Mortality after ovarian cancer (OC) surgery is increased at low volume hospitals (LVH) compared to high volume hospitals (HVH): Black women incur the greatest excess risk

Epithelial ovarian cancer consists of multiple histotypes differing in etiology and clinical course. The most prevalent histotype is high-grade serous ovarian cancer (HGSOC), which often presents at an advanced stage frequently accompanied with high-volume ascites. While some studies suggest that ascites is associated with poor clinical outcome, most reports have not differentiated between histological subtypes or tumor grade. We compared genome-wide gene expression profiles from a discovery cohort of ten patients diagnosed with stages III-IV HGSOC with high-volume ascites and nine patients with low-volume ascites. An upregulation of immune response genes was detected in tumors from patients presenting with low-volume ascites relative to those with high-volume ascites. Immunohistochemical studies performed on tissue microarrays confirmed higher expression of proteins encoded by immune response genes and increased tumorinfiltrating cells in tumors associated with low-volume ascites. Comparison of 149 advanced-stage HGSOC cases with differential ascites volume at time of primary surgery indicated low-volume ascites correlated with better surgical outcome and longer overall survival. These findings suggest that advanced stage HGSOC presenting with low-volume ascites reflects a unique subgroup of HGSOC, which is associated with upregulation of immune related genes, more abundant tumor infiltrating cells and better clinical outcomes.

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Factors Associated With Use of a High-Volume Cancer Center by Black Women With Ovarian Cancer

Journal of Oncology Practice ◽

10.1200/jop.18.00741 ◽

2019 ◽

Vol 15 (9) ◽

pp. e769-e776

Author(s):

Renee A. Cowan ◽

Elyse Shuk ◽

Maureen Byrne ◽

Nadeem R. Abu-Rustum ◽

Dennis S. Chi ◽

...

Keyword(s):

Ovarian Cancer ◽

Black Women ◽

Insurance Coverage ◽

High Volume ◽

Cancer Center ◽

Black Communities ◽

Related Factors ◽

Self Advocacy ◽

Factors Affecting ◽

Institutional Review

OBJECTIVE: Disparities exist between population subgroups in the use of gynecologic oncologists and high-volume hospitals. The objectives of this study were to explore the experiences of black women obtaining ovarian cancer (OC) care at a high-volume center (HVC) and to identify patient-, provider-, and systems-related factors affecting their access to and use of this level of care. MATERIALS AND METHODS: Twenty-one semistructured interviews were conducted as part of an institutional review board–approved protocol with women who self-identified as black or African American, treated for OC at a single HVC from January 2013 to May 2017. Recurring themes were identified in transcribed interviews through the process of independent and collaborative thematic content analysis. RESULTS: Five themes were identified: (1) internal attributes contributing to black women’s ability/desire to be treated at an HVC, (2) pathways to high- and low-volume centers, (3) obstacles to obtaining care, (4) potential barriers for black women interested in treatment at an HVC, and (5) suggestions for improving HVC use by black women. Study participants who successfully accessed care were comfortable navigating the health care system, understood the importance of self-advocacy, and valued the expertise of an HVC. Barriers to obtaining care at an HVC included lack of knowledge about the HVC, lack of referral, transportation difficulties, and lack of insurance coverage. CONCLUSION: In this qualitative study, black women treated at an HVC shared attributes and experiences that helped them access care. There is a need to collaborate with black communities and establish interventions to reduce barriers, facilitate access, and disseminate information about the value of receiving care for OC at an HVC.

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Histologic Subtypes of Ovarian Carcinoma: Selected Diagnostic and Classification Problems in Bulgaria: Is Low Hospital Volume an Issue?

Tumori Journal ◽

10.5301/tj.5000571 ◽

2016 ◽

Vol 103 (2) ◽

pp. 148-154 ◽

Cited By ~ 2

Author(s):

Vesela Ivanova ◽

Tihomir Dikov ◽

Nadya Dimitrova

Keyword(s):

