Vulvar cancer survival by primary treatment modality: A retrospective cohort study.

OBJECTIVE: To compare survival and complications for women with vulvar cancer treated with primary radiation vs surgery. METHODS: Retrospective cohort study of Kaiser Permanente members diagnosed with vulvar squamous cell carcinoma (SCC) between 2008 and 2018 and treated with primary surgery (PS only), surgery with adjuvant radiation (PS + RT), or primary radiation (PRT). Primary outcomes were 1- and 3-year overall (OS) and progression-free (PFS) survival. Multivariable regression adjusted for age, stage, comorbidities, and smoking. RESULTS: We included 201 women: 114 PS only (56.7%), 36 PS + RT (17.9%), and 51 PRT (25.4%). PS only patients had less advanced disease. Crude 1- and 3-year OS were 96.5% and 82.6% for PS only compared to 72.2% and 48.3% for PS + RT and 72.6% and 53.9% for PRT (p < 0.001). There were no statistical differences in hazard of death when controlling for stage and other covariates (PRT vs PS only: aHR 1.35, 95% CI 0.61-2.99; PS + RT vs PS only: aHR 1.28, 95% CI 0.60-2.75; PS + RT vs PRT: aHR 0.95, CI 0.48-1.90). Older age and stage III disease were poor prognostic factors. Risk of lymphedema was elevated with PS + RT (36.1% vs 20.2% for PS only and 9.8% for PRT, p = 0.011). Wound infection was more likely in surgical groups, whereas hospital readmission and blood transfusion were more common with PRT. CONCLUSIONS: Vulvar cancer survival was not statistically different among women treated with primary radiation compared to primary surgery when controlling for stage. Surgery followed by adjuvant radiation demonstrated elevated rates of lymphedema. Primary radiation therapy may be an acceptable alternative to primary surgery in women who are likely to need adjuvant therapy.

Mohs surgery for female genital Paget's disease: a prospective observational trial.

BACKGROUND: Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy. OBJECTIVE: This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease. STUDY DESIGN: We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival. RESULTS: Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99). CONCLUSION: Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.

Cost-effectiveness analysis of margin-controlled surgery for vulvar Paget's disease.

Objectives: To determine the cost of two surgical treatment approaches for vulvar Paget's disease and model the cost-effectiveness considering differences in recurrence and reoperation over time. Methods: We assessed cost-effectiveness between excision guided by Mohs micrographic surgery (MMS-E) and traditional wide local excision (WLE). We examined billing data from patients with vulvar Paget's disease who underwent MMS-E (cases, n = 24, 2018-2022) or WLE (controls, n = 64, 1990-2020). We created typical treatment bundles incorporating physician-administered services and facility costs standardized to Medicare reimbursements in 2022 United States Dollars (USD). The primary measure of effectiveness was disease-free years of life. A secondary analysis estimated quality-adjusted life years (QALY). A Markov model simulated treatment pathways over a 10-year time horizon. Transition probabilities were based on institutional recurrence rates (3-year RR 6.7 % for MMS-E vs 34.1 % for WLE). We used a willingness-to-pay threshold of 100,000 USD per QALY. Results: The cost of a single surgical episode was 34,664 USD for MMS-E and 14,969 USD for WLE. In the setting of lower recurrence rates with MMS-E, the incremental cost was 12,789 USD per disease-free year gained. A secondary analysis incorporating QALY showed an incremental cost of 72,820 USD per QALY. Conclusions: MMS-E appears to be a cost-effective treatment for vulvar Paget's disease compared to historic standard of care. Our ability to estimate quality of life gained by avoiding disease recurrence was limited by scant data for this rare condition; thus, future studies incorporating health utility values are needed to facilitate a more comprehensive analysis.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative.

OBJECTIVE: To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative. METHODS: A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic. RESULTS: Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds. DISCUSSION: A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Factors associated with postpartum readmission for hypertensive disorders of pregnancy.

