Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and the Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California; the Department of Obstetrics and Gynecology, Tottori University, Tottori, the Department of Gynecologic Oncology, Hyogo Cancer Center, Hyogo, the Department of Gynecology, the Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, the Department of Gynecologic Oncology, Aichi Cancer Center Hospital, Aichi, the Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, the Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, the Department of Obstetrics and Gynecology, the Jikei University School of Medicine, Tokyo, the Department of Obstetrics and Gynecology, Iwate Medical University, Iwate, and the Department of Obstetrics and Gynecology, Tokai University, Kanagawa, Japan.
Obstet Gynecol. 2019 Jun;133(6):1086-1098. doi: 10.1097/AOG.0000000000003280.
To examine the association between surgical volume and survival of women with early-stage cervical cancer who underwent radical hysterectomy.
This is a nationwide multicenter retrospective study examining consecutive women with clinical stage IB1-IIB cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy from 2004 to 2008 (N=5,964). The surgical volume per site over the 5-year period was defined as low-volume (fewer than 32 surgeries, 46 [39.7%] institutions, n=649 [10.9%]), mid-volume (32-104 surgeries, 60 [51.7%] institutions, n=3,662 [61.4%]), and high-volume (105 surgeries or more, 10 [8.6%] institutions, n=1,653 [27.7%]). Surgical volume-specific survival was examined with multivariable analysis and propensity score matching.
The median number of surgeries per site was 44 (interquartile range, 17-65). The 5-year disease-free survival rates among stage IB1-IIB disease were 77.2%, 79.9%, and 84.5% for low-, mid-, and high-volume groups, respectively. On multivariable analysis, women in high-volume centers had a decreased risk of recurrence (adjusted hazard ratio [HR] 0.69, 95% CI 0.58-0.82, P<.001) and all-cause mortality (adjusted HR 0.73, 95% CI 0.59-0.90, P=.003) compared with those in mid-volume centers. Specifically, women in high-volume centers had a decreased risk of local recurrence (adjusted HR 0.62, 95% CI 0.49-0.78, P<.001) but not distant recurrence (adjusted HR 0.85, 95% CI 0.67-1.06, P=.142) compared with those in mid-volume centers. Among 1,700 women with clinical stage IB1 disease treated with surgery alone, surgery at high-volume centers was associated with a decreased risk of recurrence (adjusted HR 0.45, 95% CI 0.25-0.79, P=.006) and all-cause mortality (adjusted HR 0.29, 95% CI 0.11-0.76, P=.013) compared with surgery at mid-volume centers on multivariable analysis. After propensity score matching, surgery at high-volume centers remained an independent prognostic factor for decreased recurrence (adjusted HR 0.69, 95% CI 0.57-0.84, P<.001) and all-cause mortality (adjusted HR 0.75, 95% CI 0.59-0.95, P=.016) compared with surgery at mid- and low-volume centers on multivariable analysis.
Hospital volume for radical hysterectomy may be a prognostic factor for early-stage cervical cancer. Surgery at high-volume centers is associated with decreased local recurrence risk and improved survival.
探讨根治性子宫切除术治疗早期宫颈癌患者的手术量与生存率的关系。
这是一项全国多中心回顾性研究，纳入了 2004 年至 2008 年间接受根治性子宫切除术和盆腔淋巴结切除术的临床分期为 IB1-IIB 期宫颈癌的连续女性患者（N=5964）。5 年内每个中心的手术量定义为低手术量（<32 例，46 个机构，n=649[10.9%]）、中手术量（32-104 例，60 个机构，n=3662[61.4%]）和高手术量（105 例或以上，10 个机构，n=1653[27.7%]）。采用多变量分析和倾向评分匹配法对手术量与生存率进行了评估。
每个中心的中位数手术例数为 44 例（四分位间距，17-65）。IB1-IIB 期疾病的 5 年无病生存率分别为低手术量组 77.2%、中手术量组 79.9%和高手术量组 84.5%。多变量分析显示，与中手术量组相比，高手术量中心的患者复发风险（调整后的危险比[HR]0.69，95%置信区间[CI]0.58-0.82，P<.001）和全因死亡率（调整后的 HR 0.73，95%CI 0.59-0.90，P=.003）均降低。具体而言，与中手术量组相比，高手术量组的局部复发风险（调整后的 HR 0.62，95%CI 0.49-0.78，P<.001）降低，但远处复发风险（调整后的 HR 0.85，95%CI 0.67-1.06，P=.142）无差异。在 1700 例接受单纯手术治疗的临床分期为 IB1 期的女性中，与中手术量组相比，高手术量组的复发风险（调整后的 HR 0.45，95%CI 0.25-0.79，P=.006）和全因死亡率（调整后的 HR 0.29，95%CI 0.11-0.76，P=.013）降低。多变量分析后，高手术量组仍然是降低复发风险（调整后的 HR 0.69，95%CI 0.57-0.84，P<.001）和全因死亡率（调整后的 HR 0.75，95%CI 0.59-0.95，P=.016）的独立预后因素。
根治性子宫切除术的医院手术量可能是早期宫颈癌的预后因素。高手术量中心的手术与局部复发风险降低和生存改善相关。
