Survival disparities in non-Hispanic Black and White cervical cancer patients vary by histology and are largely explained by modifiable factors.

PURPOSE: We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities. METHODS: Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC). RESULTS: This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively). CONCLUSIONS: Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors.

Effect of Serial Pregnancies on Physical Fitness.

INTRODUCTION: Pregnancy has a profound impact on physical fitness, and delivery does not allow for rapid return to peak performance levels as physiologic changes can persist for greater than 1 year postpartum. Multiple studies across all military services have documented decrements in physical performance with pregnancy among women. The purpose of this study was to determine the impact of serial pregnancies on physical fitness and body composition in a cohort of Army women. We hypothesized that a second pregnancy would be associated with increasing decrements in physical fitness in active duty soldiers beyond that seen following a first delivery. MATERIALS AND METHODS: This retrospective cohort study screened all active duty soldiers who had delivered a singleton pregnancy of ≥32 weeks gestation between January 1, 2011 and March 31, 2017 at a single military medical center. This roster of eligible women was used to extract Army Physical Fitness Test (APFT) and height/weight data from the U.S. Army Digital Training Management System. Soldiers who delivered their first 2 pregnancies over this period were included. Select antepartum, intrapartum, and postpartum data were collected from the electronic medical record. The primary outcome variables were raw scores for push-ups, sit-ups, and run events as well as weight measures across the 2 pregnancies. The secondary outcomes were the failure rates on both the APFT events and body mass index measurements. Data were analyzed using paired t-tests to compare the means of APFT scores across the 2 pregnancies. The subjects served as their own controls. This study was approved by Regional Health Command-Pacific. RESULTS: A total of 2,103 active duty soldiers delivered singleton pregnancies at Tripler Army Medical Center between January 2011 and March 2017. Among these, 16 women delivered both their first- and second-term pregnancies and had APFT data available for analysis. Average age at time of first and second delivery was 26.1 and 28.1 years, respectively. Mean time separating the first postpartum APFT from the delivery was 8.8 months for the first pregnancy and 7.3 months following the second.A significant decrease in mean sit-up score was found comparing APFT-1 with APFT-2 (72.1 vs 65.7, P = .043) and comparing APFT-1 to APFT-3 (72.1 vs 60.9, P = .002). A significant increase in mean run time was found comparing APFT-1 to APFT-3 (16.9 minutes vs 17.9 minutes, P = .010) and APFT-2 to APFT-3 (17.5 minutes vs 17.9 minutes, P = .027). Comparing APFT-1 to APFT-3 showed a significant decrease in sit-up raw scores (P = .002), run times (P = .010), and total APFT scores (P = .01). Overall, the data show a trend of decreasing performance in all APFT events across the 3 APFTs and a trend toward higher failure rates. This cohort of soldiers did not experience weight gain following the pregnancies. CONCLUSIONS: The present study is the first to analyze the association of serial pregnancies on physical fitness utilizing a validated physical fitness test, and the results suggest that a second pregnancy is associated with progressive worsening of performance. This study is limited by the small sample size, and future studies could further elucidate the degree to which serial pregnancies affect physical fitness.

The rare occurrence of unifocal peritoneal mesothelioma: a case report, literature review, and future directions.

Background: Mesothelioma is a rare, aggressive disease originating from mesothelial cells and carries a poor prognosis. Mesothelioma may arise from the pleura, pericardium, or peritoneum. Peritoneal mesothelioma (PM) usually spreads in a diffuse manner; however, a localized unifocal form of PM may occur. Literature on unifocal mesothelioma remains scarce. Case Description: Herein, we highlight a case of localized epithelioid PM in an 81-year-old gentleman with the unique challenges faced during management. The pelvic mass was 7 cm, well-circumscribed, and hyper-vascular with fibrous attachments to the abdominal wall. The patient had a peritoneal cancer index (PCI) of 4 on initial diagnostic laparoscopy. Diagnosis was confirmed by histology. Resection of the mass with a partial omentectomy was performed. Months later, the patient developed recurrence detected on follow-up imaging in the peri-splenic region. The patient underwent cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for 60 minutes using mitomycin C and cisplatin followed by an uneventful recovery. Our case report is followed by a review of literature on disease pathophysiology, treatment options, and recently promising immunotherapy approaches. Conclusions: CRS and HIPEC remains the standard treatment regimen for patients with PM. Nonetheless, a more nuanced approach might be indicated in specific patients with localized unifocal PM. Disease distribution and burden may impact the decision on surgical management in selected patients.

Immuno-Molecular Targeted Therapy Use and Survival Benefit in Patients with Stage IVB Cervical Carcinoma in Commission on Cancer®-Accredited Facilities in the United States.

