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1.
Gynecol Oncol ; 187: 192-197, 2024 May 24.
Article in English | MEDLINE | ID: mdl-38795507

ABSTRACT

OBJECTIVES: The incidence of venous thromboembolism (VTE) following radical surgery for vulvar carcinoma remains poorly characterized, and recommendations for postoperative chemoprophylaxis are varied. Our objective was to assess the incidence of postoperative VTE in patients undergoing surgery for vulvar carcinoma and to determine if VTE incidence differs by radical vulvectomy with or without lymph node assessment. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients with a diagnosis of vulvar cancer undergoing radical vulvectomy with or without lymph node assessment from 2012 to 2020. Clinical characteristics and 30-day incidence of VTE as well as other postoperative outcomes were abstracted. Variables were compared using Chi-square test and Fischer's exact test, as well as Kruskal-Wallis and Wilcoxon rank sum tests where appropriate. RESULTS: A total of 1672 patients underwent radical vulvectomy for vulvar carcinoma. 11 patients (0.7%) experienced postoperative VTE within 30 days of surgery. The incidence of VTE was similar when radical vulvectomy was performed alone or with lymph node dissection by any method (p = 0.116). Longer operative times (p = 0.033) and greater postoperative length of stay (p = 0.001) were associated with increased risk of postoperative VTE. CONCLUSIONS: The incidence of postoperative VTE is low in patients undergoing radical vulvar surgery in this national cohort. Inguinofemoral lymph node dissection by any method does not appear to be a risk factor for VTE when compared to radical vulvectomy alone. Further research is needed to determine if extended VTE prophylaxis is beneficial in this population.

2.
J Natl Compr Canc Netw ; 22(2): 91-97, 2024 02 16.
Article in English | MEDLINE | ID: mdl-38364368

ABSTRACT

BACKGROUND: Distress among gynecologic oncology patients correlates with poor clinical outcomes and decreased quality of life. The purpose of this study was to determine risk factors for elevated NCCN Distress Thermometer (DT) results among postoperative gynecologic oncology patients. PATIENTS AND METHODS: We performed a retrospective chart review of all postoperative visits over a 5-year period. NCCN DT results were analyzed as both discretized values (DT ≤3 = low distress; DT 4-8 = moderate distress; DT ≥9 = high distress) and continuous variables. Patients with a DT score ≥4 were referred to social work. Univariate and multivariate regression analyses were performed to compare NCCN DT results with clinical and sociodemographic variables. Statistical significance was P<.05. RESULTS: In total, 1,795 NCCN DT results were included, with uterine (37.72%) being the most common disease site. Benign pathology was known prior to completion of the NCCN DT in 13.15% of patients. Most patients (71.75%) endorsed low levels of distress. Moderate/High levels of distress were reported by 28.25% of patients. Increasing levels of distress were significantly associated with younger age (P=.006), history of depression (P≤.001), status as a current smoker (P=.028), and history of asthma (P=.041). Knowledge of benign pathology was associated with low levels of distress (P=.002). Procedure type and disease site were not associated with distress. CONCLUSIONS: More than one-fourth of postoperative patients in a gynecologic oncology practice reported moderate or high distress. Distress was highest among those with malignancy regardless of disease site or surgical intervention. Benign pathology correlated with decreased distress. Identified associations with distress provide opportunities for prevention, early intervention, and tailored counseling.


Subject(s)
Genital Neoplasms, Female , Neoplasms , Humans , Female , Genital Neoplasms, Female/surgery , Genital Neoplasms, Female/complications , Retrospective Studies , Quality of Life , Stress, Psychological/epidemiology , Stress, Psychological/etiology , Stress, Psychological/psychology , Neoplasms/complications , Risk Factors , Surveys and Questionnaires
3.
Radiology ; 307(5): e223281, 2023 06.
Article in English | MEDLINE | ID: mdl-37158725

ABSTRACT

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.


