Over a million new cases of and half million deaths due to gynecologic cancers occur annually worldwide.1 In 2011, a provincial health care system in a higher resource location designated improvement to the system of care for gynecologic cancer patients as a priority. At the time, many patients received care in lower volume hospitals with less access to multidisciplinary or specialist care. A need to examine ways to establish a network that would formalize the flow of patients through the care continuum and to create a framework for enabling best practices was identified. There was a need for recommendations that would allow a collaborative community of practice supported by formal interorganizational processes to evolve to facilitate adherence to guidelines and best practices at a system-wide level. To support this, a systematic review of organizational factors in gynecologic oncology was conducted, and a consensus process was undertaken to develop recommendations for the optimal organization of gynecologic oncology services, with the ultimate goal of improving patient care. The resulting recommendations are based on an international evidence base and address issues that are common to many health care systems in higher resource locations. Thus, the recommendations contained in this guideline may have broad application to health care systems that are in the process of reorganizing and improving the delivery of gynecologic oncology services.
A working group was formed that included expertise in gynecologic oncology, medical oncology, radiation oncology, pathology, research methodology, and surgery (Appendix 1). The working group determined that the scope of the guideline would include optimal system-level organization of services for women who have been diagnosed with gynecologic cancer or have an ovarian mass with the Risk of Malignancy Index (RMI) score greater than 200. The scope does not include the following noninvasive cases: cervical intraepithelial neoplasia and carcinoma in situ (≤stage T1A1); vaginal intraepithelial neoplasia; vulvar intraepithelial neoplasia; ovarian masses with an RMI score of less than 200, as these cases have a low likelihood of being invasive2; and gestational trophoblastic neoplasia (GTN).
To develop recommendations for organization of gynecologic oncology services, the following research questions were asked:
- Does treatment by a gynecologic oncologist (GYO) result in better outcomes than treatment by a gynecologist (GYN) or general surgeon?
- Are there better outcomes for patients with gynecologic cancer treated in designated centers compared with nondesignated centers?
- Is there a volume-outcome relationship between number of procedures by a physician/hospital and patient surgical or survival outcomes?
Outcomes of interest were overall or disease-specific survival; short-term survival; adequate staging, degree of cytoreduction, and/or optimal cytoreduction for ovarian cancer patients; and discrepancy rates between specialist pathologists compared with nonspecialist pathologists.
In addition, questions related to implementation/organization included the following:
- How will services be regionally organized? Will specialized gynecologic oncology centers (GOCs) be designated?
- If designated centers are recommended:
- What is the optimal relationship or network of care between designated and nondesignated centers?
- What are the human and physical resources requirements of a designated (specialized) center?
Literature Search Strategy and Quality Assessment
A systematic review was conducted of Web sites of guideline developers, relevant cancer agencies, and Medline and EMBASE from 1996 to 2011 using search terms related to gynecologic malignancies, combined with organization of services, patterns of care, and various facility and physician characteristics. Reference lists of included articles were searched for additional citations. The search engine Google Scholar was used to identify articles using the terms gyn(a)ecological cancer and centralisation or centralization or volumes, and an environmental scan using the Google search engine for existing guidance documents or standards for local networks was conducted on January 5, 2011. The working group agreed to use a previously published document as the source for recommendations related to multidisciplinary teams.3
English language systematic reviews of cohort studies or individual cohort studies that reported at least 1 of the primary outcomes of interest were eligible for inclusion. Case-control studies, case series, letters, and editorials were excluded.
Guideline quality assessment was conducted using the Appraisal of Guidelines for Research and Evaluation II instrument.4 Systematic reviews were assessed for quality using the Assessment of Multiple Systematic Reviews tool.5
Literature Search Results
The literature search located 1 relevant clinical practice guideline (CPG) that scored well on the Appraisal of Guidelines for Research and Evaluation II instrument. One systematic review was found that received a high quality rating according to Assessment of Multiple Systematic Reviews. Thirty-three observational studies that assessed 1 or more of the domains of interest related to gynecologic malignancies or the impact of organizational factors were identified (Table 1).
Synthesis of Evidence and Development of Recommendations
Data were extracted by a methodologist and verified by a project research assistant. Despite the inclusion of a methodologically rigorous systematic review, and a relevant CPG, the evidence base as a whole was determined by working group consensus to be of lower quality due to retrospective nonrandomized study designs and considerable heterogeneity across studies in comparison groups and outcomes of interest. Therefore, recommendations were drafted by the working group using the published evidence supplemented by the informal consensus of the working group where necessary.
