OBJECTIVE: To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer. METHODS: In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort. RESULTS: A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy. CONCLUSIONS: Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

Agostino Gemelli IRCCS Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy

Amsterdam University Medical Centres Amsterdam Noord Holland The Netherlands

Bellvitge University Hospital L'Hospitalet de Llobregat Catalunya Spain

Catholic University of the Sacred Heart Milano Lombardia Italy

Clinic of Obstetrics and Gynecology Hospital San Gerardo Monza Italy

Clinical Hospital Center Rijeka Rijeka Croatia

Department of Gynaecological Oncology Queen Alexandra Hospital Portsmouth NHS Trust Portsmouth UK

Department of Gynecologic Oncology La Fe University and Polytechnic Hospital Valencia Spain

Department of Gynecologic Oncology La Paz University Hospital Madrid Spain

Department of Gynecologic Oncology Saglik Bilimleri University Antalya Research and Training Hospital Antalya Turkey

Department of Gynecologic Oncology Universidad de Navarra Pamplona Navarra Spain

Department of Gynecologic Oncology University Clinic of Gynecology and Obstetrics Faculty of Medicine Ss Cyril and Methodius University of Skopje Skopjeskopje Macedonia

Department of Gynecologic Oncology Zekai Tahir Burak Women's Health Education and Research Hospital Ankara Turkey

Department of Gynecological Oncology Radboudumc Nijmegen Netherlands

Department of Gynecology and Oncology Jagiellonian University Krakow Poland

Department of Gynecology Centre Oscar Lambret Lille France

Department of Gynecology Instituto Português de Oncologia de Lisboa Lisbon Portugal

Department of Gynecology University Maternal Hospital Canary Islands Las Palmas Las Palmas Spain

Department of Medicine and Surgery University of Milan Bicocca Milan Italy

Department of Obstetrics and Gynecology Clinica Universidad de Navarra Madrid Spain

Department of Obstetrics and Gynecology Hospital Clinico San Carlos IdISSC Complutense University Madrid Spain

Department of Obstetrics and Gynecology Tampere University Hospital Tampere Finland

Department of Obstetrics and Gynecology Unit of Gynecologic Oncology

Department of Obstetrics and Gynecology University of Liege Liege Belgium

Department of Obstetrics and Gynecology University of Prague Prague Czech Republic

Department of Oncogynecology Grigoriev Institute for Medical Radiology NAMS of Ukraine Harkiv Ukraine

Department of Oncogynecology Kazahskij naucno issledovatel'skij institut onkologii i radiologii Almaty Kazakhstan

Department of Oncology Radiology and Radiation Medicine 5 N Karazin Kharkiv National University Harkiv Ukraine

Department of Preventive Medicine and Public Health Clinica Universidad de Navarra Pamplona Navarra Spain

Department of Preventive Medicine and Public Health Universidad de Navarra Pamplona Spain

Department of Surgery Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy

Department of Surgery LISOD Israeli Oncological Hospital Kyiv Region Ukraine

Division of Gynecologic Oncology 1st Department of Obstetrics and Gynecology Alexandra Hospital National and Kapodistrian University of Athens Athens Greece

Division of Gynecologic Oncology IRCCS Azienda Ospedaliero Universitaria di Bologna Policlinico S Orsola Malpighi Bologna Italy

Endoscopica Malzoni Center for Advanced Endoscopic Gynecologic Surgery Avellino Italy

Faculty of Medicine University of Debrecen Debrecen Hungary

Hospital Universitario Donostia San Sebastian Spain

Institut Curie Paris Île de France France

Institute of Obstetrics and Gynecology

IPO PORTO Porto Portugal

Istanbul University Cerrrahpasa Medical Faculty istanbul Turkey

Istituto Europeo di Oncologia Milan Italy

Lviv Oncology Center Lviv Ukraine

Metaxa Cancer Hospital of Piraeus Piraeus Attika Greece

National Center of Oncology Baku Azerbaijan

North Estonia Medical Centre Tallinn Estonia

Queen Elizabeth Hospital Gateshead Gateshead UK

University Hospitals of Leicester NHS Trust Leicester Leicester UK

University Oncologic Hospital Sofia Bulgaria

UOC Ginecologia Oncologica Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica Policlinico Agostino Gemelli IRCCS Rome Italy