Subject(s)
Adnexal Diseases , Ovarian Neoplasms , Female , Humans , Adnexal Diseases/diagnostic imaging , Adnexal Diseases/pathology , Ovarian Neoplasms/diagnostic imaging , Predictive Value of Tests , Magnetic Resonance Imaging/methods , Sensitivity and Specificity , Ultrasonography/methods
4.
Int J Gynecol Cancer ; 2023 Dec 07.
Article in English | MEDLINE | ID: mdl-38088182

ABSTRACT

OBJECTIVE: The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. METHODS: Patients with SLNs-isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan-Meier methods. RESULTS: 494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs-isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1-3.0) and 2.6 years (IQR 0.6-4.2) in the SLN-isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN-isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. CONCLUSIONS: Patients with SLNs-isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs-isolated tumor cells was not associated with worse overall survival.

5.
Eur Radiol ; 32(5): 3220-3235, 2022 May.
Article in English | MEDLINE | ID: mdl-34846566

ABSTRACT

OBJECTIVES: Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging. METHODS: Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms. RESULTS: An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific. CONCLUSIONS: This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging. KEY POINTS: • This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.


Subject(s)
Ovarian Neoplasms , Female , Humans , Magnetic Resonance Imaging/methods , Magnetic Resonance Spectroscopy , Ovarian Neoplasms/diagnostic imaging , Tomography, X-Ray Computed
6.
Gynecol Oncol ; 162(3): 751-755, 2021 09.
Article in English | MEDLINE | ID: mdl-34148718

ABSTRACT

OBJECTIVES: Minimally invasive surgery (MIS) is increasingly utilized for gynecologic cancers. While incidence of venous thromboembolism (VTE) after MIS is low, some guidelines recommend extended chemoprophylaxis for these patients undergoing MIS. Our objectives were to determine incidence of postoperative VTE in patients undergoing MIS, evaluate differences in the incidence by MIS modality and assess the need for extended chemoprophylaxis. METHODS: We conducted a retrospective cohort study including all patients undergoing MIS (robot-assisted, multi-port laparoscopy, single-port laparoscopy) for gynecologic cancers between January 2014 and December 2018 at our institution. Demographic and perioperative variables were collected. Patients <18 years, with benign pathology, or on preoperative anticoagulation were excluded. Chi-square, Fisher's exact test, and one-way ANOVA were performed to determine risk factors related to VTE occurrence. RESULTS: We identified 806 patients who underwent MIS with median age 61. Most had Stage I disease (81.5%) and uterine cancer (81.5%). Five VTE events occurred within 90 days following surgery (0.6%). Incidence of 90-day VTE did not differ between MIS modalities (p = 0.6). Patients with longer OR times (p = 0.004) were more likely to experience VTE. Age, smoking status, BMI, type of cancer and stage were not significant risk factors for VTE. CONCLUSIONS: The incidence of postoperative VTE in patients with gynecologic cancers undergoing MIS is low and does not appear to differ by MIS modality. Given the very low incidence of postoperative VTE, extended chemoprophylaxis is unlikely to benefit patients with gynecologic malignancies undergoing MIS procedures.


Subject(s)
Minimally Invasive Surgical Procedures/adverse effects , Ovarian Neoplasms/surgery , Uterine Cervical Neoplasms/surgery , Venous Thromboembolism/epidemiology , Aged , Female , Humans , Middle Aged , Minimally Invasive Surgical Procedures/statistics & numerical data , Ovarian Neoplasms/epidemiology , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective Studies , Uterine Cervical Neoplasms/epidemiology , Venous Thromboembolism/etiology
7.
Gynecol Oncol ; 162(3): 590-598, 2021 09.
Article in English | MEDLINE | ID: mdl-34274133