PURPOSE: To investigate IMT use and survival in real-world stage IVB cervical cancer patients outside randomized clinical trials. METHODS: Patients diagnosed with stage IVB cervical cancer during 2013-2019 in the National Cancer Database and treated with chemotherapy (CT) ± external beam radiation (EBRT) ± intracavitary brachytherapy (ICBT) ± IMT were studied. The adjusted hazard ratio (AHR) and 95% confidence interval (CI) for risk of death were estimated in patients treated with vs. without IMT after applying propensity score analysis to balance the clinical covariates. RESULTS: There were 3164 evaluable patients, including 969 (31%) who were treated with IMT. The use of IMT increased from 11% in 2013 to 46% in 2019. Age, insurance, facility type, sites of distant metastasis, and type of first-line treatment were independently associated with using IMT. In propensity-score-balanced patients, the median survival was 18.6 vs. 13.1 months for with vs. without IMT (p < 0.001). The AHR was 0.72 (95% CI = 0.64-0.80) for adding IMT overall, 0.72 for IMT + CT, 0.66 for IMT + CT + EBRT, and 0.69 for IMT + CT + EBRT + ICBT. IMT-associated survival improvements were suggested in all subgroups by age, race/ethnicity, comorbidity score, facility type, tumor grade, tumor size, and site of metastasis. CONCLUSIONS: IMT was associated with a consistent survival benefit in real-world patients with stage IVB cervical cancer.

Mandatory HPV Vaccination; Opportunity to Save Lives, Improve Readiness and Cut Costs.

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the U.S. military and accounts for more healthcare visits than the next two most common STIs combined. Human papillomavirus is preventable with a safe, effective, prophylactic vaccine that has been available since 2006, yet vaccination rates remain low. The vaccine is approved for females and males aged 9-45 years for prevention of HPV-related dysplasia and cancers. Although it is recommended by the Centers for Disease Control and Prevention (CDC)'s Advisory Committee on Immunization Practices (ACIP), it is not part of the U.S. military's mandatory vaccine list. Human papillomavirus does not just affect female service members-male service members have a higher reported seropositive rate than their civilian counterparts and can develop oropharyngeal, anal, or penile cancers as sequelae of HPV. Oropharyngeal cancer, more common in males, is the fastest growing and most prevalent HPV-related cancer in the USA. Several countries, such as Australia and Sweden, have successfully implemented mandatory vaccine programs and have seen rates of HPV-related diseases, including cancer, decline significantly. Some models project that cervical cancer, which is the fifth-most common cancer in active duty women, will be eliminated in the next 20 years as a result of mandatory vaccination programs. Between higher seropositive rates and lack of widespread vaccination, HPV dysplasia and cancer result in lost work time, decreased force readiness, negative monetary implications, and even separation from service. With more than half of the 1.3 million service members in the catch-up vaccination age range of less than 26 years of age, we are poised to have a profound impact through mandatory active duty service member vaccination. Although multiple strategies for improving vaccination rates have been proposed, mandatory vaccination would be in line with current joint service policy that requires all ACIP-recommended vaccines. It is time to update the joint service guidelines and add HPV vaccine to the list of mandatory vaccines.

The effect of pregnancy and the duration of postpartum convalescence on the physical fitness of healthy women: A cohort study of active duty servicewomen receiving 6 weeks versus 12 weeks convalescence.

INTRODUCTION: Pregnancy profoundly affects cardiovascular and musculoskeletal performance requiring up to 12 months for recovery in healthy individuals. OBJECTIVE: To assess the effects of extending postpartum convalescence from 6 to 12 weeks on the physical fitness of Active Duty (AD) soldiers as measured by the Army Physical Fitness Test (APFT) and Body Mass Index (BMI). METHODS: We conducted a retrospective study of AD soldiers who delivered their singleton pregnancy of ≥ 32weeks gestation at a tertiary medical center. Pre- and post-pregnancy APFT results as well as demographic, pregnancy, and postpartum data were collected. Changes in APFT raw scores, body composition measures, and failure rates across the 6-week and 12-week convalescent cohorts were assessed. Multivariable regressions were utilized to associate risk factors with failure. RESULTS: Four hundred sixty women met inclusion criteria; N = 358 in the 6 week cohort and N = 102 in the 12 week cohort. Demographic variables were similar between the cohorts. APFT failure rates across pregnancy increased more than 3-fold in both groups, but no significant differences were found between groups in the decrement of performance or weight gain. With the combined cohort, multivariable regression analysis showed failure on the postpartum APFT to be independently associated with failure on the pre-pregnancy APFT (OR = 16.92, 95% CI 4.96-57.77), failure on pre-pregnancy BMI (OR = 8.44, 95% CI 2.23-31.92), elevated BMI at 6-8 weeks postpartum (OR = 4.02, 95% CI 1.42-11.35) and not breastfeeding at 2 months (OR = 3.23, 95% CI 1.48-7.02). Within 36 months of delivery date, 75% of women had achieved pre-pregnancy levels of fitness. CONCLUSION: An additional 6 weeks of convalescence did not adversely affect physical performance or BMI measures in AD Army women following pregnancy. Modifiable factors such as pre- and post-pregnancy conditioning and weight, weight gain in pregnancy and always breastfeeding were found to be significant in recovery of physical fitness postpartum.

A Case of Vulvar Cavernous Lymphangioma.

Cystic (cavernous) lymphangioma of the vulva is a benign tumor of lymphatic vessels with only 10 cases previously reported in the medical literature worldwide. The following is a case of bilateral vulvar cavernous lymphangiomas in a 23-year-old woman with bilateral soft tissue masses of the labia majora. Prior unsuccessful management included aspiration, incision, and drainage. Surgical marsupialization of both masses led to resolution and the subsequent histologic diagnosis of cavernous lymphangioma. Although rare, cavernous lymphangioma should be included in the differential diagnosis of soft tissue masses of the distal labia. Cavernous lymphangioma can mimic other more common vulvar soft tissue masses such as Bartholin's cyst.