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socioeconomic status229 and adjustment for age, and comorbidity234 Table 7.
Four original studies8,10,13,16 not included in the systematic reviews mentioned above were also
identified178,215,217,220. In a large cohort study 31,897 stage IIIC -IV ovarian cancer patients, Mercado
et al.215 showed that the hazard ratio for death for advanced stage patients was 1.63 when treated by
a general surgeon as compared to a gynecologic oncologist/gynecologist Cox regression controlling
for age, comorbidity, and hospital location. Treatment by a physician of another specialty was also
associated with higher hazard of death as compared to treatment by a gynecologic
oncologist/gynecologist. Like Mercado et al.215, Elit et al.217 reported that treatment by a physician of
another specialty was associated with higher hazard of death as compared to treatment by a
gynecologic oncologist association adjusted for age, comorbidity, residence location, stage, and
grade Table 7.
In a study conducted by Vernooij et al.220, gynecologists were classified according to their level of
specialization as specialized, semi-specialized or general gynecologists. Specialized gynecologists
have subspecialized during a mostly 2-year fellowship in a cancer center or have spent most of their
career in gynecological oncology and are recognized as specialized gynecologists by the Dutch
Society of Gynecological Oncology. Semi-specialized gynecologists are not formally trained in
oncology but surgically treat the majority of ovarian and endometrial cancer patients in the semi-
specialized hospital they work in. Furthermore in contrast to general gynecologists, semi-specialized
gynecologists visit conferences and lectures on gynecologic cancer and take part in structured
regional oncology consultations. The authors mentionned that specialization of the gynecologist did
not influence survival significantly data not shown. Cox multivariate analyses reported by
Kumpulainen et al.178 indicated also that specialization of the gynecologist did not influence survival
significantly Table 7.
Impact of physician specialty on surgical outcome: among the studies included in the systematic LoE 2-
review published by du Bois et al.209, 10 studies224,229,231,233,236,237,239,241,244,245 evaluated the surgical
outcome with respect to residual postoperative tumor in advanced ovarian cancer. None of these
studies performed multivariate analyses. Only 4 reports233,236,237,239 used complete resection without
residual tumor as outcome variable, others chose heterogeneous definitions of so-called optimal
debulking including proportional measures e.g., debulking > 95%, met ric measures e.g. maximum
diameter of residual tumor ≤ 1 mm, ≤ 2 mm or < 2 cm, or combined classes e.g., > 95 % debulking,
residual < 15 mm.
All studies documented association in favor of gynecologic oncologist compared with
obstetrician/general gynecologist or others regardless of the outcome variable used. However, only 4
associations reached statistical significance Table 8. Six studies included comparisons among
disciplines general surgeon vs. obstetrician/general gynecologist . In 5 trials, the degree of
cytoreduction was higher among patients treated by an obstetrician/general gynecologist regardless
of the outcome variable used the associations reached statistical significance in 3 studies.
As part of a pooled analysis including two studies233,236, Vernooij et al.228 showed that stage III
patients operated by a gynecologic oncologist were significantly more often debulked to no residual
disease than patients treated by a general gynecologist RR = 2.3, 95% CI = 1.5 -3.5; p < 0.05. In
another pooled analysis 5 studies 224,229,231,233,236, gynecologic oncologi sts achieved debulking to < 2
cm residual tumor among stage III patients 1.4 times more often than general gynecologist 95% CI
= 1.2-1.5, p < 0.05.
In the study mentioned above and conducted by Vernooij et al.220, the differences between general,
semi-specialized and specialized gynecologists were small but statistically significant optimal
debulking in 40%, 42%, and 45% of the patients respectively; p = 0.05. However, logistic
regression analysis showed that there was no difference between gynecological specialties data not
shown. The authors also mentioned that a collaboration between a gynecologist and a general
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