ABSTRACT

OBJECTIVE: To assess oncologic outcomes in endometrial cancer patients with low-volume metastasis (LVM) in the sentinel lymph nodes (SLNs). METHODS: Patients with endometrial cancer and SLN-LVM (≤2 mm) from December 3, 2009, to December 31, 2018, were retrospectively identified from 22 centers worldwide. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV, adnexal involvement, or unknown adjuvant therapy (ATx) were excluded. RESULTS: Of 247 patients included, 132 had isolated tumor cell (ITC) and 115 had micrometastasis (MM). Overall 4-year recurrence-free survival (RFS) was 77.6% (95% CI, 70.2%-85.9%); median follow-up for patients without recurrence was 29.6 (interquartile range, 19.2-41.5) months. At multivariate analysis, Non-endometrioid (NE) (HR, 5.00; 95% CI, 2.50-9.99; P < .001), lymphovascular space invasion (LVSI) (HR, 3.26; 95% CI, 1.45-7.31; P = .004), and uterine serosal invasion (USI) (HR, 3.70; 95% CI, 1.44-9.54; P = .007) were independent predictors of recurrence. Among 47 endometrioid ITC patients without ATx, 4-year RFS was 82.6% (95% CI, 70.1%-97.2). Considering 18 ITC patients with endometrioid grade 1 disease, without LVSI, USI, or ATx, only 1 had recurrence (median follow-up, 24.8 months). CONCLUSIONS: In patients with SLN-LVM, NE, LVSI, and USI were independent risk factors for recurrence. Patients with any risk factor had poor prognosis, even when receiving ATx. Patients with ITC and grade 1 endometrioid disease (no LVSI/USI) had favorable prognosis, even without ATx. Further analysis (with more patients and longer follow-up) is needed to assess whether ATx can be withheld in this low-risk subgroup.


Subject(s)
Endometrial Neoplasms/pathology , Endometrial Neoplasms/therapy , Neoplasm Recurrence, Local/pathology , Sentinel Lymph Node/pathology , Aged , Carcinoma, Endometrioid/pathology , Carcinoma, Endometrioid/therapy , Female , Humans , Lymphatic Metastasis , Middle Aged , Neoplasm Staging , Treatment Outcome
8.
J Minim Invasive Gynecol ; 26(4): 727-732, 2019.
Article in English | MEDLINE | ID: mdl-30138740

ABSTRACT

STUDY OBJECTIVE: We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions. DESIGN: Retrospective multi-institution cohort (Canadian Task Force classification II-2). SETTING: Three tertiary cancer referral cancer centers. PATIENTS: Patients with endometrial and vulvar cancer undergoing lymph node evaluation. INTERVENTIONS: Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment. MEASUREMENTS AND MAIN RESULTS: Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins. CONCLUSIONS: Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.


Subject(s)
Genital Neoplasms, Female/diagnosis , Genital Neoplasms, Female/surgery , Gynecologic Surgical Procedures/education , Sentinel Lymph Node Biopsy/methods , Surgeons , Surgical Oncology/education , Abdomen/pathology , Endometrial Neoplasms/diagnosis , Endometrial Neoplasms/pathology , Endometrial Neoplasms/surgery , Female , Genital Neoplasms, Female/pathology , Humans , Lymph Node Excision/methods , Lymph Nodes/pathology , Pelvis/pathology , Retrospective Studies , Sentinel Lymph Node/pathology , Vulvar Neoplasms/pathology , Workload
9.
Gynecol Oncol ; 148(1): 28-35, 2018 01.
Article in English | MEDLINE | ID: mdl-29221835

ABSTRACT

OBJECTIVE: We sought to compare the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey responses of women who underwent gynecologic surgery at our institution across patient factors and surgical approach. METHODS: We identified patients with returned HCAHPS surveys following an inpatient laparoscopic surgery or laparotomy in gynecologic surgery from 10/1/2012-9/30/2015. Exclusions included patient age<18years, discharge by a service other than Gynecologic Surgery, or refusal of Minnesota research authorization. HCAHPS composite measures were calculated using published top-box and summary star rating methodologies and dichotomized as "high" versus "low." Chi-square, Fisher's exact, and Wilcoxon rank sum tests, and multivariable logistic regression were performed. RESULTS: Of 403 women who met inclusion criteria, 109 (27%) underwent laparoscopic surgery (19% laparoscopic hysterectomy and 8% other laparoscopic procedures) and 294 (73%) laparotomy (28% open hysterectomy and 47% other open procedures). Length of stay (LOS) was longer for laparotomy cases vs. laparoscopy cases (median 2.5days following open hysterectomy and 4days following other open procedures vs 1day following laparoscopic hysterectomy and other laparoscopic procedures, p<0.001). Patients who underwent laparotomy other than hysterectomy were more likely to have low summary scores (79% vs 66% laparoscopic hysterectomy, 66% open hysterectomy, and 52% other laparoscopic procedures, p=0.005). After adjustment, non-hysterectomy laparotomy cases were more likely to have a low summary score than non-hysterectomy laparoscopy (OR 3.86, 95% CI 1.71-8.68, p=0.001). This significance did not remain after further adjusting for LOS. CONCLUSION: In Gynecologic Surgery, patients undergoing laparotomy gave lower hospital ratings compared to laparoscopy. Those with longer LOS reported poorer patient experience, which is the driving variable for lower scores. In the future, it may be necessary to adjust for surgical approach when reporting patient experience scoring.


