Trends in use of radiation therapy, chemotherapy, and combination chemoradiotherapy in advanced uterine cancer before, during, and after GOG 258.

OBJECTIVE: To explore the use of Gynecologic Oncology Group 258 (GOG 258) study regimens before, during, and after the study. METHODS: Patients aged 18 years or older with endometrial cancer between 2004-2019 were identified in the National Cancer Database. Inclusion criteria were stage III or IVA of any histology and stage I-IVA clear cell or serous histologies with positive washings that received adjuvant therapy. Adjuvant therapy use was examined in the pre-GOG 258 era (before 2009), during GOG 258 enrollment and maturation (2010-2017), and after results presentation in 2017 (2018-2019). Two-sided Cochran-Armitage tests, Wilcoxen rank sum tests, and χ2 tests were used for continuous and categorical variables. Multi-variable logistic regression assessed factors associated with the receipt of chemoradiotherapy compared with chemotherapy only or radiation therapy only. RESULTS: From 2004 to 2019, 41 408 high-risk endometrial cancer patients received adjuvant therapy (12% radiation therapy, 38% chemotherapy, 50% chemoradiotherapy). Chemoradiotherapy increased over the GOG 258 study period (40% before study opening, 54% during enrollment, and 59% after results). Serous (OR 0.6, 95% CI 0.6 to 0.7) and clear cell histology (0.7, 0.6 to 0.8), higher grade (0.8, 0.7 to 0.9), and lymph node positivity (0.8, 0.7 to 0.9) were negatively associated with receipt of chemoradiotherapy compared with single-modality treatment. Non-Hispanic Black ethnicity (0.8, 0.8 to 0.9) and residing ≥50 miles from the treatment facility (0.8, 0.7 to 0.9) were also negatively associated with chemoradiotherapy. Private insurance (1.2, 1.0 to 1.4) and treatment at community hospitals (1.2, 1.2 to 1.3) were positively associated with chemoradiotherapy. CONCLUSION: Despite the lack of benefit in the GOG 258 experimental arm, chemoradiotherapy use increased during study enrollment and after results publication.

The impact of the ban on elective surgery in New York City during the coronavirus outbreak on gynecologic oncology patient care.

Introduction: Elective surgical procedures were suspended during the coronavirus disease pandemic (COVID-19) in New York City (NYC) between March 16 and June 15, 2020. This study characterizes the impact of the ban on surgical delays for patients scheduled for surgery during this first wave of the COVID-19 outbreak. Methods: Patients who were scheduled for surgical treatment of malignant or pre-invasive disease by gynecologic oncologists at three NYC hospitals during NYC's ban on elective surgery were included. Outcomes of interest were the percentage of patients experiencing surgical delay and the nature of delays. Kruskal-Wallis, chi-square, and logistic regression tests were performed with significance set at p < 0.05. Results: Of the 145 patients with malignant or pre-invasive diseases scheduled for surgery during the ban on elective surgery, 40% of patients experienced one or more surgical delays, 10% experienced two or more and 1% experienced three surgical delays. Of patients experiencing an initial delay, 77% were hospital-initiated and 11% were due to known or suspected personal COVID-19. Overall, 81% of patients completed their planned treatment, and 93% of patients underwent their initially planned surgery. Among patients for whom adjuvant therapy was recommended, 67% completed their planned treatment, and the most common reasons for not completing treatment were medically indicated followed by concerns regarding COVID-19. Conclusion: During the ban on elective surgery in NYC during the first outbreak of the COVID-19 pandemic, many patients experienced minor surgical delays, but most patients obtained appropriate, timely care with either surgery or alternative treatment.

Qualitative analysis of gynecologic oncology patients' experience with treatment holidays.

