Impact of guideline adherence on patient outcomes in early-stage epithelial ovarian cancer

doi:10.1016/j.ejso.2015.01.006

European Journal of Surgical Oncology (EJSO)

Volume 41, Issue 4, April 2015, Pages 585-591

https://doi.org/10.1016/j.ejso.2015.01.006 Get rights and content

Abstract

Aim

The aim of this study was to evaluate the effects of adherence to National Comprehensive Cancer Network (NCCN) guidelines on survival outcomes in patients with early-stage epithelial ovarian cancer.

Methods

Our institutional cancer registry data on 266 patients with Stage I epithelial ovarian cancer was reviewed retrospectively and compliance with treatment guidelines for surgery and adjuvant treatment was determined. Patients were categorized according to adherence or non-adherence. The primary endpoints were recurrence-free survival and disease-specific survival. Hazard ratios (HRs) for survival were estimated with a Cox proportional hazards model.

Results

Of the 266 patients, 71 (26.7%) underwent adequate surgical staging in accordance with the guidelines. The guidelines for adjuvant chemotherapy were followed adequately in all 71 patients that were adherent to surgical staging and in 163 of the 195 patients with non-adherence to surgical staging (83.6%). Multivariate analysis, adjusted for prognostic factors, identified higher recurrence-free survival (HR, 0.36; 95% CI, 0.15–0.88) and disease-specific survival (HR, 0.42; 95% CI, 0.16–1.12) among patients whose treatment adhered to both surgical and chemotherapy guidelines, although disease-specific survival was not statistically significant. When excluding clear cell histology from the cohort, the guideline-adherent group had significantly better disease-specific survival than the non-adherent group (HR, 0.13; 95% CI, 0.02–0.94).

Conclusion

The results of this study suggest that adherence to NCCN guidelines may improve survival outcomes in patients with early-stage epithelial ovarian cancer, particularly in cases other than clear cell histology.

Introduction

Recent studies have shown that adherence to treatment guidelines has survival benefits for cancer patients.1, 2, 3 The National Comprehensive Cancer Network (NCCN) established working, expert consensus, and evidence-based guidelines for organ-specific cancer care in order to provide state-of-the-art treatment information.⁴ These guidelines are the most widely used standards for cancer care.

The current NCCN guidelines for ovarian cancer recommend appropriate surgical staging, followed in most patients by adjuvant chemotherapy. Comprehensive surgical staging should be performed in order to rule out occult metastasis in apparent early-stage disease, as previous reports have shown that around 30% of patients are upstaged after complete staging operation.⁵ Approximately 20% of all epithelial ovarian cancer is diagnosed at an early stage and survival rates of 90–100% have been reported for patients who were properly staged and were found to have Stage IA or IB disease.⁶ However, a significant proportion of clinicians do not perform complete surgical staging as favorable outcomes are expected in early-stage ovarian cancer.7, 8 Moreover, the unexpected diagnosis of ovarian malignancy is made in between 0% and 19% of cases during a final pathologic examination following a laparoscopic operation.⁹ To date, there are few reports that show that compliance with consensus recommendations in early-stage ovarian cancer improves survival outcomes.7, 8

The aim of this study was to evaluate adherence to treatment guidelines and the impact of adherence to guidelines on survival outcomes in early-stage epithelial ovarian cancer.

Section snippets

Study population

After receiving institutional review board approval, medical records were reviewed retrospectively for all patients treated surgically for epithelial ovarian cancer between January 1991 and December 2010 at Seoul National University Hospital. Patients were eligible for inclusion if they (1) had International Federation of Gynecology and Obstetrics (FIGO) Stage I epithelial ovarian cancer and (2) had undergone an operation due to an ovarian tumor. A total of 270 women were identified. Four

Results

The baseline characteristics are listed in Table 1. The median age is 46.0 years (range: 14–81 years) and the mean follow-up is 8.4 years (range: four months to 22 years). The distribution of tumor grade and histology was significantly different between the guideline adherent and non-adherent groups. Table 2 shows the procedures performed in surgical staging. Para-aortic lymph node dissection was performed in just 28.2% of patients, whereas washing cytology was performed in 94.7% during

