Ovarian cancer treatment in the Netherlands; the effect of care provider...


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Title Ovarian cancer treatment in the Netherlands; the effect of care provider on the outcomes of treatment between 1996-2003
Period 07 / 2005 - 03 / 2008
Status Completed
Dissertation Yes
Research number OND1318014
Data Supplier ZONMW


Ovarian cancer is the most lethal gynaecologic malignancy in The Netherlands. Optimal cytoreductive surgery in combination with platinum based combination chemotherapy is the cornerstone of treatment. In several countries optimal debulking rates and survival were found to be better for specialized gynaecologists operating in specialized centres than for general gynaecologists operating in community hospitals. In The Netherlands, however, the majority of the patients with ovarian cancer is operated by the latter group of gynaecologists. The issue of centralisation has been discussed for many years now but in absence of sound evidence, the discussion remains opinion based. Therefore the objective of this study is to answer the question: does consistent referral of women with ovarian cancer to gynaecologic oncologists in specialised, multidisciplinary centres result in a survival- and economic benefit compared to the current treatment-policy? A retrospective cohort analysis will be performed to investigate if there is a difference in treatment result, survival and costs of care between Dutch ovarian cancer patients treated in community hospitals and patients treated in multidisciplinary, specialised centres. In addition, comparisons will be made between patients treated by gynaecologic oncologists and patients treated by general gynaecologists. In the first year, survival data of Dutch women diagnosed with ovarian cancer between 1996 and 2002 will be obtained by linking incidence-data of the Cancer Registries (IKCs) to mortality data of Statistics Netherlands (CBS). Kaplan-Meier survival curves will be computed and tested statistically by the log rank test. To compare the different treatment groups in detail, a random sample of about 1100 of these patients will be drawn. Half of this population are patients who are treated in multidisciplinary, specialised centers and these centers will be randomly selected. The other 550 patients are treated in community hospitals and they will be randomly selected from the National Medical Registration (LMR). Additional data will be collected from patient records in the first and second year. Economic evaluation will comprise a comparison of costs and a comparison of patient outcome in terms of survival and QALYs . In the third year, writing and publication will be done. Ovarian cancer is the most lethal gynaecologic malignancy in The Netherlands. According to the Netherlands Cancer Registry, ovarian cancer affects about 1300 women yearly. Two-thirds of them present in advanced stages, which have 5 years survival ranging from 29% for stage III to 13% for stage IV (2003). Theoretically, prognosis of ovarian cancer could be improved by screening to detect ovarian cancer in an earlier stage. However, no true precursor lesions of ovarian cancer have been detected and little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. Ovarian cancer can start as a unifocal disease and progress to diffuse disease, but it can also develop from multiple foci within the abdomen. Regarding timing of progression (important to determine screening interval) it is known that the disease can develop within very short notice (a few months). So far screening was found not to result in reduction of mortality(Bell, Petticrew et al. 1998). Therefore, to improve prognosis of ovarian cancer patients we should aim at optimising therapy. The objective of this study is to investigate the relation between organisation of care and costs and results of treatment of ovarian cancer in the Netherlands. Survival and costs of care will be compared between patients treated in community hospitals and patients treated in multidisciplinary specialised care centres. A secondary objective is to investigate differences in the two treatment modalities, surgery and chemotherapy, between community hospitals and specialised centres. Surgery will be evaluated by comparing patients treated by gynaecologic oncologists and patients treated by general gynaecologists. To assess the added value of care by specialised oncologists, chemotherapeutic regimes in peripheral hospitals and in specialised centres will be compared. The incidence of ovarian cancer in The Netherlands is about 1300 patients a year and most of the patients present with disease around the age of 60 years. The majority of the patients presents with advanced stage disease, for which prognosis is poor. Screening for ovarian cancer to detect the disease in an earlier stage did not influence mortality until now (Bell, Petticrew et al. 1998). Optimising treatment is the most efficient investment at this moment to fight this `silent killer`. Maximal cytoreduction and platinum based chemotherapy are the cornerstones of therapy and the contribution of cytoreductive surgery in terms of survival seems to be 9-12 months (Heintz 1998). The success of the operation is related to the capacity of the gynaecologist to debulk the tumor mass. In several foreign studies an improvement in survival was found when patients where primarily operated by gynaecologic oncologists instead of general gynaecologists. In 1992 Eisenkop et al reported a difference in median survival of 18 months (median survival of 35 months versus 17 months (P value Preliminary studies: Feasibility of our study was assessed by investigating availability of the necessary data from the different data sources we are going to use. Data on patient age, stage, histology of the tumor, type of treatment and type of hospital of treatment were extracted from the files of the Comprehensive Cancer Center Middle Netherlands. A summary of these data can be found in the pdf-file `IKMN`. A preliminary comparison of the distribution of prognostic and treatment-characteristics among community and specialized hospitals can be made based on these data. Between 1996 and 2000 250 patients (53%) were treated in the community hospitals in the Middle-Netherlands-region and 86 (18%) in the academic hospital (UMC Utrecht). The remainder of the patients were either operated outside the region (7% of the patients) or not operated (21%). Slightly younger patients were treated in the academic hospital than in the community hospitals (average age at diagnosis 54 vs 59 years).There were no differences between community and specialized hospitals in the proportion of early (I and II) (resp. 54 and 52%) and the late (III and IV) stages (both 43%), of optimally debulked patients (31 and 30%) and of people who received chemotherapy in addition to surgery (49 and 48%). More detailed data from a random sample of the patients was obtained from the Landelijke Medische Registratie (LMR) and from patient records. For an overview of the data that are available from the LMR, a random list was extracted from all ovarian cancer patients hospitalised in the Netherlands for ovarian cancer (pdf-file `LMR`).

Abstract (NL)

Nederlandse patiënten met ovariumcarcinoom of eierstokkanker overleven minder vaak dan patiënten in West-Europa en de Verenigde Staten. Jaarlijks wordt het bij ongeveer 1100 vrouwen gediagnosticeerd, minder dan veertig procent van de patiënten wordt behandeld door gynaecologen gespecialiseerd in oncologie. Floor Vernooij vermoedde dat deze situatie geen optimale zorg garandeert. Zij onderzocht het effect van type behandelaar en ziekenhuis bij 8621 ovariumcarcinoom-patiënten. Patiënten met een vroeg stadium van de ziekte blijken langer te overleven na behandeld te zijn in semi-gespecialiseerde en gespecialiseerde ziekenhuizen. Gespecialiseerde gynaecologen, die jaarlijks meer dan twaalf ovariumcarcinoom-operaties verrichtten, halen de beste resultaten. Vernooij pleit voor een verhoging van het specialisatie-niveau en concentratie van de chirurgische behandeling van ovariumcarcinoom-patiënten in Nederland. Ovariumcarcinoom-patiënten zouden hierdoor gemiddeld zeven maanden langer kunnen leven. Floor Vernooij promoveert op 4 maart aan de Universiteit Utrecht.

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Supervisor Prof.dr. Y. van der Graaf
Supervisor Prof.dr. A.P.M. Heintz
Doctoral/PhD student Dr. F. Vernooij
Doctoral/PhD student Dr. P.O. Witteveen


D23120 Oncology

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