OBJECTIVE: Patients with advanced or recurrent gynecologic malignancies occasionally take breaks from systemic treatment colloquially referred to as "treatment holidays" or "chemotherapy holidays." There are no data from the patient perspective that help describe this experience. METHODS: Patients with recurrent or advanced primary gynecologic malignancies who had decided to enter a treatment holiday were recruited and interviewed. A treatment holiday was defined as a planned temporary break or delay in treatment for a patient with recurrent or advanced primary gynecologic malignancy for reasons other than pursuit of hospice or best supportive care, research protocol violation or unacceptable toxicity. Interviews were audiotaped, transcribed and then analyzed using an inductive thematic analysis. RESULTS: Of 6 total patients identified for participation, 5 completed interviews with ages ranging from 57 to 80 years. Two participants returned to their previous treatment regimen after their holiday therapy, two switched therapies, and one remained on an extended break from systemic treatment. Treatment holidays were experienced as a break from the physical and psychological routine of being a cancer patient, but also brought about feelings of a lack of structure, uncertainty, and led to a confrontation with mortality issues. Overall, participants had favorable experiences which were initiated by their providers in whom they had a deep sense of trust. CONCLUSION: Patients experience treatment holidays as a positive and valuable break from the physical and psychosocial routine of cancer treatment and illness. These experiences produce distinct emotional needs that clinicians should address to best support patients electing treatment holidays.

Enhanced recovery Pathways in gynecologic surgery: Are they safe and effective in the elderly?

OBJECTIVE: To compare perioperative outcomes of the elderly versus non-elderly patients on ERPs undergoing laparotomy for gynecologic surgery. METHODS: From January 2016 to June 2017, patients undergoing elective laparotomies for gynecologic surgery were enrolled in a perioperative ERP protocol. Outcomes were compared between the elderly (age ≥ 70 years) and the non-elderly (age ≤ 69 years). Primary outcomes were length of stay and perioperative complication rates. Comparisons were performed using chi-squared tests or Fisher's exact tests for categorical data and Student's t-test or Wilcoxon rank-sum tests for continuous variables, with p < 0.05 for significance. RESULTS: One hundred eighty-nine patients were enrolled in the study, including 16 patients ≥ 70 years old. The median age was 75 years for the elderly and 45 years for the non-elderly. Elderly patients were more likely to have more complex surgery and longer operative times (absolute median difference of 39 min). Despite the increasing complexity of surgical procedures for elderly patients, there were no statistically significant differences in serious inpatient complications (Clavien-Dindo score 3A or greater), pain and nausea scores, 30-day complications and readmission rates. Elderly patients had a longer median length of stay compared to non-elderly patients by one day (p < 0.001), however, this was not statistically significant on multivariate analysis. CONCLUSION: In our series, elderly patients on the ERP had similar rates of complications and readmission when compared to non-elderly patients, despite undergoing more complex surgeries. This suggests that ERP may be feasible and safe in the elderly population undergoing elective gynecologic laparotomy.

Ultrasound and Histopathologic Correlation of Ovarian Cystadenofibromas: Diagnostic Value of the "Shadow Sign".

OBJECTIVES: Cystadenofibromas (CAFs) are rare benign ovarian tumors without a widely accepted ultrasound (US) pattern. They are usually described by as thin-walled, unilocular or multilocular, and at times septated cysts with scant blood flow and no solid components. We describe a unique US feature, the "shadow sign," seen in prospectively diagnosed benign CAFs. We also provide the histopathologic basis for this typical US appearance. METHODS: Ultrasound (US) examinations were performed in our obstetric and gynecologic US unit. Pathologic examinations were performed by a dedicated gynecologic pathology team. The US and pathology department's database was searched for the diagnosis of a CAF between 2010 and 2017. RESULTS: We identified 20 patients who underwent transvaginal US examinations with a sole US diagnosis of a CAF, and the tumors were surgically removed. The common US feature across the 20 cases was the presence of hyperechoic avascular shadowing nodules. The correlating histologic features were unilocular or multilocular cysts with a smooth internal wall surface lined by a simple epithelium and occasional robust polypoid fibrous stroma. CONCLUSIONS: This US marker helps in differentiating CAFs from borderline ovarian tumors, which do not show this US feature. We hope that recognizing the suggested shadow sign as an additional descriptor of CAFs will lead to minimizing their unnecessary removal and eliminating additional and unnecessary imaging by computed tomography and magnetic resonance imaging.