Subject(s)
Genital Neoplasms, Female/surgery , Gynecologic Surgical Procedures/methods , Gynecologic Surgical Procedures/statistics & numerical data , Health Care Surveys/statistics & numerical data , Patient Outcome Assessment , Patient Satisfaction/statistics & numerical data , Female , Humans , Laparoscopy/methods , Laparoscopy/statistics & numerical data , Laparotomy/methods , Laparotomy/statistics & numerical data , Middle Aged , Quality Indicators, Health Care
10.
Gynecol Oncol ; 145(1): 21-26, 2017 04.
Article in English | MEDLINE | ID: mdl-28159407

ABSTRACT

OBJECTIVE: We sought to determine survival associated with residual disease (RD) after primary debulking surgery (PDS) for advanced ovarian cancer (OC), and evaluate impact on complications and survival after practice changes to improve PDS. METHODS: Outcome variables were collected for patients undergoing PDS for FIGO (2009) stage IIIC OC from 2003 to 2011. The cohort was divided into time periods (2003-2006 vs. 2007-2011), before and after cytoreduction standardization. RD categories were: RD0, RD 0.1-0.5cm, RD 0.6-1.0cm, and RD>1cm. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. RESULTS: 447 patients (mean age, 65.3years) met inclusion criteria. RD for the entire cohort: RD0=44.5%; RD 0.1-0.5cm=30.9%; RD 0.6-1.0cm=11.4%; and RD>1cm=13.2%, with median OS of 58months, 35months, 29months, and 22months, respectively. OS was significantly better for RD0 vs. all other RD categories (p≤0.001), and for RD 0.1-1.0cm vs. RD>1cm (p=0.01). RD0 improved from 32.7% to 54.3% (p<0.001), and RD>1cm decreased from 20.3% to 7.3% (p<0.001) when comparing the 2003-2006 (n=202) vs. 2007-2011 (n=245) cohorts. Surgical complexity increased in the latter time period (24.3% vs. 41.2%). 30-day Accordion grade 3-4 morbidity remained consistent (18.8% vs. 20.8%, p=0.60), 30-day mortality decreased (4.5% to 1.2%, p=0.035), and median OS improved from 36 to 40months after cytoreduction standardization. CONCLUSION: Patients with RD0 had longest OS, with survival advantage for RD1 when compared to RD>1cm. These data support PDS to lowest RD even when RD0 cannot be obtained. Practice improvement efforts can increase RD0 rates, improving OS without compromising morbidity.


Subject(s)
Cytoreduction Surgical Procedures , Neoplasms, Cystic, Mucinous, and Serous/surgery , Neoplasms, Glandular and Epithelial/surgery , Ovarian Neoplasms/surgery , Aged , Carcinoma, Ovarian Epithelial , Cohort Studies , Disease-Free Survival , Female , Humans , Kaplan-Meier Estimate , Middle Aged , Neoplasm Staging , Neoplasm, Residual , Neoplasms, Cystic, Mucinous, and Serous/mortality , Neoplasms, Glandular and Epithelial/mortality , Ovarian Neoplasms/mortality , Retrospective Studies , Survival Rate
11.
Gynecol Oncol ; 147(3): 503-508, 2017 12.
Article in English | MEDLINE | ID: mdl-28964622