Discussion

In this study, a wide variation in clinical practice, and in particular surgical staging, was observed, despite readily available standards for cancer care. Guidelines for surgical staging were followed completely in only 26.7% of cases examined. Previous studies have also shown that compliance to surgical guidelines is poor in clinical practice.8, 11 Adequate surgical staging was performed in only 32.8% of 121 patients from seven hospitals in the Netherlands.⁸ In the ACTION trial approximately

Conflicts of interest

All authors declare no conflict of interest.

Acknowledgment

None.

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Cited by (29)

Short-term survival analysis of a risk-adjusted model for ovarian cancer care
2024, Gynecologic Oncology
To quantify the impact on short-term ovarian cancer survival associated with treatment at high-performing hospitals using the observed-to-expected ratio (O/E) for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care.
This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to California Cancer Registry 1996–2017. A fit logistic regression model, risk-adjusted for patient and disease characteristics, was used to calculate O/E for each hospital stratified by hospital annual case volume. Cox proportional hazards model was used for survival analyses at 3, 6, 12, 24 months and stratified according to sociodemographic characteristics.
The study population included 35,725 subjects treated at 443 hospitals:
Low-O/E – 26.4% of cases; Intermediate-O/E – 55.5% of cases; and High-O/E - 18.1% of cases. Overall median survival by hospital category was: High-O/E = 72.5 months (95% CI = 68.6–78.6 months), Intermediate-O/E = 68.6 months (95% CI = 65.9–71.6 months), Low-O/E = 47.0 months (95% CI = 44.2–49.2 months). Initial treatment at a High-O/E hospital (HR = 1.00) was a statistically significant and independent predictor of improved short-term survival compared to Low-O/E hospitals at 3 months (HR = 1.46, 95% CI = 1.29–1.65), 6 months (HR = 1.35, 95% CI = 1.22–1.50), 12 months (HR = 1.27, 95% CI = 1.17–1.38), and 24 months (HR = 1.19, 95% CI = 1.11–1.27). Significant and independent associations between improved sort-term survival and High/O/E care were observed for Whites, Hispanics, Asian/Pacific Islanders (A/PI), across SES strata, and among all payer categories.
Ovarian cancer care at a High-O/E hospital is an independent predictor of improved outcome and the survival advantage is disproportionately weighted toward the short-term time horizon following diagnosis.
Adherence to COVID-19 nutritional guidelines and their impact on the clinical outcomes of hospitalized COVID-19 patients
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Our study results indicated that adherence to guidelines, particularly guideline knowledge, was associated with the length of hospital stay in critically ill patients and their mortality due to COVID-19. These results agreed with recent studies showing that adherence to guidelines by practitioners improved the health outcomes and survival rates of cancer patients [22,23]. Despite continuous efforts to improve doctors' guideline adherence, guideline nonadherence is still a major concern across all medical fields [24].
Coronavirus disease 2019 (COVID-19) patients are at high risk of malnutrition, and their doctors are part of a multidisciplinary team, including nutritionists. However, adherence to nutritional guidelines may be difficult in the context of capacity constraints during the COVID-19 pandemic. The aim of this study was to investigate barriers to doctors' adherence to nutritional guidelines and the impacts of guideline adherence on the outcomes of hospitalized COVID-19 patients.
A multinational electronic survey involving 51 doctors was conducted between November 2020 and January 2021 from 17 COVID-19-designated hospitals in countries with high (Indonesia) and low (Vietnam) numbers of confirmed COVID-19 cases.
In general, doctors reported concerns related to nutritional practices in patients with Covid-19 which included feeling stress when performing medical nutritional therapy (65%), lacking self-efficacy or confidence in performing nutritional care (49%), lacking clear nutritional guidelines (45%), and experiencing budget limitations (33%). A regression analysis adjusted for age, country, and the number of hospitalized COVID-19 cases revealed that guideline knowledge (β: −1.01 (−1.78, −0.23); p = 0.012) and awareness of guidelines (β: −1.37 (−2.66, −0.09); p = 0.037) were negatively correlated with the length of stay of critically ill COVID-19 patients, but non-significant after adjusting for specialization of the doctor. When stratified according to country, a significant relationship between guideline adherence and length of stay of critically ill patients was only found in Vietnam [guideline adherence: β: −0.55 (−1.08, −0.03); p = 0.038; guideline knowledge: β: −1.01 (−1.9, −0.13); p = 0.027] after adjusting for age, specialty, and number of hospitalized COVID-19 cases. In Indonesia, the significant relationship between guideline adherence and mortality of COVID-19 patients remained strong (β: −14 (−27, −1); p = 0.033) after adjusting for age, specialty, and number of hospitalized COVID-19 cases