Carboplatin/Paclitaxel Induction in Ovarian Cancer: The Finer Points.

The carboplatin/paclitaxel doublet remains the chemotherapy backbone for the initial treatment of ovarian cancer. This two-drug regimen, with carboplatin dosed using the Calvert formula, yielded convincing noninferior outcomes when compared with the prior, more toxic, regimen of cisplatin/paclitaxel. Carboplatin's dose-limiting toxicity is thrombocytopenia; however, when this drug is properly dosed and combined with paclitaxel, the doublet's cycle 1 dose in chemotherapy-naive women is generally safe. Carboplatin (unlike cisplatin) contributes minimally to the cumulative sensory neuropathy of paclitaxel, thus ensuring noticeable reversibility of neuropathy symptoms following completion of 6 cycles and only occasionally requiring cessation or substitution of the taxane. Paclitaxel is responsible for the hair loss associated with the carboplatin/paclitaxel doublet; preventive measures must be considered for patients who would otherwise refuse treatment. Several first-line phase III trials, as well as ongoing trials for which only preliminary results have been published, have fueled debates on the optimal dose and schedule; these have focused not only on weekly vs q3-weeks paclitaxel, but also on other modifications and the advisability of adding bevacizumab. Our view is that results of this doublet in the first-line treatment of ovarian cancer are driven primarily by carboplatin, given that ovarian cancer is a platinum-sensitive disease. Consequently, the roles of the accompanying paclitaxel dose and schedule and the addition of bevacizumab are currently unsettled, and questions regarding these issues should be decided based on patient tolerance and comorbidities until additional data are available.

Timing is everything: intraperitoneal chemotherapy after primary or interval debulking surgery for advanced ovarian cancer.

PURPOSE: To evaluate the outcomes of intraperitoneal chemotherapy (IP) compared with those of intravenous chemotherapy (IV) in patients with advanced ovarian cancer after neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) or primary debulking surgery (PDS). METHODS: Patients with advanced epithelial ovarian carcinoma treated with PDS or NACT and IDS from 2006 to 2015 were identified. Comparative statistics were used to evaluate covariates, and survival rates were calculated using the Kaplan-Meier method and compared with log-rank tests. RESULTS: Sixty-six patients received NACT followed by IDS with residual disease of ≤ 1 cm; 42 of these patients (63.6%) received IP therapy; and 24 patients (36.3%) had IV therapy only after IDS. The median progression-free survival (PFS) was 16.0 months in the IP group and 13.5 months in the IV group (p = 0.13). The estimated median overall survival (OS) was 64.0 months with IP and 50.0 months with IV (p = 0.44). During the same study period, 149 patients underwent optimal PDS after which 93 patients (62.4%) received IP and 56 patients (37.6%) were given IV chemotherapy. Patients after IP demonstrated improved survival outcomes when compared to patients after IV therapy. The median PFS was 28.0 months after IP and 16.5 months after IV (p = 0.0006), and the median OS was not reached for IP and 50.0 months after IV (p < 0.0001). CONCLUSIONS: Although IP chemotherapy after PDS is associated with improved survival, IP therapy after NACT and IDS, despite high rates of completion, may not have the same degree of survival advantage over IV therapy.

Laparoscopy decreases the disparity in postoperative complications between black and white women after hysterectomy for endometrial cancer.

