Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System.

OBJECTIVE: To examine trends in minimally invasive hysterectomy and power morcellation use over time and associated clinical characteristics. METHODS: We conducted a trend analysis and retrospective cohort study of all women 18 years of age and older undergoing hysterectomy for benign conditions at Kaiser Permanente Northern California collected from electronic health records. Generalized estimating equations and Cochran-Armitage testing were used to assess the primary outcomes, hysterectomy incidence, and proportion of hysterectomies by surgical route and power morcellation. Logistic regression analysis was used to assess secondary outcomes, clinical characteristics, and complications associated with surgical route. RESULTS: There were 31,971 hysterectomies from 2008 to 2015; the incidence decreased slightly from 2.86 (95% confidence interval [CI] 2.85-2.87) to 2.60 (95% CI 2.59-2.61) per 1,000 women (P<.001). Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001). Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001). The proportion of nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 and decreased to 0.02% in 2015 (P<.001). Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies comprising 7.8% of hysterectomies in 2015. Women with large uteri (greater than 1,000 g) were more likely to receive abdominal hysterectomies than minimally invasive hysterectomy (adjusted relative risk 11.62, 95% CI 9.89-13.66) and laparoscopic hysterectomy with power morcellation than without power morcellation (adjusted relative risk 5.74, 95% CI 4.12-8.00). Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55-51.31). CONCLUSION: A high minimally invasive hysterectomy rate is primarily associated with uterine size and can be maintained without power morcellation.

Disparities in the allocation of treatment in advanced ovarian cancer: are there certain patient characteristics associated with nonstandard therapy?

OBJECTIVE: To explore data from the National Cancer Database to identify pretreatment patient characteristics associated with receipt of nonstandard treatment for advanced ovarian cancer. METHODS: Between 2003 and 2006, there were 47,390 patients with ovarian cancer registered with the National Cancer Database. Variables included demographics, insurance, Charlson comorbidity score, zip income, and facility characteristics. Multivariable log binomial regression analyses were performed to assess factors associated with nonstandard care. RESULTS: Among the 47,390 patients, 27,045 (81%) were stage IIIC or IV. After excluding patients with missing treatment information (n=1,129 [2.38%]), 13,789 (53.21%) had received standard treatment. In multivariable analyses, uninsured and Medicaid-insured patients were less likely to receive standard treatment as compared with privately insured patients (relative risk 0.88, 95% confidence interval [CI] 0.83-0.93 and relative risk 0.91, 95% CI 0.86-0.95, respectively). African Americans and Hispanics were also less likely to receive standard treatment (relative risk 0.87, 95% CI 0.83-0.92 and relative risk 0.89, 95% CI 0.84-0.94, respectively). Patients with a Charlson comorbidity score of 2+ were less likely to receive standard care (relative risk 0.74, 95% CI 0.68-0.80). Treatment at a community cancer hospital compared with a teaching hospital was also less likely to be associated with standard treatment (relative risk 0.83, 95% CI 0.80-0.87). CONCLUSION: In this large multi-institutional cohort, approximately 47% of patients with stage IIIC and IV ovarian cancer did not receive standard treatment. Pretreatment patient characteristics such as race, insurance status, age, Charlson comorbidity score, and facility type were associated with nonstandard treatment.