Ovarian cancer treatment in the Netherlands : the effect of care provider on the outcomes of treatment between 1996-2003

Ovarian cancer has a very poor prognosis. Symptoms develop late in the disease and therefore it is usually diagnosed in an advanced stage. Attempts to detect the disease at an earlier stage have not been successful thus far. Therefore, optimal treatment seems to be the most efficient means at the moment to fight this ‘silent killer’. Prior studies consistently found that specialized gynaecologists, or gynaecological oncologists, performed adequate surgery significantly more often than general gynaecologists and survival was better after treatment in specialized hospitals. In the Netherlands about 1100 patients are diagnosed with ovarian cancer annually. Treatment of ovarian cancer patients takes place in almost all of the about 100 Dutch hospitals. Less than 40% of the ovarian cancer patients are treated by gynaecological oncologists. The question is whether the present Dutch system suffices to provide optimal care to ovarian cancer patients. We investigated this question in a cohort of 8621 Dutch ovarian cancer patients diagnosed between 1996 and 2003. All Dutch hospitals were classified according to specialization level (general, semi-specialized or specialized). About 40% of the patients had been treated in general hospitals, 41% in semi-specialized hospitals and 19% in specialized hospitals. Relative 5-year survival was 39%. Survival of patients older than 50 years with an early stage disease was longer after treatment in semi-specialized and specialized hospitals than in general hospitals. There was only a modest effect of hospital-specialization on the survival of patients with advanced ovarian cancer. Treatment outcomes were investigated in more detail in a sample of 1077 patients. Only 24% of the patients with early stage disease who received surgery by a general gynaecologist had been adequately staged, compared to about 60% of the patients operated by semi-specialized and specialized gynaecologists. Less than half of the patients with advanced disease received optimal debulking and specialization of the gynaecologists had little impact on the outcomes. However, gynaecologists performing more than 12 ovarian cancer surgeries per year (high-volume gynaecologists) achieved optimal debulking 3 times more often than gynaecologists operating 6 or less ovarian cancer surgeries annually. In addition, patients treated in specialized hospitals and by high-volume gynaecologists survived longer. We found no association between hospital type and the outcomes of first-line chemotherapy. However, overall survival was better in hospitals with 2 or more medical oncologists and in hospitals where 7 or more ovarian cancer patients were treated annually. This indicates that there might be an effect of the hospital type on the efficacy of second-line chemotherapy. Finally, the cost-effectiveness of treatment in general, semi-specialized and specialized hospitals was compared and the effect of improved treatment in specialized settings was investigated. With the present surgical results, treatment in semi-specialized hospitals was most cost-effective. However, if the percentages of adequately staged and optimally debulked patients were equal to the percentages described in literature, ovarian cancer care in specialized hospitals would also be a cost-effective strategy. These results imply that there is room for improvement of the Dutch treatment outcomes by increasing the level of specialization and concentrating ovarian cancer care