OBJECTIVES: Black race has been associated with increased 30-day morbidity and mortality following surgery for endometrial cancer. Black women are also less likely to undergo laparoscopy when compared to white women. With the development of improved laparoscopic techniques and equipment, including the robotic platform, we sought to evaluate whether there has been a change in surgical approach for black women, and in turn, improvement in perioperative outcomes. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2010 to 2015 were identified. Comparative analyses stratified by race and hysterectomy approach were performed to assess the relationship between race and perioperative outcomes. RESULTS: A total of 17,692 patients were identified: of these, 13,720 (77.5%) were white and 1553 (8.8%) were black. Black women were less likely to undergo laparoscopic hysterectomy compared to white women (49.3% vs 71.3%, p<0.0001). Rates of laparoscopy in both races increased over the 6-year period; however these consistently remained lower in black women each year. Black women had higher 30-day postoperative complication rates compared to white women (22.5% vs 13.6%, p<0.0001). When laparoscopic hysterectomies were isolated, there was no difference in postoperative complication rates between black and white women (9.2% vs 7.5%, p=0.1). CONCLUSIONS: Overall black women incur more postoperative complications compared to white women undergoing hysterectomy for endometrial cancer. However, laparoscopy may mitigate this disparity. Efforts should be made to maximize the utilization of minimally invasive surgery for the surgical management of endometrial cancer.

Society of Gynecologic Oncology Future of Physician Payment Reform Task Force report: The Endometrial Cancer Alternative Payment Model (ECAP).

Health care in the United States is in the midst of a significant transformation from a "fee for service" to a "fee for value" based model. The Medicare Access and CHIP Reauthorization Act of 2015 has only accelerated this transition. Anticipating these reforms, the Society of Gynecologic Oncology developed the Future of Physician Payment Reform Task Force (PPRTF) in 2015 to develop strategies to ensure fair value based reimbursement policies for gynecologic cancer care. The PPRTF elected as a first task to develop an Alternative Payment Model for thesurgical management of low risk endometrial cancer. The history, rationale, and conceptual framework for the development of an Endometrial Cancer Alternative Payment Model are described in this white paper, as well as directions forfuture efforts.

"Best practices in risk reducing bilateral salpingo-oophorectomy: the influence of surgical specialty".

BACKGROUND: Risk-reducing bilateral salpingo-oophorectomy (RRBSO) increases survival in patients at high risk of developing ovarian cancer. While many general gynecologists perform this procedure, some argue it should be performed exclusively by specialists. In this retrospective observational study, we identified how often optimal techniques were used and whether surgeons' training impacted implementation. METHODS: We used the ACOG guidelines highlighting various aspects of the procedure to determine which elements were consistent with best practices to maximize surgical prophylaxis. All cases of RRBSO from 2006 to 2010 were identified. We abstracted data from the operative and pathology reports to review the techniques employed. Fisher's exact test and chi-square were utilized to compare differences between groups (InStat, La Jolla, CA). RESULTS: Among 263 RRBSOs, 22 were performed by general gynecologists and 241 by gynecologic oncologists. Gynecologic oncologists were more likely to perform pelvic washings-217/241 vs. 10/22 (p < .0001). They were more likely to include a description of the upper abdomen-220/241 vs. 12/22 (p < .0001). Oncologists were more likely to utilize a retroperitoneal approach to skeletonize the infundibulopelvic ligaments-157/241 vs. 3/22 (p < .0001). When operations were performed by oncologists, the specimens were more often completely sectioned-217/241 vs. 16/22 (p = .003). The use of a retroperitoneal approach among gynecologic oncologists increased over the study period (chi-square for trend, p < .0001). There was no visible trend in performance improvement in any other area when looking at either group. CONCLUSION: Gynecologic oncologists are more likely to adhere to best practice techniques when performing RRBSO, though there was room for improvement for both groups.

Adjuvant Human Papillomavirus Vaccination for Secondary Prevention: A Systematic Review.