Inadequate nutritional knowledge is a key barrier to guideline adherence, and this was international and may be related to doctors' specialties and the COVID-19 pandemic. Adherence to nutritional guidelines may represent a prognostic factor for survival in COVID-19 patients.
Disparities in ovarian cancer treatment and overall survival according to race: An update
2021, Gynecologic Oncology
Citation Excerpt :
Several studies suggest that Black patients are less likely to receive treatment as outlined by the National Comprehensive Cancer Network (NCCN) guidelines [7,8,9]. Failure to comply with NCCN guidelines is associated with worse survival outcomes in most cancers, including ovarian cancer [10–11]. This finding is significant because it represents a modifiable risk factor that could be addressed to improve survival outcomes in Black patients.
To determine whether guideline non-adherence is associated with Black race.
A retrospective review of National Cancer Database records of women diagnosed with epithelial ovarian cancer from 2012 to 2016 who identified as “White” or “Black” was performed. Exposure was adherence or non-adherence to National Comprehensive Cancer Network guidelines for treatment. Outcomes were differences in disease characteristics and overall survival in months.
Of the 29,948 eligible patients, 93% (n = 27,744) were White and 7% (n = 2204) were Black. Having stage IV disease (OR 1.45, 95% CI 1.23–1.70; P < 0.001) and treatment in a comprehensive (OR 1.58, 95% CI 1.16–2.15; P = 0.0039) or academic (OR 2.30, 95% CI 1.70–3.12; P < 0.001) treatment facility were associated with Black race. Adherence to guidelines did not predict Black race (OR for adherence 1.0021, 95% CI 0.89–1.13; P = 0.97). Median survival for White patients with adherent care was 63.4 months and 51.4 months for Black patients (P = 0.0001). Median survival for White patients with non-adherent care was 60.5 months and 47.2 months for Black patients (P < 0.0001). Median overall survival was 61.1 months in White patients and 49.3 months in Black patients (P < 0.0001).
Our data suggest that while Black patients and patients who receive non-NCCN guideline directed care have worse survival outcomes, guideline adherence is not independently associated with Black race. We must consider other socioeconomic, environmental and system factors that are contributing to the survival discrepancy in Black patients with ovarian cancer.
The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder
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Guidelines also play an important role for healthcare systems as references for quality assurance and improvement efforts, and for researchers and funding organizations in identifying gaps in knowledge where future research is needed. There is a large and growing research literature showing that adherence to evidence-based guidelines lowers mortality rates and healthcare costs in disorders including breast cancer [28], ovarian cancer [29], pneumonia [30], heart failure [31], coronary artery disease [32], and atrial fibrillation [33]. Similarly, studies demonstrate that adherence to evidence-based guidelines results in greater symptom reduction in major depressive disorder [34], reduced medication adverse effects and greater symptom reduction in schizophrenia [35,36], lower healthcare costs in lower-back pain [37], and greater likelihood of achieving blood glucose control in diabetes [38].
Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.
Adherence to treatment guidelines as a major determinant of survival disparities between black and white patients with ovarian cancer
2021, Gynecologic Oncology
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Studies to identify modifiable factors, in contrast, could provide valuable information to design cost-effective measures that could be readily implemented to improve survival. Adherence to guideline-recommended treatment has been shown to reduce mortality among patients with ovarian cancer [6,7]. Several studies have found that black patients, compared with their white counterparts, receive less guideline-adherence surgical and chemotherapeutic interventions [8–10].