Ovarian Cancer ◽

Quality Of Care ◽

Ovarian Carcinoma ◽

Cancer Patients ◽

Hospital Volume ◽

Clear Cell ◽

High Volume ◽

Ovarian Carcinomas ◽

Low Volume

Purpose To provide an overview of the morphologic subtypes of ovarian carcinomas in Bulgaria in relation to current healthcare organization using Bulgarian National Cancer Registry data. Further, we investigated hospital volume as a factor influencing the quality of care for patients with ovarian cancer. Methods Bulgarian National Cancer Registry ovarian carcinoma data were retrieved (2009-2011) and distribution of histologic types was analyzed. Cases were divided and compared with respect to main treatment: no surgery, surgery at hospitals dealing with ≥30 ovarian cancer patients/year (high volume), and surgery at hospitals dealing with <30 ovarian cancer patients/year (low volume). We then estimated the odds of being diagnosed with adenocarcinoma and carcinoma not otherwise specified (NOS) vs specified morphologies (serous, endometrioid, clear cell, and mucinous), including age, grade, stage, and hospital volume, in a logistic regression model. Results A total of 2,041 ovarian carcinomas were distributed as follows: serous 47.7%, mucinous 11.9%, endometrioid 5.8%, clear cell 1.8%, and adenocarcinoma and carcinoma NOS 32.5%. More than half of cancer patients (n = 1,100, 53.9%) were surgically treated in low-volume hospitals and they had a larger proportion of cases with adenocarcinoma and carcinoma NOS: 33.3%, in comparison with 24.0% in high-volume hospitals (p<0.0001). The odds of being diagnosed with unspecified morphology, assumed as a proxy of suboptimal quality of care, are higher for patients surgically treated in low-volume hospitals (odds ratio 1.50 [95% confidence interval 1.21-1.87]) compared with high-volume hospitals after adjustment for age, stage, and grade. Conclusions The results of our study may serve policymakers and healthcare professionals when optimizing diagnosis and treatment of ovarian cancer in Bulgaria.

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Failure to Rescue As a Source of Variation in Hospital Mortality for Ovarian Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2012.43.2906 ◽

2012 ◽

Vol 30 (32) ◽

pp. 3976-3982 ◽

Cited By ~ 65

Author(s):

Jason D. Wright ◽

Thomas J. Herzog ◽

Zainab Siddiq ◽

Rebecca Arend ◽

Alfred I. Neugut ◽

...

Keyword(s):

Ovarian Cancer ◽

Complication Rate ◽

Major Complication ◽

High Volume ◽

Complication Rates ◽

Failure To Rescue ◽

High Volume Hospital ◽

Lower Complication ◽

Major Complication Rate ◽

Low Volume

Purpose Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer. Patients and Methods The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and “failure to rescue” rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared. Results We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital. Conclusion Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.

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Correlation of differential ascites volume with primary cytoreductive surgery outcome, lymph node involvement, and disease recurrence in advanced ovarian cancer

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000310 ◽

2019 ◽

Vol 29 (5) ◽

pp. 922-928

Author(s):

Ingrid Lai ◽

Maria N Daniel ◽

Barry P Rosen ◽

Taymaa May ◽

Christine Massey ◽

...

Keyword(s):

Ovarian Cancer ◽

High Volume ◽

High Grade ◽

Advanced Stage ◽

Serous Ovarian Cancer ◽

Lower Serum ◽

Primary Surgery ◽

Serum Ca125 ◽

Volume Group ◽

Low Volume

ObjectiveHigh-grade serous ovarian cancer accounts for a disproportionate number of deaths from gynecologic malignancies. It typically presents at an advanced stage and with a high volume of ascites a common presenting feature. The aims of this study is to evaluate the association between ascites volume at the time of primary surgery for advanced stage ovarian cancer with surgical outcomes and patterns of recurrence.MethodsA retrospective review of stage III/IV high-grade serous ovarian cancer patients who underwent primary surgery at two centers between March 2003 to June 2016. Patients were categorized as low-volume ascites (≤ 200 mL) vs high-volume (≥ 1 L). Patients with an unknown volume of ascites or neoadjuvant chemotherapy were excluded. Patients' characteristics were compared for the two groups. Probability of recurrence over time and the HR from a proportional hazards model for sub-distribution were calculated.ResultsA total of 210 patients were included, 90 (42.9%) patients in the low-volume and 120 (57.1%) patients in the high-volume group. Patients in the low-volume group were older with a median age of 60.2 years vs 56.8 years in the high-volume group and had lower serum CA-125 levels (mean 223 vs 971.5 U/mL). The low-volume group had better surgical outcome with suboptimal debulking (> 1 cm residual disease) in only 17.8 % vs 39.2 % in the high-volume group and had longer median time to recurrence (2.8 years in low-volume vs 1.6 years high-volume group). At the time of recurrence, the low-volume group had a less disseminated pattern of recurrence, lower rates of ascites (20 % in the low-volume group vs 37.2 % in the high-volume group), and a trend toward lower serum CA125 levels (mean 352.8 vs 596.9 U/mL).ConclusionsAdvanced stage serous ovarian cancer patients who present with low-volume ascites have lower serum CA125 levels, more optimal cytoreduction rates, and longer disease-free interval. The low-volume group had less ascites, less disseminated disease, and a trend toward lower serum CA125 levels at the time of recurrence.

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Hospital Case-Volume and Mortality After Ovarian Cancer Surgery: A Population-Based Retrospective Cohort Study

10.21203/rs.3.rs-92574/v1 ◽

2020 ◽

Author(s):

Bo Rim Kim ◽

Heewon Kim ◽

Se-gyeong Joo ◽

Eun Jin Jang ◽

Junwoo Jo ◽

...