BACKGROUND: Postpartum readmission has negative implications for patients and health systems. Previous studies suggest that up to 5% of women with hypertensive disorders of pregnancy experience postpartum readmission. Studies examining factors associated with postpartum readmission for hypertension have had small sample sizes and conflicting results. OBJECTIVE: This study aimed to characterize the incidence of and risk factors for postpartum readmission for hypertensive disorders of pregnancy among a cohort of women with preexisting hypertensive disorders of pregnancy. STUDY DESIGN: This was a retrospective cohort study of pregnant women with known hypertensive disorders of pregnancy who delivered live births in a large managed care organization in 2018. The primary outcome was hospital readmission for a hypertensive diagnosis or stroke within 42 days after delivery. The primary exposure of interest was persistent postpartum hypertension, defined as a maximum systolic blood pressure of ≥140 mm Hg or maximum diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge from delivery hospitalization. Continuous and categorical variables were compared using bivariate analysis. Risk factors independently associated with postpartum readmission were identified using multivariable logistic regression. RESULTS: Of 42,022 women who delivered in 2018, 7151 had hypertensive disorders of pregnancy-an incidence of 17%. The rate of postpartum readmission among women with hypertensive disorders of pregnancy was 4.43% (317 of 7151). The following risk factors were associated with increased odds of postpartum readmission in women with hypertensive disorders of pregnancy: systolic blood pressure of ≥140 mm Hg within 24 hours before discharge (adjusted odds ratio, 2.29; 95% confidence interval, 1.71-3.07), diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge (adjusted odds ratio, 1.33; 95% confidence interval, 1.02-1.73), maternal age of ≥30 years (30-34: adjusted odds ratio, 1.57; 95% confidence interval, 1.12-2.19; 35-39: adjusted odds ratio, 2.36; 95% confidence interval, 1.70-3.28; ≥40: adjusted odds ratio, 2.95; 95% confidence interval, 1.95-4.46), receipt of magnesium sulfate (adjusted odds ratio, 1.47; 95% confidence interval, 1.11-1.94), and receipt of inpatient rapid-acting antihypertensive medication (adjusted odds ratio, 1.46; 95% confidence interval, 1.10-1.93). In addition, 1 blood pressure of ≥140/90 mm Hg within 24 hours before discharge increased the odds of readmission (adjusted odds ratio, 1.98; 95% confidence interval, 1.37-2.87). Furthermore, 2 or more elevated blood pressure values further increased the odds (adjusted odds ratio, 3.14; 95% confidence interval, 2.33-4.24). Median postpartum day of readmission was day 5 (interquartile range=3). CONCLUSION: Hospital readmission for postpartum hypertension was associated with persistent postpartum hypertension (blood pressure of ≥140/90 mm Hg), increasing maternal age, and more severe antepartum hypertension. Women with these characteristics may be targeted in future quality initiatives to mitigate readmission.

Treatment of invasive Paget's disease of the vulva in pregnancy: A case report.

•Invasive adenocarcinoma of the vulva arising from extramammary Paget's disease is possible in women of child-bearing age.•Radical vulvectomy, sentinel lymph node biopsy, and inguinal lymphadenectomy are safe and feasible during pregnancy.•Chemotherapy may be used as adjuvant therapy for vulvar adenocarcinoma during pregnancy when radiation is contraindicated.•Primary cesarean delivery may be considered for pregnant women with recent vulvar surgery.•Trastuzumab may be considered for maintenance therapy of Her2/Neu positive vulvar cancer in postpartum women.

Barriers and facilitators to preventive cancer screening in Limited English Proficient (LEP) patients: Physicians' perspectives.

BACKGROUND: Limited English proficient (LEP) patients receive fewer recommended preventive screenings than English-speaking patients. Studies have explored patients' perceptions of the factors that contribute to this disparity, but little research has focused on physicians' perceptions. OBJECTIVE: To describe physicians' perceptions of the barriers and facilitators to preventive cancer screening in LEP patients. DESIGN: Qualitative interview study using a semi-structured interview guide. PARTICIPANTS: Eight primary care physicians from Wisconsin. APPROACH: Each interview was systematically coded to illuminate important themes. KEY RESULTS: A variety of barriers specifically hinder LEP patients' receipt of cancer screening, including poor language proficiency, lack of transportation, unfamiliarity with the concept of prevention, complex scheduling systems, poor interpretation, and limited physician time to discuss preventive care. While physicians identified many factors that facilitate preventive screening in general, they mentioned few that are perceived as specific to LEP patients. CONCLUSION: We found that primary care physicians attribute the low rates of preventive cancer screening among LEP populations to a variety of patient, provider, interpreter, and system factors, most of which go beyond simple language barriers. Interventions designed to reduce these barriers and enhance the impact of identified facilitators should be multifactorial and designed to engage primary care physicians.