Importance: Human papillomavirus (HPV) vaccination is recommended for children and younger adults but not older adults or those with prior HPV exposure, leaving a large portion of the population at risk for HPV-mediated disease. Emerging data suggest a possible role for vaccination as an adjuvant treatment for individuals with HPV-related clinical disease. Objective: To systematically review the literature regarding HPV vaccination for secondary disease prevention after treatment of active clinical disease across disease sites to serve as a platform for the management of HPV-related disease of the head and neck. Evidence Review: A systematic search from August 3 to 21, 2015, of the PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science, Biosis Citation Index, Current Contents Connect, Scientific Library Online, and Global Health databases used PRISMA guidelines to identify 326 relevant articles related to adjuvant use of HPV vaccination. Primary search terms were (HPV vaccine OR human papillomavirus vaccine OR papillomarvirus vaccines OR alphapapillomavirus vaccine) AND (HPV OR human papillomavirus OR alphapapillomavirus OR papillomaviridae OR virus warts OR wart virus) AND (recurrence OR relapse OR reoccurrence OR recurrences OR relapses OR relapsing). Forty-five full texts in English were reviewed, with 19 articles included in the final review. In some studies, subpopulations of individuals with HPV DNA positivity and/or seropositivity were extracted for inclusion. Included studies were assessed for bias and separated based on the presence of active clinical disease or HPV DNA positivity or seropositivity. Findings: Nineteen studies with 22 474 unique patients were included in the review. When HPV vaccination was used as an adjuvant treatment for active clinical disease, 9 of 12 studies reported decreased disease recurrence, decreased disease burden, or increased intersurgical interval. In contrast, none of the 7 studies of vaccination in individuals with HPV DNA positivity and/or seropositivity without clinical disease reported improved outcomes. Conclusions and Relevance: Differences between adjuvant vaccination in HPV-mediated clinical disease and vaccination in HPV DNA-positive and/or HPV-seropositive populations posit underlying differences in disease and immune processes. These data suggest that additional evaluation of adjuvant HPV vaccination in individuals with active clinical disease is warranted.

Uterine Sarcomas: The Latest Approaches for These Rare but Potentially Deadly Tumors.

Uterine sarcomas are rare malignant uterine neoplasms that are responsible for a large majority of uterine cancer-associated deaths. The subtypes include leiomyosarcomas, endometrial stromal tumors, and adenosarcomas. Standard treatment includes complete surgical resection. Adjuvant treatment with chemotherapy, hormonal therapy, or radiation may be considered in patients with high-risk disease. However, because the ability of adjuvant treatment to improve overall survival in patients with uterine sarcomas is unclear, there is no standard recommendation regarding adjuvant therapy. The risk in forgoing chemotherapy is that uterine sarcomas have a tendency to develop distant recurrences. Many cytotoxic agents have been investigated in clinical trials in an attempt to identify an effective treatment that can improve the course of this disease. Adjuvant radiation appears to improve local control but has no significant impact on survival. In this review we discuss preoperative diagnosis and the role of pathology, and we summarize the current literature regarding the management of uterine sarcomas.

The safety of same-day discharge after laparoscopic hysterectomy for endometrial cancer.

OBJECTIVE: To determine factors influencing discharge patterns after laparoscopic hysterectomy for endometrial cancer and to evaluate the safety of same-day discharge during the 30-day postoperative period. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2010 to 2014 were identified and categorized by their hospital length of stay. Statistical analyses were performed to assess the relationship between hospital stay and demographics, medical comorbidities, intraoperative surgical factors and postoperative outcomes. RESULTS: A total of 9020 patients had laparoscopic hysterectomies for endometrial cancer and of these, 729 patients (8.1%) were successfully discharged on the day of surgery. These patients were younger and had lower body mass indexes and fewer medical comorbidities than patients who were admitted after their procedure. The same-day discharge group underwent surgical procedures of less complexity than the hospital admission group based on shorter operative times and fewer relative value units (RVUs). There was a lower rate of surgical site infections in the same-day discharge group, and no difference in rates of other postoperative complications including hospital readmissions and reoperations. CONCLUSIONS: Rates of laparoscopic hysterectomy for endometrial cancer are gradually increasing but the rates of same-day discharge have increased at a much slower rate. Same-day discharge has been successful despite differences in preoperative demographics, medical comorbidities and intraoperative surgical complexity. Overall postoperative complication rates were equivalent despite length of hospital stay, demonstrating the safety and feasibility of same-day discharge after laparoscopic hysterectomy for endometrial cancer.

