The Role of Specialisation in the Management and Survival of Patients With Ovarian and Endometrial Cancer

Crawford, Simon Callander (2002) The Role of Specialisation in the Management and Survival of Patients With Ovarian and Endometrial Cancer. MD thesis, University of Glasgow.

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Aims: The primary aim was to assess the role of specialisation, particularly that of specialist surgery, in the management of epithelial ovarian cancer and in particular the extent to which differences in the surgery performed are related to survival. Secondary aims evolved from initial observations. The survival difference between gynaecologists and general surgeons was explored and further evidence for the role of the multidisciplinary clinic [MDC] was examined. The role of specialisation in the management of patients with endometrial cancer was explored to allow parallel observations to be drawn for this neglected cancer that is treated by the same gynaecologists treating ovarian cancer. Methods: Three studies were undertaken: (0 A retrospective case note review of patients registered with ovarian cancer between 1995 & 1997 in Scotland was undertaken. Pre-defined and piloted datasets were abstracted from patient medical case records. These were linked to survival data. This study was used to explore the relationship between the operating surgeon's approach to surgery, surgery performed, success of surgery and survival. Information on the MDC and chemotherapy was also collected. This data was compared with previously reported data from 1992-1994 to examine changes in treatment over time and to relate these to survival. Statistical analysis with Cox proportional hazards model was used to correct for important prognostic factors. (ii) A prospective observational study of 1077 patients recruited into an international phase-III prospective randomised clinical trial in ovarian cancer [SCOTROC] was undertaken. Detailed surgical data was collected in addition to other treatment and patient data. This study was used as a vehicle for exploring international variations in surgery and their relationship to survival. (iii) A retrospective case note review of all patients registered with endometrial cancer between 1996 & 1997 in Scotland was undertaken. Pre-defined and piloted datasets were abstracted from patient medical records. This was used to explore the relationship of staging quality and specialisation and the relationship between staging and the use of adjuvant treatment and survival. Results: (i) Data on 83% of registered patients could be abstracted for patients with ovarian cancer diagnosed between 1995 & 1997. The Scottish ovarian cancer study showed that although there were differences in the approach to surgery, the actual success in terms of the probability of optimal debulking was no different between 'specialist' and 'non-specialist gynaecologists. This was reflected in no observed survival difference. A difference in survival between gynaecologists and general surgeons was shown. This could be explained by statistical correction for bowel obstruction found at laparotomy. Comparison of the Scottish 1995-97 cohort with similarly collected data from 1992-94 showed no improvement in the extent of surgery. There was a modest improvement in survival between the cohorts that was maximal at 18 months. In multivariate analysis this could be accounted for by increased attendence at the MDC. (ii) SCOTROC demonstrated that patients recruited from the United Kingdom underwent less extensive surgery and these patients had a lower probability of being optimally debulked. These patients' operations took less time to perform. Only early survival data is available. However at present no statistical differences in survival are seen, although there is evidence that survival curves are beginning to diverge. Full survival data are awaited. (iii) Data on 94% of patients diagnosed with endometrial cancer in 1996/7 was abstracted. Multivariate survival analysis of the Scottish endometrial cancer study shows that patients who were more adequately staged were more likely to receive appropriate adjuvant radiotherapy and, in those patients with advanced disease, survived longer. Discussion: The benefits of specialist surgery in ovarian cancer in Scotland are less certain than previous studies have suggested. The survival difference between general surgeons and gynaecologists may be a result of lead-time bias. A difficulty is that the exact role of surgery in advanced ovarian cancer is still uncertain. SCOTROC provides a unique opportunity to use international variations in surgery to assess the benefits of more extensive surgery. Final conclusions from SCOTROC should be guarded until full survival data are available. It may be that survival in advanced ovarian cancer cannot be improved by improvements in surgery alone. The importance of the MDC as a favourable prognostic factor is confirmed and strengthened by the study results. The importance of staging as a process is demonstrated as an important prognostic factor in patients with endometrial cancer and the role of the MDC as a decision-making forum is discussed. Although specialist gynaecologists in Scotland perform more appropriate staging the study was not powered to demonstrate a survival advantage by this group of clinicians and none could be demonstrated.

Item Type: Thesis (MD)
Qualification Level: Doctoral
Additional Information: Adviser: Charles R Gillis
Keywords: Medicine, Oncology
Date of Award: 2002
Depositing User: Enlighten Team
Unique ID: glathesis:2002-76192
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 19 Nov 2019 16:29
Last Modified: 19 Nov 2019 16:29

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