The recommendations drafted by the working group were circulated to the 13-person organizational guideline expert panel, which included expertise in gynecologic oncology, gynecology, pathology, and nursing, as well as a vice president from a central cancer treatment hospital (Appendix 1). The comments of the expert panel were incorporated into the draft in an iterative cycle, and the guideline subsequently received expert panel approval.
External Review by Clinicians and Other Experts
The external review process included a targeted peer review by 3 clinical and/or methodological experts to obtain direct feedback on the draft report and a professional consultation that was intended to facilitate dissemination of the final guidance to practitioners.
Targeted Peer Review
During the development process, 3 clinical and/or methodological experts identified by the working group were approached and agreed to participate. Their locations included Canada, the United Kingdom, and Australia. The draft report and an evaluation questionnaire were sent via e-mail on February 11, 2013. Written comments were invited. The working group reviewed the peer review results and made changes to the draft guideline accordingly.
Conducted between February 12, 2013 and March 12, 2013, the professional consultation asked participants to rate the quality of the guideline, whether they would use and/or recommend it, whether they perceived barriers or enablers to implementation, and for other comments. The survey targeted practitioners in gynecologic oncology, pathology, systemic therapy, radiation oncology, surgical or imaging leads, and regional vice presidents. Forty-two practitioners participated in this survey. The working group reviewed the results of the survey and revised the draft accordingly.
The guideline development process resulted in an overall recommendation that to provide high-quality, patient-centered care throughout the patient journey, treatment of most invasive gynecologic cancers should be performed by subspecialists in designated GOCs, with minimum annual volumes. This recommendation is the opinion of the working group based on the consensus that GOCs will be best equipped to provide the resources that are needed to support the work of GYOs, including proximity to other members of the multidisciplinary team, and more specialized pathology expertise, capacity to support multidisciplinary cancer conferences, facilitation of accrual to clinical trials, and the necessary human and physical resources outlined in detail in the recommendations below (Table 2).
The working group agreed that to facilitate a formal partnership with processes to ensure accountability, implementation of the aforementioned recommendations should include a link between GOCs and affiliated centers as illustrated in Figure 1. In addition, the working group concluded that the recommendations outlined previously would require a supportive structure including specific human, physical, and collaborating services. These services are outlined in the recommendations below.
In addition, the consensus of the working group was supportive of previous guidance related to multidisciplinary care.3 The primary purpose of the multidisciplinary cancer conference is to ensure that all appropriate diagnostic tests, treatment options, and treatment recommendations are generated for each cancer patient discussed prospectively in a multidisciplinary forum.3 Consensus-based recommendations for multidisciplinary teams in the context of gynecologic oncology are outlined in Table 3.
In summary, the working group concluded that all cases of invasive ovarian, vulvar, and cervical cancer should be referred to the coordinator of a multidisciplinary cancer conference at a designated specialized center (a GOC) and that surgical treatment for these cases take place only at these centers and be performed by a GYO. This recommendation was based on the consensus that GOCs will be best equipped to provide the resources that are needed to support the work of GYOs, including proximity to other members of the multidisciplinary team, and more specialized pathology expertise, capacity to support multidisciplinary cancer conferences, facilitation of accrual to clinical trials, and the necessary human and physical resources.
Surgery is often the primary treatment for patients, but the guideline development process also considered delivery of chemotherapy and radiation, and other services such as palliative care. The consensus was that, provided a strong linkage was established and maintained with a GOC, these other treatments could be delivered at affiliated centers to allow patients to receive ongoing treatments closer to home. Often where care is not centralized, multidisciplinary teams from specialized hospitals closely collaborate with other hospitals, and many GYNs have a special interest in gynecologic oncology although no formal training.8 These features of the gynecologic oncology center–affiliated center partnership will be important to ensure that the recommendations have an impact on patient outcomes.
It is recognized that these recommendations will likely not have an overall positive impact on wait times for treatment. However, several of the recommendations should help to minimize the exacerbation of the wait times problem due to the projected patient population increase, through better flow of patients, and more collaboration treatment. The implementation of these recommendations will necessitate recruitment of more GYOs and designation of more GOCs to handle this increase in operative cases.
The working group expects that reorganization as a result of these guidelines will result in more consistent care, greater access to multidisciplinary teams and subspecialists, and dissemination of best practices. As reorganization occurs, it will also be important to ensure that centers are following these best practices, which will be embedded in auditable disease management pathways to realize the full potential for improvements in patient-related outcomes.
