title: The effect of centralization of primary surgery on survival in ovarian cancer patients.
abstract: OBJECTIVE
  To examine the effect of centralized surgery on overall survival in patients with ovarian cancer and, in particular, patients with advanced disease (stage III/IV).
  
  
  METHODS
  In a historical prospective study design, patients referred from community hospitals to a teaching hospital for primary surgery during the 2-year period, 1995-1997, were included as cases. For each referred case, two controls, matched for International Federation of Gynecology and Obstetrics (FIGO) stage and age, were selected among patients who had had primary surgery at the referral hospitals (nonteaching) in the years, 1992-1995. Kaplan-Meier survival curves were computed and tested statistically by the log rank test. Cox proportional hazard model was applied for estimation of prognostic factors of survival.
  
  
  RESULTS
  There was no difference in postoperative mortality for stage I/II patients by level of care (community hospitals versus teaching hospital). However, for advanced stage disease (III + IV), the controls had significantly shorter crude survival than patients who had been operated on at the teaching hospital (5-year survival: 4% versus 26%; median survival: 12 months versus 21 months) (P=.01). Multivariable analyses showed that completed chemotherapy and size of residual tumor after primary surgery were independent prognostic factors of survival. Patients optimally operated on at the teaching hospital had significantly lower risk of death compared with all other groups, independently of chemotherapy. This indicates that the extent of cytoreductive surgery and the overall management undertaken in the teaching hospital are significant predictors of improved survival.
  
  
  CONCLUSIONS
  Centralization of primary ovarian cancer surgery in one health region in Norway has improved survival for patients with advanced disease. Patients with apparent advanced ovarian cancer should be referred to a subspecialty unit for primary surgery, and every effort should be made to attain as complete cytoreduction as possible.
authors.affiliation: Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway. solveig.tingulstad@medisin.ntnu.no
authors.forename: Solveig
authors.initials: S
authors.lastname: Tingulstad
authors.forename: Finn Egil
authors.initials: FE
authors.lastname: Skjeldestad
authors.forename: Bjørn
authors.initials: B
authors.lastname: Hagen
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D006764:Hospitals, Community / Q000458:organization & administration / Q000592:standards; D006784:Hospitals, Teaching / Q000458:organization & administration / Q000592:standards; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D009664:Norway; D010051:Ovarian Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D010052:Ovariectomy / Q000379:methods / Q000401:mortality*; D011183:Postoperative Complications / Q000401:mortality*; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012017:Referral and Consultation; D012041:Regional Medical Programs / Q000458:organization & administration*; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis