Frailty in ovarian cancer identified the need for increased postoperative care requirements following cytoreductive surgery.

OBJECTIVES: We sought to examine the relationship between frailty and complicated postoperative courses, including intensive care unit (ICU) admission and non-home discharge, in patients with advanced ovarian cancer (OC) undergoing primary debulking surgery (PDS) for curative intent. METHODS: Patients were identified from a retrospectively collected database at a single institution between 1/1/2003-12/31/2011. A frailty index was derived from 30 items representing comorbidities and activities of daily living, each scored as 0, 0.5, or 1, and calculated as the total summated score divided by the total number of non-missing items. Frailty was defined as an index ≥0.15. Associations with binary outcomes were assessed using logistic regression. RESULTS: A total of 535 patients met inclusion criteria. Frail patients were older, mean age 67.8 versus 63.2 years (p < 0.001), but there was no difference in grade, stage, or serous histology. Almost half of the frail patients (48.9%, 64/131) were admitted to the ICU compared to 20.5% (83/404) of non-frail patients. Frailty remained an independent predictor of 30-day ICU admission (adjusted odds ratio (aOR) 3.20, 95% CI: 2.03-5.06) in a multivariable model including age, preoperative albumin, surgical complexity, and residual disease. Frail patients were also more likely to have a non-home discharge (24.2% vs. 7.0%). Frailty independently predicted non-home discharge (aOR 2.58, 95% CI: 1.35-4.93) after adjusting for age, BMI, and stage. CONCLUSION: Frailty is a measurable, objective clinical syndrome that has impact on postoperative outcomes in advanced OC and should be considered when decision-making about treatments and counseling patients.

Functional not chronologic age: Frailty index predicts outcomes in advanced ovarian cancer.

OBJECTIVES: To assess the impact of frailty as measured by a frailty deficit index (FI) on outcomes in advanced epithelial ovarian cancer (EOC) after primary debulking surgery (PDS). METHODS: Women with Stage IIIC/IV EOC who underwent PDS between 1/1/2003-12/31/2011 were included. Medical records were reviewed for patient characteristics and outcomes. The FI includes 30 items scored at 0, 0.5 or 1 and is calculated by summing across all the item scores and dividing by the total. Frailty was defined as a FI ≥0.15. Associations were assessed using logistic regression and Cox proportional hazards regression. RESULTS: Of the 535 studied, 78% had stage IIIC disease and mean (SD) age was 64.3 (11.3) years. Median FI was 0.08, and 131 patients (24.5%) were considered frail with FI ≥0.15. Compared to non-frail patients, frail patients were more likely to have an Accordion grade 3+ complication (28.2 vs. 18.8%; odds ratio (OR): 1.70, 95% CI: 1.08-2.68) and more likely to die within 90days of surgery (16.0 vs. 5.2%; OR: 3.48, 95% CI: 1.83-6.61). After adjusting for known risk factors, these associations remained significant, adjusted OR (aOR): 1.62, 95% CI: 1.00-2.62; aOR: 2.60, 95% CI 1.32-5.10; and aOR: 0.57, 95% CI 0.34-0.97, respectively. Overall survival (OS) for the entire cohort was 39.6months (m). OS was shorter in the frail versus non-frail (median 26.5 vs 44.9m, p<0.001). Frailty was independently associated with death (adjusted hazard ratio: 1.52, 95% CI: 1.21-1.92) after adjusting for known risk factors. CONCLUSIONS: Frailty is a common finding in patients with EOC and is independently associated with worse surgical outcomes and poorer OS. Routine assessments of frailty can be incorporated into patient counseling and decision-making for the EOC patient beyond simple reliance on single factors such as age.

Tao brush endometrial cytology is a sensitive diagnostic tool for cancer and hyperplasia among women presenting to clinic with abnormal uterine bleeding.