Preoperative experience for public hospital patients with gynecologic cancer: Do structural barriers widen the gap?

BACKGROUND: Widespread disparities in care have been documented in women with gynecologic cancer in the United States. This study was designed to determine whether structural barriers to optimal care were present during the preoperative period for patients with gynecologic cancer. METHODS: A retrospective review was conducted for patients undergoing surgery for a gynecologic malignancy at a public hospital or a private hospital staffed by the same team of gynecologic oncologists between July 1, 2013 and July 1, 2014. RESULTS: Two hundred fifty-seven cases were included for analysis (public hospital, 69; private hospital, 188). Patients treated at the private hospital were older (58 vs 52 years; P = .004) and had similar medical comorbidities (median Charlson comorbidity index at both hospitals, 6) but required fewer hospital visits in preparation for surgery (2 vs 4; P < .001). Public hospital patients had a longer wait time from the diagnosis of disease to surgery (63 vs 34 days; P < .001). According to a multiple linear regression model, the public hospital setting was associated with a longer interval from diagnosis to surgery with adjustments for the insurance status, age at diagnosis, cancer stage, and number of preoperative hospital visits (P < .001). CONCLUSIONS: Patients at the public hospital were subject to a greater number of preoperative visits and had to wait longer for surgery than patients at the private hospital. Attempts to reduce health care disparities should focus on improving efficiency in health care delivery systems once contact has been established.

A prospective comparison of postoperative pain and quality of life in robotic assisted vs conventional laparoscopic gynecologic surgery.

OBJECTIVE: We sought to compare robotic vs laparoscopic surgery in regards to patient reported postoperative pain and quality of life. STUDY DESIGN: This was a prospective study of patients who presented for treatment of a new gynecologic disease requiring minimally invasive surgical intervention. All subjects were asked to take the validated Brief Pain Inventory-Short Form at 3 time points to assess pain and its effect on quality of life. Statistical analyses were performed using Pearson x(2) and Student's t test. RESULTS: One hundred eleven were included in the analysis of which 56 patients underwent robotic assisted surgery and 55 patients underwent laparoscopic surgery. There was no difference in postoperative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. There was a statistically significant difference found at the delayed postoperative period when evaluating interference of sleep, favoring laparoscopy (ROB 2.0 vs LSC 1.0; P = .03). There were no differences found between the robotic and laparoscopic groups of patients receiving narcotics (56 vs 53, P = .24, respectively), route of administration of narcotics (47 vs 45, P > .99, respectively), or administration of nonsteroidal antiinflammatory medications (27 vs 21, P = .33, respectively). CONCLUSION: Our results demonstrate no difference in postoperative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. Furthermore, pain did not appear to interfere consistently with any daily activity of living. Interference of sleep needs to be further evaluated after controlling for bilateral salpingo-oophorectomy.

Trends in bilateral oophorectomy at the time of hysterectomy for benign disease.

OBJECTIVE: To identify patient characteristics associated with bilateral oophorectomy or removal of remaining ovary at the time of benign hysterectomy, and to estimate trends in the performance of oophorectomy from 2001 to 2006. METHODS: This was a cross-sectional analysis using the New York State Department of Health Statewide Planning and Research Cooperative System. Women aged 18 years or older undergoing hysterectomies for benign gynecologic conditions were included. We evaluated factors associated with oophorectomy on both univariable and multivariable analyses and assessed for changes in performance of oophorectomy over the course of the study. RESULTS: Forty-seven percent of 144,877 hysterectomies included oophorectomy. Women who underwent oophorectomy were older and were more likely to have a family history of breast or ovarian cancer, a personal history of breast cancer, ovarian cysts, or endometriosis. Women who underwent vaginal or laparoscopic hysterectomy or had uterine prolapse were less likely to undergo oophorectomy. Both race and insurance status were associated with performance of oophorectomy. From 2001 to 2006, there was an 8% absolute decrease in the performance of oophorectomy at the time of benign hysterectomy for women of all ages, with a 10.4% decrease in women aged younger than 55 (P for trend <.001). CONCLUSION: Age, route of hysterectomy, and concomitant gynecologic diagnoses influence oophorectomy rate. From 2001 to 2006, a significant decrease in the performance of oophorectomy at the time of benign hysterectomy was noted in women aged younger than 55 years. Recent studies of complications of hormone therapy and prophylactic oophorectomy may have influenced patients' and physicians' decision-making, leading to lower oophorectomy rates. LEVEL OF EVIDENCE: II.