ABSTRACT

OBJECTIVE: To investigate the association between intraperitoneal (IP) disease dissemination patterns, residual disease (RD), surgical complexity, and molecular subtypes in advanced high-grade serous ovarian cancer (HGSOC). METHODS: 741 patients with operable stage III-IV HGSOC undergoing primary debulking surgery at Mayo Clinic from 1994 to 2011 were categorized into four mutually exclusive IP disease dissemination patterns: upper abdominal (60%), miliary (16%), lower abdominal (15%), and pelvic (9%). Surgical complexity was classified as high, intermediate, or low; RD status was defined as 0, 0.1-0.5, 0.6-1.0, or >1cm; molecular subtype assignments were derived from expression profiling of tumors from 334 patients. RESULTS: Patients with either miliary or upper abdominal dissemination patterns were less likely to achieve RD0 compared to patients with pelvic and lower abdominal dissemination patterns (25% vs. 9% and 62%, each P<0.001) despite higher surgical complexity (39% vs. 6% and 20%, each P<0.001). Among the subset with molecular subtype data, patients with mesenchymal subtype of tumors were more likely to have upper abdominal or miliary dissemination patterns compared to patients with differentiated, proliferative, or immunoreactive subtypes (90% vs. 77%, 70%, 69%, respectively, P<0.05). CONCLUSIONS: IP disease dissemination patterns are associated with RD, surgical complexity, and tumor molecular subtypes. Patients with upper abdominal or miliary dissemination patterns are more likely to have mesenchymal HGSOC and in turn achieve lower rates of complete resection. This provides a plausible model for how the biologic behavior of molecular subtypes is manifest in disease and oncologic outcomes.


Subject(s)
Cystadenocarcinoma, Serous/pathology , Cystadenocarcinoma, Serous/surgery , Ovarian Neoplasms/pathology , Ovarian Neoplasms/surgery , Aged , Female , Humans , Middle Aged , Neoplasm Staging , Neoplasm, Residual , Peritoneal Cavity/pathology
12.
J Natl Compr Canc Netw ; 14(5): 539-50, 2016 05.
Article in English | MEDLINE | ID: mdl-27160232

ABSTRACT

OBJECTIVE: To identify risk factors associated with refusal of recommended chemotherapy and its impact on patients with epithelial ovarian cancer (EOC). METHODS: We identified patients in the National Cancer Data Base diagnosed with EOC from January 1998 to December 2011. Patients who refused chemotherapy were identified and compared with those who received recommended, multiagent chemotherapy. Univariate and multivariable analyses were performed using chi-square test with Bonferroni correction, binary logistic regression, log-rank test, and Cox proportional hazards modeling. The threshold for statistical significance was set at a P value of less than 0.05. RESULTS: From a cohort of 147,713 eligible patients, 2,707 refused chemotherapy. These patients were compared with 92,212 patients who received recommended multiagent chemotherapy. Older age, more medical comorbidities, not having insurance, and later year of diagnosis were directly and significantly associated with chemotherapy refusal when analyzed using multivariable logistic regression. In addition, lower-than-expected facility adherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer, treatment at low-volume center, lower grade, and higher stage were all significantly and independently associated with chemotherapy refusal. Median overall survival of patients who received multiagent chemotherapy was significantly longer than that of those who refused chemotherapy (43 vs 4.8 months; P<.0005). After controlling for known patient, facility, and disease prognostic factors, chemotherapy refusal is significantly associated with increased risk of death. CONCLUSIONS: Refusal of recommended chemotherapy carries significant risk of early death from ovarian cancer. Our data demonstrate that the decision to refuse chemotherapy is multifactorial and, in addition to unalterable factors (eg, stage/grade, age), involves factors that can be changed, including facility type and payor. Efforts at addressing these discrepancies in care can improve compliance with chemotherapy recommendations in the NCCN Guidelines for Ovarian Cancer and outcomes.


Subject(s)
Neoplasms, Glandular and Epithelial/drug therapy , Ovarian Neoplasms/drug therapy , Aged , Carcinoma, Ovarian Epithelial , Female , Humans , Middle Aged , Neoplasms, Glandular and Epithelial/pathology , Ovarian Neoplasms/pathology , Risk Factors , Treatment Outcome , United States
13.
Gynecol Endocrinol ; 30(12): 868-71, 2014.
Article in English | MEDLINE | ID: mdl-25254620

ABSTRACT

While the field of oncofertility raised awareness about fertility concerns in oncology patients, new applications for fertility preservation are emerging, such as transgender medicine. As transgender medicine evolves, the number of individuals seeking gender reassignment hormone therapy is drastically increasing, generating a population of patients with unmet fertility needs and unknown reproductive potential. We present the first case report of a female-to-male (FtM) transgender patient to undergo oocyte cryopreservation before initiating androgen therapy. Our patient is a 17-year-old FtM transgender person undergoing gender transition throughout adolescence with an endocrinologist. The patient wished to complete androgen therapy before starting his first year of college to avoid gender ambiguity. After extensive consultation and psychological assessment, the patient was considered an appropriate candidate and proceeded with oocyte cryopreservation. He underwent baseline fertility testing followed by successful ovarian stimulation and surgical retrieval. We recommend that a discussion of reproductive health concerns and fertility preservation options be incorporated into the comprehensive care of transgender patients.