Keyword(s):

Ovarian Cancer ◽

Confidence Interval ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

High Volume ◽

Volume Effect ◽

Cancer Surgery ◽

Annual Number ◽

Case Volume ◽

Low Volume

Abstract Background: The goal of ovarian cancer surgery has recently shifted from optimal cytoreduction to more complete resection. This study attempted to reassess and update the association between surgical case-volume and both in-hospital and long-term mortality after ovarian cancer surgery using recent data.Methods: Data from all adult patients who underwent ovarian cancer surgery in Korea between 2004 and 2017 were obtained from the database of Korean National Health Insurance Service. Hospitals were categorized by average annual number of surgeries considering overall distribution of case-volume. Postoperative in-hospital and 1, 3, 5-year mortality were analyzed using logistic regression. Results: During the study period, 23,487 ovarian cancer surgeries were performed in 354 hospitals. High-, medium-, and low-volume centers were defined as >100 cases/year, 30-100 cases/year, and <30 cases/year, respectively. In-hospital mortality was significantly higher in medium-volume (1.63%; adjusted odds ratio, 2.28; confidence interval, 1.64-3.17; P <0.001) and low-volume (1.62%; adjusted odds ratio; 2.12; confidence interval, 1.55-2.90; P <0.001) centers compared to high-volume centers (1.13%). In addition, 1-year mortality after ovarian cancer surgery was 6.26%, 7.07%, and 8.06% for high-volume, medium-volume, and low-volume centers, respectively, and the differences among the groups were significant. However, case-volume effect was not apparent in 3- and 5-year mortality after ovarian cancer surgery.Conclusion: Case-volume effect was observed for in-hospital and 1-year mortality after ovarian cancer surgery while no clear association was found between the case-volume and 3- or 5-year mortality.

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Hospital case-volume and mortality after ovarian cancer surgery: a population-based retrospective cohort study

10.21203/rs.3.rs-92574/v2 ◽

2021 ◽

Author(s):

Bo Rim Kim ◽

Heewon Kim ◽

Se-gyeong Joo ◽

Eun Jin Jang ◽

Junwoo Jo ◽

...

Keyword(s):

Ovarian Cancer ◽

Confidence Interval ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

High Volume ◽

Volume Effect ◽

Cancer Surgery ◽

Annual Number ◽

Case Volume ◽

Low Volume

Abstract Background The goal of ovarian cancer surgery has recently shifted from optimal cytoreduction to more complete resection. This study attempted to reassess and update the association between surgical case-volume and both in-hospital and long-term mortality after ovarian cancer surgery using recent data. Methods Data from all adult patients who underwent ovarian cancer surgery in Korea between 2004 and 2017 were obtained from the database of Korean National Health Insurance Service. Hospitals were categorized by average annual number of surgeries considering overall distribution of case-volume. Postoperative in-hospital and 1, 3, 5-year mortality were analyzed using logistic regression. Results During the study period, 23,487 ovarian cancer surgeries were performed in 354 hospitals. High-, medium-, and low-volume centers were defined as > 100 cases/year, 30–100 cases/year, and < 30 cases/year, respectively. In-hospital mortality was significantly higher in medium-volume (1.63%; adjusted odds ratio, 2.28; confidence interval, 1.64–3.17; P < 0.001) and low-volume (1.62%; adjusted odds ratio; 2.12; confidence interval, 1.55–2.90; P < 0.001) centers compared to high-volume centers (1.13%). In addition, 1-year mortality after ovarian cancer surgery was 6.26%, 7.07%, and 8.06% for high-volume, medium-volume, and low-volume centers, respectively, and the differences among the groups were significant. However, case-volume effect was not apparent in 3- and 5-year mortality after ovarian cancer surgery. Conclusions Case-volume effect was observed for in-hospital and 1-year mortality after ovarian cancer surgery while no clear association was found between the case-volume and 3- or 5-year mortality.

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Quality of care in advanced ovarian cancer: How important is provider specialty?

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.e16519 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. e16519-e16519

Author(s):

C. Mercado ◽

D. Zingmond ◽

B. Y. Karlan ◽

E. Sekaris ◽

J. Gross ◽

...

Keyword(s):

Quality Of Life ◽

Ovarian Cancer ◽

Cancer Patients ◽

Gynecologic Oncology ◽

Advanced Ovarian Cancer ◽

High Volume ◽

Case Volume ◽

Low Volume ◽

Lower Hazard

e16519 Background: Ovarian cancer is one of the most aggressive and deadly cancers in women. While the mainstay of therapy is surgery, ovarian cancer surgical procedures are performed by surgeons with different specialty training, including gynecology, gynecologic oncology, general surgery, and others. We examine the degree to which surgeon specialty impacts survival and other quality of life-related outcomes in advanced ovarian cancer patients. Methods: Analyses of Stage 3c/4 ovarian cancer patients were performed from 4 states (California, Washington, New York, Florida). Four databases were linked for each state: cancer registry, inpatient-hospital discharge, AMA masterfile, and 2000 U.S. Census SF4 File. Multivariate modeling was performed to identify predictors of survival as well as proxy quality of life-related outcomes, as measured by creation of a fecal ostomy. Hospital case volume was defined as low volume (LV) [0–4 cases], middle volume (MV) [5–9], high volume (HV) [10–19], and very high volume (VHV) [20+]. Results: 60,405 ovarian cancer patients were identified; 53% were Stage 3c/4. Mean age was 64 years. Patients had lower hazard of death when treated in higher volume hospitals as compared to LV [HV (Hazard Ratio) HR = 0.89, p < 0.0001; VHV HR = 0.79, p < 0.001]. Patients treated by gynecologists/gynecologic-oncologists had lower hazard of death (HR = 0.61, p < 0.0001) as compared to other surgeons (non-gynecologist), controlling for hospital type, case volume, comorbidity, and demographics. Also, patients treated by a trained gynecologist had the lowest chance of having an ostomy performed as compared to those of other specialties (HR = 0.22, p < 0.0001). Factors associated with receiving treatment from a non-gynecologist included low volume, rural patient residence, poverty, and high comorbidity. Conclusions: Stage 3c/4 ovarian cancer patients have better survival when treated by gynecology-trained surgeons. Our data suggest that gynecology-trained specialists optimize quality of life-related outcomes, specifically minimizing the creation of a fecal ostomy. Surgeon specialty was more important than procedure volume for these outcomes. Referral to gynecology-trained surgeons would improve survival and quality of life outcomes in advanced ovarian cancer patients. No significant financial relationships to disclose.

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Factors associated with the access and use of a high-volume cancer center by black women with ovarian cancer: A qualitative study

Gynecologic Oncology ◽

10.1016/j.ygyno.2018.04.313 ◽

2018 ◽

Vol 149 ◽

pp. 136

Author(s):

R.A. Cowan ◽

E. Shuk ◽

M.E. Byrne ◽

N.R. Abu-Rustum ◽

D.S. Chi ◽

...

Keyword(s):

Ovarian Cancer ◽

Black Women ◽

Qualitative Study ◽

High Volume ◽

Cancer Center ◽

Factors Associated

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High-Volume Hospitals with High-Volume and Low-Volume Surgeons: Is There a “Field Effect” for Pancreaticoduodenectomy?

The American Surgeon ◽

10.1177/000313481608200514 ◽

2016 ◽

Vol 82 (5) ◽

pp. 407-411 ◽

Cited By ~ 3

Author(s):

Thomas W. Wood ◽

Sharona B. Ross ◽

Ty A. Bowman ◽

Amanda Smart ◽

Carrie E. Ryan ◽

...

Keyword(s):

Hospital Mortality ◽

Field Effect ◽

Hospital Volume ◽

Patient Discharge ◽

High Volume ◽

Surgeon Volume ◽

Hospital Charges ◽

Leapfrog Group ◽

Discharge Status ◽

Low Volume

Since the Leapfrog Group established hospital volume criteria for pancreaticoduodenectomy (PD), the importance of surgeon volume versus hospital volume in obtaining superior outcomes has been debated. This study was undertaken to determine whether low-volume surgeons attain the same outcomes after PD as high-volume surgeons at high-volume hospitals. PDs undertaken from 2010 to 2012 were obtained from the Florida Agency for Health Care Administration. High-volume hospitals were identified. Surgeon volumes within were determined; postoperative length of stay (LOS), in-hospital mortality, discharge status, and hospital charges were examined relative to surgeon volume. Six high-volume hospitals were identified. Each hospital had at least one surgeon undertaking ≥ 12 PDs per year and at least one surgeon undertaking < 12 PDs per year. Within these six hospitals, there were 10 “high-volume” surgeons undertaking 714 PDs over the three-year period (average of 24 PDs per surgeon per year), and 33 “low-volume” surgeons undertaking 225 PDs over the three-year period (average of two PDs per surgeon per year). For all surgeons, the frequency with which surgeons undertook PD did not predict LOS, in-hospital mortality, discharge status, or hospital charges. At the six high-volume hospitals examined from 2010 to 2012, low-volume surgeons undertaking PD did not have different patient outcomes from their high-volume counterparts with respect to patient LOS, in-hospital mortality, patient discharge status, or hospital charges. Although the discussion of volume for complex operations has shifted toward surgeon volume, hospital volume must remain part of the discussion as there seems to be a hospital “field effect.”

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