Nineteen studies were included in the review. Eleven studies considered the effect of treatment by gynaecologic oncologists (n=13,045). Fourteen studies looked at the effect of treatment in a specialised hospital (n=23,134). Most of the studies were carried out in the USA or the UK.
Staging: Gynecologic oncologists performed more lymph node dissections in patients with FIGO I and II disease (60% to 78% versus 26% to 36%; three studies). The percentage of adequate cancer staging was significantly greater in gynecologic oncologists (43% to 47%) than general gynecologists (15% to 22%) (two studies). Specialist hospitals reported more staging procedures than non-specialist hospitals (two studies).
Debulking: A significant difference in favour of gynecologic oncologists compared to general gynecologists was found for optimal debulking to less than 2cm residual disease (relative risk 1.4, 95% CI: 1.2 to 1.5; five studies) and debulking to no residual degree in patients with stage III disease (relative risk 2.3, 95% CI: 1.5 to 3.5; two studies). No evidence of statistical heterogeneity was found. Patients operated on in specialist hospitals had a better chance of receiving optimal debulking than patients operated on in non-specialised hospitals (odds ratios ranged from 2.9 to 6.0; four studies).
Surgery and chemotherapy: Patients treated in a specialised hospital were more likely to receive chemotherapy (odds ratio 1.82, 95% CI: 1.08 to 3.07) compared to patients in a non-specialised hospital (four studies). Patients treated by a gynecologic oncologist were more likely to receive chemotherapy compared to patients treated by a general gynecologist (relative risk 1.14, 95% CI: 1.07 to 1.22; five studies). Two studies looked at the difference in chemotherapy rates and survival rates between different providers and found no significant differences; hazard ratios for specialised providers ranged from 0.75 to 0.77 and for general providers ranged from 0.77 to 0.79.
Postoperative complications: No statistically significant differences were found in post-operative complication rates between different providers.
Survival: Three studies found that treatment by a gynecologic oncologist resulted in longer survival in patients with advanced disease compared with general gynecologists. However, this was not generalisable to the whole patient population: the difference was only significant in one study in women 70 years or older with advanced disease. Other results were less consistent across studies. Treatment in a specialist hospital, compared to a non-specialist hospital, resulted in better survival in five of seven studies.
Effect of specialised gynecologist versus the effect of specialised hospital: 18 out of 19 studies reported better outcomes from specialised settings (gynecologist oncologist or specialised hospital, or both). One study found a significant association between hospital volume and overall survival (hazard ratio 0.03), which increased further when surgeon volume was included in the analysis (hazard ratio 0.15). Two studies found that the effect of surgeon specialty could not be explained by surgical volume of the hospital or type of hospital. Three studies found that use of chemotherapy affected the relationship between hospital type and survival.