title: The impact of improving outcomes guidance on surgical management of vulval squamous cell cancer in southwest England (1997-2002).
abstract: OBJECTIVE
  The objective of this study was to assess the impact of reorganisation of gynaecological services in southwest England following adoption of regionally agreed evidence-based guidelines and publication of the National Improving Outcomes Guidance in 1999.
  
  
  METHODS
  Prospective audit with cross-checking against histological reports.
  
  
  METHODS
  All 19 acute hospitals in the four Cancer Networks of southwest England.
  
  
  METHODS
  All subjects with squamous or verrucous vulval cancer diagnosed between 1997 and 2002.
  
  
  METHODS
  A one-page minimum data set proforma agreed by the South West Gynaecology Tumour Panel was completed by surgeons after treatment of each patient, and was sent to South West Cancer Intelligence Service for entry, collation and analysis. Data are presented for the years 1997 to 2002 inclusive, and comparisons were made between each of the three 2-year cohorts.
  
  
  METHODS
  These are standards derived from the guidance.
  
  
  RESULTS
  There were 436 squamous or verrucous vulval cancers registered. Recording of staging was missing in 20% of subjects. The percentage of subjects operated upon by lead gynaecological cancer surgeons increased from 78% in cohort 1 to 93% in cohort 3 (P < 0.001). There is a trend towards more conservative operations, which have lower co-morbidity. High activity surgeons achieved better rates of tumour-free skin margins, but even these were adequate only in 49% of operations. Lymphadenectomy rates did not follow guidance.
  
  
  CONCLUSIONS
  Centralisation of care of this rare cancer should continue, but specialists need to increase their efforts to ensure adequate skin margins and lymphadenectomy rates while balancing morbidity and the likelihood of recurrence in both fit and frail patients.
authors: Department of Gynaecology, Derriford Hospital, Plymouth, UK.
authors: A D
authors: AD
authors: Falconer
authors: L
authors: L
authors: Hirschowitz
authors: J
authors: J
authors: Weeks
authors: J
authors: J
authors: Murdoch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D004739:England; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008485:Medical Audit; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016896:Treatment Outcome; D014846:Vulvar Neoplasms / Q000601:surgery*