Expert Point of View: William Cliby, MD

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William Cliby, MD

Matthew A. Powell, MD

David M. O’Malley, MD

When asked to comment on the study presented by Lin et al at the Annual Meeting on Women’s Cancer, William Cliby, MD, Chair, Division of Surgery, The Mayo Clinic, Rochester, Minnesota, said, “This study is important because of its size and the utilization of the National Cancer Data Base—the largest, national resource designed specifically to look at trends in national cancer care, create benchmarks, and serve as a basis for quality improvement. The results confirm findings from earlier, smaller studies: facility case volume of cancer affects survival. This effect was seen across gynecologic cancers. The challenge for providers, patients, and payors is to develop improved systems that facilitate getting these complex patients to regional high-volume centers.”

Matthew A. Powell, MD, Associate Professor, Washington University School of Medicine, St. Louis, and Chair of the Quality and Outcomes Committee for the Society of Gynecologic Oncology, explained that his committee seeks to understand problems and identify deficiencies in the care of women with gynecologic malignancies. Addressing these issues should improve patient outcomes, he noted.

“Outcomes based on research such as that presented by Dr. Lin are vital for us to help meet our goals,” Dr. Powell said. He noted that for nearly all aspects of complex medical care in the United States, increased volume of the provider and facility have been associated with improved results.

Centralization of Care

“Solid organ transplant is a great example where better results were seen at higher-volume centers, and this has led to centralization of care to high-volume centers. Several European countries have evaluated their outcomes for patients with cancer and have mandated centralized care due to superior results. The Norwegian health system has been the most successful in formalizing its management of patients with ovarian cancer and mandating centralization of care,” Dr. Powell continued.

Dr. Lin’s study utilizes the National Cancer Data Base, which was established in 1989 and captures data on approximately 26 million patients from more than 1,500 participating hospitals, including nearly 70% of newly diagnosed cancers each year.

“The study showed that treatment of gynecologic cancer at high-volume centers is associated with improved outcomes independent of significant prognostic factors. Patients treated at high-volume centers lived on average over 1 year longer. Elderly and advanced-stage patients are more likely to be treated at low-volume centers. These data support regionalization of gynecologic cancer care and identify areas for improvement,” Dr. Powell stated.

Multidisciplinary Teamwork

A third expert commenting on this paper, David M. O’Malley, MD, Assistant Professor at The James Cancer Hospital and Richard J. Solove Research Institute, Ohio State University College of Medicine, Columbus, emphasized the importance of multidisciplinary teamwork at high-volume centers.

 “One of the greatest impacts on overall survival in women who have been diagnosed with a gynecologic cancer is treatment at a center that not only offers specialty care but also offers care to a large number of patients. Dr Lin’s report is not able to identify the factors responsible for these findings. Most likely, this highly significant improvement in overall survival is related to offering comprehensive care by teams that are specialty-trained.” Dr. O’Malley said.

“The teams at high-volume institutions are often led by a specialty-trained gynecologic oncologist working with other physicians trained in the treatment of gynecologic cancers to include medical oncologists, radiation oncologists, and pain and palliative care specialists. The physicians are just a part of the team that are involved in improving care of women at these high-volume institutions; pharmacists, nurse practitioners, physician assistants, nurses, and other important team members who have been trained in the treatment of women diagnosed with gynecologic cancers are very important to the care of these women,” Dr. O’Malley stated.

He noted that it is important to identify barriers to being treated at the high-volume institutions. “The report by Dr. Lin and colleagues further provides evidence that it may be time to establish a system that deems specialty programs as centers of excellence, such as those established in other diseases in the treatment of gynecologic cancers,” he said. ■

Disclosure: Drs. Cliby, Powell, and O’Malley reported no potential conflicts of interest.

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