Improving Quality and Decreasing Cost in Gynecologic Oncology Care. Society of Gynecologic Oncology Recommendations for Clinical Practice. Issue 9 (September 2015)

• Record Type: Journal Article
• Authors: Rimel, B. J.; Burke, William M.; Higgins, Robert V.; Lee, Paula S.; Lutman, Christopher V.; Parker, Lynn
• Is Part Of: Obstetrical & gynecological survey. Volume 70:Issue 9(2015)
• Publication Date: 2015-09
• Subjects: Obstetrics -- Periodicals; Gynecology -- Periodicals; Generative organs, Female -- Surgery -- Periodicals; 618
• DOI: 10.1097/01.ogx.0000470820.38134.12
• Languages: English
• ISSNs: 0029-7828

Abstract

<abstract> <title> <x xml:space="preserve">Abstract</x> </title> <sec> <title>ABSTRACT</title> <p>Cost reduction in gynecologic oncology practice does not mean reduction of quality care. Members of the Clinical Practice Committee of the Society of Gynecologic Oncology (SGO) reviewed current practice patterns in gynecologic oncology and investigated evidence-based recommendations for potential cost containment. Published literature and guidelines were reviewed to develop evidence-based recommendations for cost-effective quality gynecologic oncology care. The following recommendations describe areas identified for cost containment specific to gynecologic oncology.</p> <p>(1) Papanicolaou (Pap) tests of the vaginal cuff in patients with a history of endometrial cancer <italic>or</italic> colposcopy for low-grade Pap tests in women with a history of cervical cancer should not be performed. Both Pap testing to detect recurrences of endometrial cancer and referral to colposcopy of cervical cancer survivors with low-grade Pap tests are ineffective strategies. Liquid-based vaginal cytology in patients treated for cervical cancer results in frequent abnormal tests, but only high-grade squamous intraepithelial lesions require colposcopy. A careful pelvic examination after patient-reported symptoms remains the best way to detect recurrences of endometrial and cervical cancers.</p> <p>(2) Routine imaging using computed tomography (CT) and positron emission tomography (PET) scans for cancer surveillance should be avoided in asymptomatic women with gynecologic cancer, specifically ovarian, endometrial, cervical, vulvar, and vaginal cancer. There is no proven survival benefit for routine radiological surveillance in endometrial cancer or other gynecologic malignancies. Survival is similar in patients with endometrial cancer for both symptomatic and asymptomatic recurrences.</p> <p>There is a high risk of disease recurrence in patients with ovarian cancer. Studies examining the ability of CT scans to detect recurrent disease have had mixed results and have not improved overall survival. Ovarian cancer recurrence can be small-volume disease that is missed on both CT and PET scans. These imaging tests can be useful to evaluate symptomatic patients or those with worrisome physical examination findings.</p> <p>Cervical cancer recurrence usually presents with symptoms. Use of CT scan to detect asymptomatic recurrence has low yield. Although several studies support the use of a single posttreatment PET scan to gain prognostic information 3 months after completion of treatment, this is not routine cancer surveillance.</p> <p>(3) Routine screening of women at low risk of ovarian cancer with ultrasound or CA-125 or other biomarkers is not recommended. The prevalence of this cancer is low, risk of recurrence is high, and there is no effective screening test. Data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a randomized trial with more than 75, 000 low-risk postmenopausal women, showed that screening with annual CA-125 and pelvic ultrasound did not improve mortality from ovarian cancer. Biomarker tests are triage tools that aid in appropriate surgical referral of women with a pelvic mass to gynecologic oncologists.</p> <p>(4) Basic level palliative care for women with advanced or relapsed gynecologic cancer should not be delayed. Referral to a palliative care specialist when needed will avoid unnecessary treatments at life's end. Early integration of palliative care in the course of standard treatment for patients with advanced lung cancer improves quality-of-life scores, improves overall survival, and substantially reduces the cost of care. Gynecologic oncologists do not speak to patients early enough about the benefits of palliative and hospice care during the last 6 to 12 months of life. Hospice care is clearly underutilized by patients and families in the last months of life. Early referral of patients to palliative care spares them from unnecessary debilitating therapy in the last months of their lives.</p> <p>The above recommendations have broad support from the Clinical Practice Committee as the best available evidence on practical ways to improve the quality and value of the care provided to women with gynecologic cancers. Their implementation can immediately improve the value of patient care.</p> </sec> </abstract>