1. Sankaranarayanan R, Ferlay J. Worldwide burden of gynecological cancer. In: Preedy VR, Watson RR. eds. Handbook of Disease Burdens and Quality of Life Measures
. New York, NY: Springer; 2010: 803–823.
2. Dodge J, Covens A, Lacchetti C, et al. Management of a suspicious adnexal mass. Toronto, ON: Cancer Care Ontario; July 7, 2011. Program in Evidence-based Care Evidence-based Series No.: 4–15
3. Wright F, De Vito C, Langer B, et al. Multidisciplinary cancer conference standards. Toronto, ON: Cancer Care Ontario; June 6, 2006. Program in Evidence-Based Care Special Report
4. Brouwers M, Kho ME, Browman GP, et al. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. CMAJ
. 2010; 182: E839–E842.
5. Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol
. 2007; 7: 10.
6. Le T, Giede C, Salem S Initial evaluation and referral guidelines for management of pelvic/ovarian masses. JCOG
. 2009; 230: 668–669.
7. Vandenberg T, Trudeau M, Coakley N, et al. Regional models of care for systemic treatment. Toronto, ON: Cancer Care Ontario; May 22, 2007. Program in Evidence-based Care Evidence-based Series No.: 12-10.
8. Vernooij F, Heintz AP, Coebergh JW, et al. Specialized and high-volume care leads to better outcomes of ovarian cancer treatment in the Netherlands. Gynecol Oncol
. 2009; 112: 455–461.
APPENDIX 1: MEMBERS OF THE GYNECOLOGIC ONCOLOGY ORGANIZATIONAL GUIDELINE DEVELOPMENT GROUP: WORKING GROUP AND EXPERT PANEL
- Dr Michael Fung-Kee-Fung (chair), gynecologic oncologist, Ottawa General Hospital, Ottawa, Ontario, Canada
- Dr James Biagi, medical oncologist, Cancer Centre of South-eastern Ontario, Queen’s University, Kingston, Ontario, Canada
- Wei Cao, project coordinator, Surgical Oncology Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Dr Terry Colgan, gynecologic pathologist, University Health Network, Toronto, Ontario, Canada
- Dr David D’Souza, radiation oncologist, London Health Sciences Centre, London, Ontario, Canada
- Dr Laurie Elit, gynecologic oncologist, Juravinski Cancer Centre, Hamilton, Ontario, Canada
- Amber Hunter, manager, Surgical Oncology Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Dr Jonathan Irish, provincial head, Surgical Oncology Program, Cancer Care Ontario, Canada
- Erin B. Kennedy, health research methodologist, PEBC, Cancer Care Ontario/McMaster University, Hamilton, Ontario, Canada
- Dr Robin McLeod, surgeon, Mount Sinai Hospital and Lead, Quality Improvement & Knowledge Transfer, Surgical Oncology Program, Cancer Care Ontario, Toronto, Ontario, Canada
- Dr Barry Rosen, gynecologic oncologist, University Health Network (Princess Margaret Hospital), Toronto, Ontario, Canada
- Dr Al Covens, gynecology oncologist, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Lindsey Crawford, regional vice president, North Simcoe Muskoka Local Health Integration Network
- Dr Denny DePetrillo, gynecology oncologist, Credit Valley Hospital, Mississauga, Ontario, Canada
- Dr Dimitrios Divaris, chief of pathology, Grand River Hospital, Kitchener-Waterloo, Ontario, Canada
- Dr Julie Ann Francis, gynecology oncologist, Kingston General Hospital, Kingston, Ontario, Canada
- Esther Green, registered nurse, Provincial Head of Nursing and Psychosocial Oncology, Cancer Care Ontario
- Dr Leonard Kaizer, medical oncologist, Credit Valley Hospital, Mississauga, Ontario, Canada
- Dr Felice Lackman, gynecologic oncologist, Markham Stouffville Hospital, Markham, Ontario, Canada
- Dr Audrey Li, radiation oncologist, Lakeridge Health, Oshawa, Ontario, Canada
- Dr Alice Lytwyn, pathologist, Juravinski Hospital, Hamilton, Ontario, Canada
- Dr Michel Prefontaine, gynecology oncologist, London Health Sciences Centre, London, Ontario, Canada
- Dr Andrew Robinson, medical oncologist, Health Sciences North, Sudbury, Ontario, Canada
- Dr Carol Wade, gynecologist, Credit Valley Hospital, Mississauga, Ontario, Canada