To evaluate whether non-adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and other factors related to treatment access contribute to racial disparities in ovarian cancer survival.
This large cohort study included patients from the National Cancer Database who were diagnosed with ovarian cancer between 2004 and 2014, with follow-up data up to 2017. The multivariable Cox regression was used to assess the effect of study variables on five-year overall survival. The proportion contributions of prognostic factors to the survival disparities were estimated using individual and sequential adjustment of these factors based on the Cox proportional hazards models.
Of the 120,712 patients eligible for this study, 110,032 (91.1%) were whites and 10,680 (8.9%) were blacks. Black patients, compared with their white counterparts, had a lower adherence to NCCN guidelines (60.8% vs. 70.4%, respectively, P < 0.001), and a higher five-year mortality after cancer diagnosis (age- and tumor characteristics- adjusted hazard ratio: 1.22, 95% confidence interval: 1.19–1.25). Non-adherence to NCCN treatment guidelines was the most significant contributor to racial disparity in ovarian cancer survival, followed by access to care and comorbidity, each explaining 36.4%, 22.7%, and 18.2% of the racial differences in five-year overall survival, respectively. These factors combined explain 59.1% of racial survival disparities. Risk factors identified for non-adherence to treatment guidelines among blacks include insurance status, treatment facility type, educational attainment, age, and comorbidity.
Adherence status to NCCN treatment guidelines is the most important contributor to the survival disparities between black and white patients with ovarian cancer. Our findings call for measures to promote equitable access to guideline-adherence care to improve the survival of black women with ovarian cancer.
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By basing recommendations on expert consensus when high-level evidence is lacking, the NCCN Guidelines fill in these gaps in the evidence and provide guidance for the management of patients in these clinical scenarios. Numerous studies have shown that concordance with NCCN Guidelines recommendations results in improved patient outcomes.15-26 However, variations in the quality of cancer care are well documented.27
The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 28 leading cancer centers dedicated to improving and facilitating quality, effective, efficient, and accessible cancer care so that patients can live better lives. The NCCN offers a number of programs and resources to give clinicians access to tools and knowledge that can help guide decision making in the management of cancer, including the flagship product, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). The NCCN Guidelines provide evidence-based, consensus-driven guidance for cancer management to ensure that all patients receive preventive, diagnostic, therapeutic, and supportive services that are most likely to lead to optimal outcomes. They are intended to assist all individuals who impact decision making in cancer care, including physicians, nurses, pharmacists, payers, patients and their families, and many others. The development of the NCCN Guidelines is an ongoing and iterative process based on a critical review of the best available evidence and the consensus recommendations made by a multidisciplinary panel of oncology experts. The NCCN Guidelines are the most detailed and frequently updated clinical practice guidelines available in any area of medicine and are the recognized standard for cancer care throughout the world. NCCN Guidelines are used by clinicians, payers, and other health care decision makers around the world to ensure delivery of high-quality, accessible, patient-centered care aimed at optimizing patient outcomes.

View all citing articles on Scopus

^☆: Poster presented at the 45th Annual Meeting of the Society of Gynecologic Oncologists, Tampa, FL, March 22–25, 2014.

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Impact of guideline adherence on patient outcomes in early-stage epithelial ovarian cancer☆

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conflicts of interest

Acknowledgment

Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

J Minim Invasive Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer

Cancer

Triple-negative breast cancer: the impact of guideline-adherent adjuvant treatment on survival – a retrospective multi-centre cohort study

Breast Cancer Res Treat

Adherence to treatment guidelines for ovarian cancer as a measure of quality care

Obstet Gynecol

NCCN clinical practice guidelines in oncology: ovarian cancer