UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, and the Biostatistics Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, and the University of Milano-Bicocca, Department of Obstetrics and Gynecology, Gynaecologic Oncology Surgical Unit, ASST-Monza, San Gerardo Hospital, Monza, Italy; the Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital (Central and Eastern European Gynecologic Oncology Group, CEEGOG), and the Department of Gynaecology and Obstetrics, University Hospital Pilsen, Charles University, Prague, the Department of Obstetrics and Gynecology, Faculty of Medicine, University Hospital and University of Ostrava, Ostrava, and the University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic; the Center for Gynaecologic Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands; the Department of Gynecological Surgery, National Institute of Neoplastic Diseases, Lima, Peru; the Department of Pelvic Cancer, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; the Baskent University School of Medicine, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, and the Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health and Research Hospital, University of Health Sciences, Ankara, Turkey; Memorial Sloan Kettering Cancer Center, New York, New York; the Gynecology Oncology Center, National Institute of Cancerology Mexico, Mexico City, Mexico; the Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia; the Wolfson Institute of Preventive Medicine, Barts Cancer Centre, Queen Mary University of London, & Barts Health NHS Trust, London, United Kingdom; the Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; the Department of Gynecologic Oncology, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina; Gynecology, Medical University of Graz, Graz, Austria; the Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain; and the Department of Gynecologic Oncology, Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil.
Obstet Gynecol. 2023 Jan 1;141(1):207-214. doi: 10.1097/AOG.0000000000005026. Epub 2022 Nov 30.
To evaluate the association of number of radical hysterectomies performed per year in each center with disease-free survival and overall survival.
We conducted an international, multicenter, retrospective study of patients previously included in the Surveillance in Cervical Cancer collaborative studies. Individuals with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1-IIA1 cervical cancer who underwent radical hysterectomy and had negative lymph nodes at final histology were included. Patients were treated at referral centers for gynecologic oncology according to updated national and international guidelines. Optimal cutoffs for surgical volume were identified using an unadjusted Cox proportional hazard model, with disease-free survival as the outcome and defined as the value that minimizes the P-value of the split in groups in terms of disease-free survival. Propensity score matching was used to create statistically similar cohorts at baseline.
A total of 2,157 patients were initially included. The two most significant cutoffs for surgical volume were identified at seven and 17 surgical procedures, dividing the entire cohort into low-volume, middle-volume, and high-volume centers. After propensity score matching, 1,238 patients were analyzed-619 (50.0%) in the high-volume group, 523 (42.2%) in the middle-volume group, and 96 (7.8%) in the low-volume group. Patients who underwent surgery in higher-volume institutions had progressively better 5-year disease-free survival than those who underwent surgery in lower-volume centers (92.3% vs 88.9% vs 83.8%, P=.029). No difference was noted in 5-year overall survival (95.9% vs 97.2% vs 95.2%, P=.70). Cox multivariable regression analysis showed that FIGO stage greater than IB1, presence of lymphovascular space invasion, grade greater than 1, tumor diameter greater than 20 mm, minimally invasive surgical approach, nonsquamous cell carcinoma histology, and lower-volume centers represented independent risk factors for recurrence.
Surgical volume of centers represented an independent prognostic factor affecting disease-free survival. Increasing number of radical hysterectomies performed in each center every year was associated with improved disease-free survival.
评估每个中心每年行根治性子宫切除术的数量与无病生存率和总生存率的相关性。
我们进行了一项国际性、多中心、回顾性研究，纳入了先前参加监测宫颈癌协作研究的患者。纳入国际妇产科联盟（FIGO）2009 分期 IB1-IIA1 宫颈癌、最终病理检查淋巴结阴性且行根治性子宫切除术的患者。患者在妇科肿瘤转诊中心根据最新的国家和国际指南进行治疗。使用未经调整的 Cox 比例风险模型确定手术量的最佳截断值，以无病生存率为结局，定义为使无病生存率分组的 P 值最小的数值。使用倾向评分匹配在基线时创建具有统计学相似的队列。
共纳入 2157 例患者。确定了两个最显著的手术量截断值，分别为 7 例和 17 例手术，将整个队列分为低容量、中容量和高容量中心。经倾向评分匹配后，分析了 1238 例患者，其中高容量组 619 例（50.0%），中容量组 523 例（42.2%），低容量组 96 例（7.8%）。在高容量机构接受手术的患者 5 年无病生存率优于在低容量中心接受手术的患者（92.3%比 88.9%比 83.8%，P=.029）。5 年总生存率无差异（95.9%比 97.2%比 95.2%，P=.70）。Cox 多变量回归分析显示，FIGO 分期大于 IB1、存在脉管间隙浸润、分级大于 1、肿瘤直径大于 20mm、微创手术方式、非鳞状细胞癌组织学和低容量中心是复发的独立危险因素。
中心的手术量是影响无病生存率的独立预后因素。每年每个中心行根治性子宫切除术的数量增加与无病生存率的提高相关。