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$a Boria, Felix $u Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain $1 https://orcid.org/0000000247616190

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$a SUCCOR quality: validation of ESGO quality indicators for surgical treatment of cervical cancer / $c F. Boria, L. Chiva, E. Chacon, V. Zanagnolo, A. Fagotti, A. Kucukmetin, C. Mom, G. Chakalova, A. Shamistan, M. Malzoni, F. Narducci, O. Arencibia, F. Raspagliesi, T. Toptas, D. Cibula, D. Kaidarova, MM. Meydanli, M. Tavares, D. Golub, AM. Perrone, R. Poka, PLM. Zusterzeel, I. Aluloski, F. Goffin, D. Haidopoulos, H. Haller, R. Jach, I. Yezhova, M. Bernardino, R. Bharathan, MM. Maenpaa, V. Sukhin, JG. Feron, R. Fruscio, K. Kukk, J. Ponce, F. Demirkiran, G. Vorgias, N. Povolotskaya, PJ. Coronado Martín, T. Marina, I. Zapardiel, N. Bizzarri, M. Gorostidi, M. Gutierrez, N. Manzour, A. Berasaluce, N. Martin-Calvo, SUCCOR study Group

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$a OBJECTIVE: To evaluate whether compliance with European Society of Gynaecological Oncology (ESGO) surgery quality indicators impacts disease-free survival in patients undergoing radical hysterectomy for cervical cancer. METHODS: In this retrospective cohort study, 15 ESGO quality indicators were assessed in the SUCCOR database (patients who underwent radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage 2009 IB1, FIGO 2018 IB1, and IB2 cervical cancer between January 2013 and December 2014), and the final score ranged between 0 and 16 points. Centers with more than 13 points were classified as high-quality indicator compliance centers. We constructed a weighted cohort using inverse probability weighting to adjust for the variables. We compared disease-free survival and overall survival using Cox proportional hazards regression analysis in the weighted cohort. RESULTS: A total of 838 patients were included in the study. The mean number of quality indicators compliance in this cohort was 13.6 (SD 1.45). A total of 479 (57.2%) patients were operated on at high compliance centers and 359 (42.8%) patients at low compliance centers. High compliance centers performed more open surgeries (58.4% vs 36.7%, p<0.01). Women who were operated on at centers with high compliance with quality indicators had a significantly lower risk of relapse (HR=0.39; 95% CI 0.25 to 0.61; p<0.001). The association was reduced, but remained significant, after further adjustment for conization, surgical approach, and use of manipulator surgery (HR=0.48; 95% CI 0.30 to 0.75; p=0.001) and adjustment for adjuvant therapy (HR=0.47; 95% CI 0.30 to 0.74; p=0.001). Risk of death from disease was significantly lower in women operated on at centers with high adherence to quality indicators (HR=0.43; 95% CI 0.19 to 0.97; p=0.041). However, the association was not significant after adjustment for conization, surgical approach, use of manipulator surgery, and adjuvant therapy. CONCLUSIONS: Patients with early cervical cancer who underwent radical hysterectomy in centers with high compliance with ESGO quality indicators had a lower risk of recurrence and death.

