Trends in Gynecologic Cancer Care in North America
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Overall, there has been tremendous movement over the last decade toward centralization of cancer care into specialized centers. This comes from the recognition that multidisciplinary care, including access to opinions from gynecologic, medical, and radiation oncologists, can improve patient outcomes. In addition to this input, it is important to have access to subspecialty pathology, diagnostic radiology, oncology nursing, and other disciplines as necessary. The population-based literature on quality of care in gynecologic cancers reflects this movement, with many articles evaluating outcomes in terms of structural variables. However, the continued presence of regional and sociodemographic variation in outcomes suggests it is still possible to achieve significant improvements in survival by concentrating efforts to improve the quality of care provided to gynecologic cancer patients. Improved outcomes for patients with ovarian cancer can be achieved by continued centralization of gynecologic cancer care and provision of care by gynecologic oncologists in high-volume centers. Further study is needed to determine if cervical cancer and vulvar cancer outcomes can be improved with centralization. For uterine cancer, at this time there do not appear to be significant improvements in outcomes related to centralization.For all gynecologic cancers, more attention should be paid to the processes of care and their impact on patient outcomes. An appropriate goal for all health care systems is to ensure all women have access to evidence-based care. This is particularly important for high-risk women, older women, and minority women, who suffer a disproportionate amount of the gynecologic cancer–related mortality and often do not receive evidence-based care. Clinical practice guidelines exist to provide guidance to clinicians as to what constitutes evidence-based care and to make recommendations concerning current best practices. Adherence to guidelines can help to reduce variations in care due to sociodemographic factors. As the provision of cancer care becomes more and more centralized, outcomes at the population level will be improved only by focusing on the processes of care. A look at the three North American health care systems shows there are issues with women having access to high-quality, timely care. This fundamental problem must be addressed to systematically improve health at the population level. Governments should strive toward the WHO goal of promoting health development in their populations by reducing inequalities in the access to health care and health promotion activities.
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