Barber Emma L, Dusetzina Stacie B, Stitzenberg Karyn B, Rossi Emma C, Gehrig Paola A, Boggess John F, Garrett Joanne M
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States.
Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States; Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
Gynecol Oncol. 2017 Jun;145(3):500-507. doi: 10.1016/j.ygyno.2017.03.014. Epub 2017 Mar 31.
To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival.
We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (>20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed.
We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n=2494) of patients and use varied widely by hospital, from 5%-55%. High utilization hospitals (n=1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23-55%), while low utilization hospitals (n=2671, 14 hospitals) had a median rate of 10% (range 5-17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83-0.97 and HR 0.85 95% CI 0.75-0.95).
Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.
评估大型医院新辅助化疗使用情况的差异，并确定新辅助化疗的医院使用情况与生存率之间的关联。
我们在国家癌症数据库中确定了2006年至2012年期间IIIC期或IV期上皮性卵巢癌的新发病例。纳入标准为在大型医院（每年>20例）接受治疗且接受化疗和手术治疗。使用逻辑回归模型根据病例组合预测因素（年龄、合并症、分期等）预测新辅助化疗的接受情况。医院根据新辅助化疗使用的观察与预期比率分为低、中、高使用医院三类。进行了生存分析。
我们确定了在55家大型医院接受治疗的11574名患者。21.6%（n = 2494）的患者使用了新辅助化疗，医院之间的使用差异很大，从5%到55%不等。高使用医院（n = 1910，10家医院）的新辅助化疗率中位数为39%（范围23%-55%），而低使用医院（n = 2671，14家医院）的中位数为10%（范围5%-17%）。对于所有卵巢癌患者，在调整临床和社会人口统计学因素后，与在低使用医院接受治疗相比，在新辅助化疗使用率为中或高的医院接受治疗与死亡率降低相关（风险比0.90，95%置信区间0.83 - 0.97；风险比0.85，95%置信区间0.75 - 0.95）。
即使在大型医院中，治疗IIIC期和IV期上皮性卵巢癌时新辅助化疗的使用也存在很大差异。在新辅助化疗使用率低的医院接受治疗的患者生存率降低。
