Disparity of ovarian cancer survival between urban and rural settings.

OBJECTIVE: To determine if there is a difference in overall survival of patients with epithelial ovarian cancer in rural, urban, and metropolitan settings in the United States. METHODS: We performed a retrospective cohort study using 2004-2016 National Cancer Database (NCDB) data including high and low grade, stage I-IV disease. Bivariate analyses used Student's t-test for continuous variables and χ2 test for dichotomous variables. Kaplan-Meier curves estimated survival of patients based on location of residence, and univariate analyses using Cox proportional HR assessed survival based on baseline characteristics. Multivariate analysis was performed to account for significant covariates. Propensity score matching was used to validate the multivariate survival model. For all tests, p<0.05 was considered statistically significant. RESULTS: A total of 111 627 patients were included with a mean age of 62.5 years for metroolitan (range 18-90), 64.0 years for rural (range 19-90) and 63.2 years for urban areas (range 18-90). Of all patients included, 94 290 were in a metropolitan area (counties >1 million population or 50 000-999 999), 15 386 were in an urban area (population of 10 000-49 999), and 1951 were in a rural area (non-metropolitan/non-core population). Univariate Cox proportional hazards models showed clinically significant differences in survival in patients from metropolitan, urban, and rural areas. Multivariate Cox proportional hazards models showed a clinically significant increase in HRs for patients in rural settings (HR 1.17; 95% CI 1.06 to 1.29). Increasing age and stage, non-insured status, non-white race, and comorbidity were also significant for poorer survival. CONCLUSION: Patients with ovarian cancer who live in rural settings with small populations and greater distance to tertiary care centers have poorer survival. These differences hold after controlling for stage, age, and other significant risk factors related to poorer outcomes. To improve clinical outcomes, we need further studies to identify which of these factors are actionable.

Metastatic malignant melanoma in an endometrial polyp.

Melanocytic metastasis to gynecologic organs is rare with most metastases to the ovaries. Metastases to the uterus, or in this case report, a uterine polyp, is exceedingly rare with only 17 cases reported in the literature. Post-menopausal bleeding is the most common presentation of metastatic melanoma in the endometrium, followed by uterine bleeding or abnormal postnatal bleeding in the premenopausal population. We present an 81-year-old woman with metastatic melanoma confined to an endometrial polyp leading to the diagnosis of widespread dissemination of the patient's acral melanoma resected 6 years prior. Although rare, metastatic melanoma should be considered as a cause for abnormal bleeding, especially in the post-menopausal patient with a history of melanoma.

The Collaborative Laborist and Midwifery Model: An Accepted and Sustainable Model.

In 2010, the OB/GYN physicians at this mid-sized midwestern medical center implemented a laborist model on the obstetrics ward. A laborist is a dedicated obstetrician within the obstetric ward who oversees the management of labor and performs deliveries as both the primary physician and also when consulted by other providers, including community obstetricians, family physicians and nurse midwives. In 2014, a collaborative obstetric model was implemented with the addition of an in-house certified nurse midwife (CNM) to assist the laborist in obstetric care. This retrospective study analyzes the impact of these care models on clinical outcomes, including rates of induction of labor, total (primary and repeat) cesarean sections, and vaginal births after cesarean section. The three time periods (i.e., pre-laborist, laborist, laborist plus CNM) periods are compared. Induction rates decreased from 48.6 percent to 46.5 percent to 28.8 percent during the three time periods. Primary cesarean section rates decreased from 15.9 percent to 14.6 percent to 13.6 percent. Total cesarean section rates slightly decreased but this was not statistically significant, going from 28.9 percent to 28.4 percent, to 27.7 percent. Vaginal births after cesarean section increased from 9.2 percent to 12.9 percent to 15 percent. Staff satisfaction was also measured utilizing anonymous surveys during the first two time periods. There was improvement in seven of the eight questions from the pre-laborist to the laborist model. In conclusion, a collaborative care model on the obstetric floor at this Institution has had a positive impact on patient care outcomes and staff satisfaction.

Cervical Cancer: Preventable Deaths Among American Indian/Alaska Native Communities.

American Indian/Alaska Native (AI/AN) individuals have twice the mortality rate of cervical cancer than the general US population. Participation in prevention programs such as cervical cancer screening and human papillomavirus (HPV) vaccination are under-utilized in this population. There are high rates of established cervical cancer risk factors among this community, with AI/AN people having a higher likelihood of infection with high-risk HPV strains not included in the 9-valent vaccine. There is a need for more robust and urgent prevention and treatment efforts in regard to cervical cancer in the AI/AN community.

Association of Distance to Gynecologic Oncologist and Survival in a Rural Midwestern State.

Objectives: Rural ovarian cancer patients experience worse survival compared to urban patients. We assessed whether distance to gynecologic oncology specialists was associated with survival for patients in a rural state. Methods: Demographic, tumor, and treatment characteristics were extracted from the Iowa Cancer Registry for patients diagnosed between 1990 and 2018. Data were linked to the county-level 2018-2019 Area Health Resource File (number of surgeons and hospital beds per 100,000 population). Rurality was defined using 2013 Rural-Urban Continuum Codes; distance to the nearest gynecologic oncologist was calculated from the centroid of the county of residence to the centroid of the nearest county with a high volume health care center with a gynecologic oncologist. Associations with survival were assessed using multivariable Cox proportional hazards models. Results: Analyses included 1,562 ovarian cancer patients. Mean distance to gynecologic oncology was 60.8 miles, and median survival was 23 months. Unadjusted models showed increased distance from gynecologic oncology had progressively greater risk of death 30-49 miles (hazard ratio [HR] = 1.09, confidence interval [CI]: 1.04-1.15), 50-69 miles (HR = 1.19, CI: 1.07-1.32), 70+ miles (HR = 1.30, CI: 1.11-1.51). In adjusted models, association of distance to gynecologic oncology with risk of death was not significant; however, more advanced cancer stage and age, unmarried status, and higher county-level poverty were independently associated with increased risk of death. Conclusions: Above and beyond demographics and stage, distance to gynecologic oncology care was not an independent predictor of ovarian cancer survival. Further studies are needed to determine how to mitigate the factors contributing to worsened ovarian cancer survival among rural patients.

Case Report: Biologic graft placement with subsequent radiation therapy following radical vulvectomy for adenoid cystic carcinoma of the Bartholin's gland.

Adenoid cystic carcinoma (ACC) of the Bartholins gland, first described by Klob in 1864, is a rare form of vulvar cancer comprising approximately 2-7% of all invasive vulvar lesions (Cardosi, 2001). Treatment consists of excision followed by radiation therapy (Cardosi, 2001; Anaf, 1999; Barcellini, 2020). Progression is indolent with later recurrence and metastases in comparison to other forms of vulvar cancer (Yang, 2006). Resection remains the gold standard for treatment followed by radiation therapy if margins are positive (Cardosi, 2001; Yang, 2006; Chang et al., 2019). We present a case of ACC of the Bartholins gland that underwent radical vulvectomy and Surgisis graft placement due to the extent of disease resection. Radiation therapy was then pursued due to positive margins with no wound breakdown despite this being the most common complication of vulvectomy with or without radiation therapy (Leminen et al., 2000). To our knowledge this is only the second case of Cook Biodesign graft placement after vulvectomy and first case of subsequent local radiation therapy to the area.