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$a Chiva, Luis $u Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain lchiva@unav.es $1 https://orcid.org/0000000219083251

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$a Chacon, Enrique $u Department of Gynecologic Oncology, Universidad de Navarra, Pamplona, Navarra, Spain $1 https://orcid.org/0000000186598602

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$a Zanagnolo, Vanna $u Istituto Europeo di Oncologia, Milan, Italy

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$a Fagotti, Anna $u Agostino Gemelli IRCCS, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy $u Catholic University of the Sacred Heart, Milano, Lombardia, Italy $1 https://orcid.org/000000015579335X

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$a Kucukmetin, Ali $u Queen Elizabeth Hospital, Gateshead, Gateshead, UK

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$a Shamistan, Aliyev $u National Center of Oncology, Baku, Azerbaijan

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$a Malzoni, Mario $u Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy

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$a Narducci, Fabrice $u Department of Gynecology, Centre Oscar Lambret, Lille, France

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$a Arencibia, Octavio $u Department of Gynecology, University Maternal Hospital Canary Islands, Las Palmas, Las Palmas, Spain

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$a Raspagliesi, Francesco $u Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

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$a Cibula, David $u Department of Obstetrics and Gynecology, University of Prague, Prague, Czech Republic

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$a Tavares, Mariana $u IPO-PORTO, Porto, Portugal

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$a Golub, Dmytro $u Department of Surgery, LISOD - Israeli Oncological Hospital, Kyiv Region, Ukraine

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$a Perrone, Anna Myriam $u Division of Gynecologic Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy $1 https://orcid.org/0000000331404772

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$a Poka, Robert $u Department of Obstetrics and Gynecology, Unit of Gynecologic Oncology; Institute of Obstetrics and Gynecology; Faculty of Medicine, University of Debrecen, Debrecen, Hungary $1 https://orcid.org/0000000318361579

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$a Zusterzeel, Petra L M $u Department of Gynecological Oncology, Radboudumc, Nijmegen, Netherlands

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$a Aluloski, Igor $u Department of Gynecologic Oncology, University Clinic of Gynecology and Obstetrics, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopjeskopje, Macedonia

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$a Goffin, Frederic $u Department of Obstetrics and Gynecology, University of Liege, Liege, Belgium

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$a Haidopoulos, Dimitrios $u Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece

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$a Haller, Herman $u Clinical Hospital Center Rijeka, Rijeka, Croatia

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$a Jach, Robert $u Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland

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$a Bharathan, Rasiah $u University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK

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$a Maenpaa, Minna M $u Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland

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$a Sukhin, Vladyslav $u Department of Oncology, Radiology and Radiation Medicine, V N Karazin Kharkiv National University, Harkiv, Ukraine $u Department of Oncogynecology, Grigoriev Institute for Medical Radiology NAMS of Ukraine, Harkiv, Ukraine $1 https://orcid.org/0000000244033707

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$a Feron, Jean-Guillaume $u Institut Curie, Paris, Île-de-France, France

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$a Fruscio, Robert $u Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy $u Clinic of Obstetrics and Gynecology, Hospital San Gerardo, Monza, Italy $1 https://orcid.org/0000000156882194

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$a Kukk, Kersti $u North Estonia Medical Centre, Tallinn, Estonia

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$a Ponce, Jordi $u Bellvitge University Hospital, L'Hospitalet de Llobregat, Catalunya, Spain

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$a Demirkiran, Fuat $u Istanbul University Cerrrahpasa Medical Faculty, istanbul, Turkey

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$a Vorgias, George $u Metaxa Cancer Hospital of Piraeus, Piraeus, Attika, Greece

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$a Zapardiel, Ignacio $u Department of Gynecologic Oncology, La Paz University Hospital, Madrid, Spain $1 https://orcid.org/0000000291757767

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$a Bizzarri, Nicolò $u UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Policlinico Agostino Gemelli IRCCS, Rome, Italy $1 https://orcid.org/000000021727904X

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$a Gorostidi, Mikel $u Hospital Universitario Donostia, San Sebastian, Spain $1 https://orcid.org/0000000151502797

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$a Gutierrez, Monica $u Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain

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$a Manzour, Nabil $u Department of Gynecologic Oncology, Universidad de Navarra, Pamplona, Navarra, Spain $1 https://orcid.org/0000000246046042

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$a Berasaluce, Arantxa $u Department of Preventive Medicine and Public Health, Clinica Universidad de Navarra, Pamplona, Navarra, Spain

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$a Martin-Calvo, Nerea $u ,Department of Preventive Medicine and Public Health, Universidad de Navarra, Pamplona, Spain

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