BACKGROUND: Abnormal uterine bleeding requires the investigation of the endometrium. Histology is typically used but there remains room for the improvement and use of cytology. METHODS: Women presenting for clinically indicated office endometrial biopsy were prospectively enrolled. Tao endometrial brushing and office endometrial biopsy were performed, and surgical procedure if clinically indicated. Tao brush cytology specimens were blindly reviewed by up to three pathologists, consensus obtained, and scored as: benign, atypical (favor benign), suspicious, positive for malignancy, or non-diagnostic. Cytology and histology were compared to surgical pathology to determine sensitivity, specificity, positive, and negative predictive values to detect AH (atypical hyperplasia) or EC (endometrial cancer). RESULTS: Clinical indications of 197 enrolled patients included postmenopausal bleeding (90, 45.7%), abnormal uterine bleeding (94, 47.7%), and abnormal endometrium on ultrasound without bleeding (13, 6.6%). Of the 197 patients, 185 (93.9%) had cytology score consensus and a total of 196 (99.5%) had consensus regarding cytology positivity. Surgical pathology diagnoses (N = 85) were 13 (15.3%) FIGO grade 1 or 2 EC, 3 (3.5%) AH, and 69 (81.2%) benign endometrium. Sensitivity and specificity to detect EC or AH were 93.7% and 100%, respectively, via endometrial biopsy; 87.5% and 63.8%, respectively, via endometrial cytology when scores of malignancy, suspicious, or atypical were considered positive. CONCLUSIONS: In a high-risk population, Tao brush endometrial cytology showed high sensitivity to detect AH and EC comparable to biopsy histology when considering scores of malignancy, suspicious, atypical, and non-diagnostic. Revisiting the potential value of endometrial cytology in the contemporary era of endometrial diagnostic workup is warranted.

Implementation of the "Pregnancy Reasonably Excluded Guide" for Pregnancy Assessment: A Quality Initiative in Outpatient Gynecologic Surgery.

OBJECTIVE: Preoperative evaluation for pregnancy at our institution lacked standardization among individual health care providers and surgical services. This pilot project aimed to improve assessment for pregnancy before scheduled outpatient gynecologic surgical procedures. The Pregnancy Reasonably Excluded Guide incorporates historic, evidence-based criteria to facilitate identification of patients with a higher chance of pregnancy. METHODS: We retrospectively reviewed documentation for women undergoing gynecologic surgery at an outpatient surgical center from March through September 2016, before and after implementation of the pregnancy assessment protocol. After implementation, all eligible women (aged 18-50 years, not undergoing an emergent or pregnancy-related procedure) were assessed using the Pregnancy Reasonably Excluded Guide on arrival to the preoperative area. The Pregnancy Reasonably Excluded Guide checklist uses traditional and World Health Organization criteria for reasonable exclusion of pregnancy. Nursing staff reviewed responses with patients and pregnancy tests were completed as indicated by patient responses. Women who were unable to read, understand, or freely respond to the checklist received pregnancy testing. Pregnancy assessment, testing, results, and delays were recorded. This project was deemed exempt by the institutional review board. RESULTS: Two hundred thirteen eligible patients underwent outpatient gynecologic procedures during the study period (excluding a 2-week washout period at implementation). In the preimplementation period, 93 of 136 patients (68%) had pregnancy risk documented; 73 of 77 (95%) had documentation in the postimplementation period (P≤.01). Pregnancy tests were completed in 45 preimplementation patients (33%) and 16 postimplementation patients (21%) (P=.06). No pregnancy test results were positive. No procedural delays were associated with pregnancy assessment. CONCLUSION: Patient-centered assessment using the Pregnancy Reasonably Excluded Guide at presentation for outpatient gynecologic surgery significantly improved evaluation and documentation of pregnancy status before scheduled procedures without increasing the number of pregnancy tests or causing procedural delays.

Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy.

OBJECTIVE: To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. METHODS: This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. RESULTS: In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. CONCLUSION: Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.