Effect of surgical volume on short-term outcomes of cytoreductive surgery for advanced-stage ovarian cancer: A population-based study from the Dutch Gynecological Oncology Audit

M D Algera; W J van Driel; B F M Slangen; M W J M Wouters; R F P M Kruitwagen; participants of the Dutch Gynecological Oncology Audit Collaborator Group

doi:10.1016/j.ygyno.2024.04.002

Effect of surgical volume on short-term outcomes of cytoreductive surgery for advanced-stage ovarian cancer: A population-based study from the Dutch Gynecological Oncology Audit

Gynecol Oncol. 2024 Apr 29:186:144-153. doi: 10.1016/j.ygyno.2024.04.002. Online ahead of print.

Authors

M D Algera¹, W J van Driel², B F M Slangen³, M W J M Wouters⁴, R F P M Kruitwagen³; participants of the Dutch Gynecological Oncology Audit Collaborator Group

Collaborators

participants of the Dutch Gynecological Oncology Audit Collaborator Group:
A J Kruse⁵, R Yigit⁶, M J A Engelen⁷, L S Nooij⁸, J W M Mens⁹, M A A de Jong¹⁰, M A D Haverkort¹¹, M van der Aa¹², J Diepstraten¹³, M A P C van Ham¹⁴, H P M Smedts¹⁵, N Reesink¹⁶, K N Gaarenstroom⁸, P M L H Vencken¹⁷, D Boll¹⁸, G Fons¹⁹, A Baalbergen²⁰, E B L van Dorst²¹, E M Roes⁹, H T C Nagel²², A van Ginkel²³, J de Waard²⁴, L N Hofman²⁵

Affiliations

¹ Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands. Electronic address: m.algera@nki.nl.
² Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Department of Gynecology, Amsterdam, the Netherlands.
³ Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands.
⁴ Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, the Netherlands.
⁵ Isala Klinieken, Zwolle, the Netherlands.
⁶ University Medical Center Groningen, Groningen, the Netherlands.
⁷ Zuyderland Medical Center, Heerlen, the Netherlands.
⁸ Leiden University Medical Center, Leiden, the Netherlands.
⁹ Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands.
¹⁰ Radiotherapeutisch Instituut Friesland, Leeuwarden, the Netherlands.
¹¹ Radiotherapy Group, Arnhem, the Netherlands.
¹² Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands.
¹³ Stichting Olijf, Utrecht, the Netherlands.
¹⁴ Radboud University Medical Center, Nijmegen, the Netherlands.
¹⁵ Amphia Ziekenhuis, Breda, the Netherlands.
¹⁶ Medical Center Twente, Enschede, the Netherlands.
¹⁷ Bravis Ziekenhuis, Roosendaal, the Netherlands.
¹⁸ Catharina Ziekenhuis, Eindhoven, the Netherlands.
¹⁹ Amsterdam University Medical Center, Amsterdam, the Netherlands.
²⁰ Reinier de Graaf Group, Delft, the Netherlands.
²¹ University Medical Center Utrecht, Utrecht, the Netherlands.
²² Haaglanden Medical Center, The Hague, the Netherlands.
²³ Rijnstate Ziekenhuis, Arnhem, the Netherlands.
²⁴ Fransiscus Gasthuis & Vlietland, Rotterdam, the Netherlands.
²⁵ Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands.

PMID: 38688188
DOI: 10.1016/j.ygyno.2024.04.002

Abstract

Objective: Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted.

Methods: This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes.

Results: A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment.

Conclusions: Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.

Keywords: Advanced-stage ovarian cancer; Clinical auditing; Complete cytoreduction; Cytoreductive surgery; Length of stay; Mortality; Postoperative complications; Surgical volume; Textbook outcome.