Subject(s)
Fertility Preservation/methods , Oocyte Retrieval , Ovulation Induction , Sex Reassignment Procedures/methods , Transgender Persons , Adolescent , Cryopreservation , Female , Humans , Male
14.
Obstet Gynecol ; 131(5): 891-898, 2018 05.
Article in English | MEDLINE | ID: mdl-29630007

ABSTRACT

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.


Subject(s)
Blood Transfusion , Endometrial Neoplasms/therapy , Laparotomy , Ovarian Neoplasms/therapy , Patient Care Bundles , Postoperative Complications/prevention & control , Aged , Antifibrinolytic Agents/therapeutic use , Blood Transfusion/methods , Blood Transfusion/standards , Blood Transfusion/statistics & numerical data , Endometrial Neoplasms/pathology , Female , Humans , Laparotomy/adverse effects , Laparotomy/methods , Middle Aged , Neoplasm Staging , Outcome and Process Assessment, Health Care , Ovarian Neoplasms/pathology , Patient Care Bundles/methods , Patient Care Bundles/standards , Retrospective Studies , Tranexamic Acid/therapeutic use , United States/epidemiology
15.
Obstet Gynecol ; 128(3): 467-475, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27500339

ABSTRACT

OBJECTIVE: To compare complications and outcomes after hysterectomy for benign compared with malignant indications in the United States. METHODS: Women who underwent hysterectomy in the United States for either benign or malignant indications from January 2008 to December 2012 were retrospectively identified using the National Surgical Quality Improvement Program database. Patients were excluded if the procedure was not performed for primary gynecologic indications. Appropriate procedures were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. Univariate and multivariable models for complication risk were estimated using logistic regression. RESULTS: We identified 59,525 eligible patients, with 49,331 (82.9%) hysterectomies performed for benign and 10,194 (17.1%) for malignant indications. All complications, including wound complications (2.5% benign compared with 5.5% malignant, P<.001), venous thromboembolism (0.33% compared with 1.7%, P<.001), urinary tract infection (2.7% compared with 3.2%, P=.009), sepsis (0.53% compared with 1.9%, P<.001), blood transfusion (2.6% compared with 11.5%, P<.001), death (0.02% compared with 0.10%, P<.001), unplanned readmission (1.8% compared with 4.5%, P<.001), and returns to the operating room (0.91% compared with 1.4%, P<.001), were significantly more common for malignant hysterectomies. The overall rate of complications for benign cases was 7.9% compared with a rate of 19.4% for malignant hysterectomy. The median operating time for laparoscopy in benign cases was significantly longer than for open or vaginal hysterectomy procedures (127 minutes compared with 105 or 94 minutes, respectively; P<.001). The median operating time in malignant cases was significantly longer than for benign cases (P<.001). CONCLUSION: Hysterectomies performed for gynecologic malignancies are associated with a more than twofold higher complication rate compared with those performed for benign conditions. Minimally invasive surgery is associated with a decreased complication rate compared with open surgery. These data can be used for patient counseling and surgical planning, determining physician and hospital costs of care, and considered when assigning value-based reimbursement.


Subject(s)
Hysterectomy , Patient Care Planning , Postoperative Complications , Uterine Diseases , Uterine Neoplasms , Adult , Female , Humans , Hysterectomy/adverse effects , Hysterectomy/methods , Hysterectomy/statistics & numerical data , Middle Aged , Patient Care Planning/organization & administration , Patient Care Planning/standards , Postoperative Complications/classification , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Quality Improvement , United States/epidemiology , Uterine Diseases/classification , Uterine Diseases/epidemiology , Uterine Diseases/surgery , Uterine Neoplasms/classification , Uterine Neoplasms/epidemiology , Uterine Neoplasms/surgery
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