed with ovarian cancer may wish to find a specialized center for initial surgery for their disease. (7)
According to a study published in the Journal of the National Cancer Institute, ovarian cancer patients treated by gynecologic oncologists have somewhat better outcomes than ovarian cancer patients treated by general gynecologists. Patients treated by gynecologic oncologists also have clearly better outcomes than those treated by general surgeons. A related study published in the same issue found no strong link between the number of ovarian cancer patients treated by a physician or hospital and ovarian cancer outcomes.
The relationship between patient outcomes and the number of patients seen at a particular hospital or by a particular doctor has received a great deal of attention over the past 25 years. In general, studies report that “high-volume” hospitals and doctors (hospitals and doctors who treat more patients with a particular condition) have better patient outcomes for specific conditions.
In the case of ovarian cancer, studies have also suggested that highly specialized physicians (gynecologic oncologists) are more likely to perform recommended ovarian cancer surgery than less specialized physicians; they may therefore more accurately assess the stage of the cancer. Accurate cancer staging is a critical component of treatment planning.
To evaluate the relationship between physician specialty and ovarian cancer outcomes, researchers evaluated 3067 ovarian cancer patients diagnosed between 1992 and 1999.[] All patients were 65 years of age or older. Thirty three percent of the patients were treated by a gynecologic oncologist, 45% of patients were treated by a general gynecologist, and 22% were treated by a general surgeon.
- Among patients with stage I or stage II ovarian cancer, recommended lymph node dissection was provided to 60% of patients treated by a gynecologic oncologist, 36% of patients treated by a general gynecologist, and 16% of patients treated by a general surgeon.
- Among patients with stage III or stage IV ovarian cancer, initial surgery included debulking (removal of as much of the tumor as possible) in 58% of patients treated by a gynecologic oncologist, 51% of patients treated by a general gynecologist, and 40% of patients treated by a general surgeon.
- Compared to patients treated by a general surgeon, risk of death was 15% lower in patients treated by gynecologic oncologists, and 14% lower in patients treated by general gynecologists.
The researchers conclude “Ovarian cancer patients treated by gynecologic oncologists had marginally better outcomes than those treated by general gynecologists and clearly superior outcomes compared with patients treated by general surgeons.”
A related study published in the same issue assessed the relationship between provider and hospital volume and ovarian cancer survival.[] The study used the same database as the study above to identify ovarian cancer patients. There was no strong link between the volume of patients seen by a surgeon or hospital and survival after ovarian cancer surgery.
The researchers conclude that “Hospital- and surgeon-specific procedure volumes are not strong predictors of survival outcomes following surgery for ovarian cancer among women aged 65 years or older.”
An editorial that accompanies these two studies cautions that both studies evaluated only older ovarian cancer patients.[] It’s unclear whether the results of these studies will apply to younger ovarian cancer patients.
- Engelen M, Kos H, Willemse P, et al. Surgery by Consultant Gynecologic Oncologists Improves Survival in Patients with Ovarian Carcinoma. Cancer. 2006; 3: 589 – 598.
- Chan J, Kapp D, Shin J, et al. Factors associated with the suboptimal treatment of women less than 55 years of age with early-stage ovarian cancer. Gynecologic Oncology. 2008;108: 95-99.
- Vernooji F, Heintz P, Witteveen P, et al. Specialized care and survival of ovarian cancer patients in the Netherlands: nationwide cohort study. Journal of the National Cancer Institute [early online publication]. March 11, 2008. DOI: doi:10.1093/jnci/djn033.
- Goff B, Matthews B, Larson E, et al. Predictors of comprehensive surgical treatment in patients with ovarian cancer. Cancer. 2007. Early online publication April 9, 2007. DOI: 10.1002/cncr.22604.
- Wimberger P, Lehmann N, Kimmig R, et al. Prognostic factors for complete debulking in advanced ovarian cancer and its impact on survival. An exploratory analysis of a prospectively randomized Phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR). Gynecologic Oncology. 2007; 106: 69-74.
- Andersen E, Knudsen A, Svarrer T, et al. The results of treatment of epithelial ovarian cancer after centralisation of primary surgery. Results from North Jutland, Denmark. *Gynecologic Oncology.*2005;99: 552-556.
 Earle CC, Schrag D, Neville BA et al. Effect of Surgeon Specialty on Processes of Care and Outcomes for Ovarian Cancer Patients.Journal of the National Cancer Institute. 2006;98:172-180.
 Schrag D, Earle C, Xu F et al. Associations Between Hospital and Surgeon Procedure Volumes and Patient Outcomes After Ovarian Cancer Resection. Journal of the National Cancer Institute. 2006;98:163-171.
 Lipscomb J. Transcending the Volume-Outcome Relationship in Cancer Care. Journal of the National Cancer Institute. 2006;98:151-154.