Ovarian cancer care for the underserved: are surgical patterns of care different in a public hospital setting?

BACKGROUND: The New York City (NYC) public hospital system includes subspecialty care for gynecologic cancers, providing care to patients regardless of insurance status. The authors sought to determine the surgical patterns of care for ovarian cancer patients in the NYC public hospital system. METHODS: Ovarian cancer cases were identified in the New York State Department of Health Statewide Planning and Research Cooperative System database for years 2001 to 2006. Cases from NYC hospitals were separated into 2 cohorts: public and other NYC hospitals. Surgeons associated with each case were identified using the database and were stratified by volume of cases and presence of subspecialty training. RESULTS: A total of 12,202 admissions for ovarian cancer were identified. Of these, 3639 involved major surgery, and 187 were performed at public hospitals. There were more African American and Asian patients in the public cohort (P < .001). The primary insurer was more likely to be Medicaid or a self-payer in the public cohort (P < 0.001). Urgent or emergent admissions comprised 55% of all admissions in public hospitals, compared with 29% of admissions in other NYC hospitals (P < .001). Patients in public hospitals were less likely to have their surgery performed by a gynecologic oncologist (57% vs 74%, P < .001) and less likely to have their surgery performed by a high-volume surgeon (21% vs 47%; P < .001) compared with patients in other NYC hospitals. CONCLUSIONS: Ovarian cancer patients treated in public hospitals are less likely to have gynecologic oncologists and high-volume surgeons involved in their care. This is a preliminary finding that warrants further investigation.

Effect of surgical volume on route of hysterectomy and short-term morbidity.

OBJECTIVE: To estimate whether a surgeon's case volume is related to route of hysterectomy and short-term morbidity. METHODS: This is a cross-sectional study collecting data on inpatient hysterectomies using the New York State Department of Health database from 2001 through 2006. An acute morbidity and mortality index was created. Surgeons' license numbers were used to generate an annual average number of hysterectomies performed. A multivariable logistic regression model assessing surgical volume on acute morbidity after controlling for known confounders was created. RESULTS: A total of 146,494 hysterectomies were performed in the state of New York. Of these, 103,181 (70.4%) were abdominal, 26,660 (18.2%) were vaginal, and 16,653 (11.4%) were laparoscopic-assisted. Twenty- six percent of hysterectomies are performed by physicians who perform, on average, fewer than 10 hysterectomies per year. The percentage of abdominal hysterectomies is 81% for surgeons performing fewer than 10 hysterectomies per year compared with 67% for surgeons performing at least 10 hysterectomies per year (P<.001). Postoperative morbidity and mortality were reported as 16.5% and 0.21%, respectively, for surgeons performing fewer than 10 hysterectomies per year as compared with 11.7% and 0.06%, respectively, for those performing at least 10 hysterectomies (P<.001). CONCLUSION: Surgeons who perform an average of 10 hysterectomies per year are more likely to perform minimally invasive hysterectomies. These surgeons also have a decrease in morbidity and mortality rates when compared with surgeons who perform fewer than 10 hysterectomies per year. LEVEL OF EVIDENCE: II.

Lysophosphatidic acid (LPA) effects on endometrial carcinoma in vitro proliferation, invasion, and matrix metalloproteinase activity.

OBJECTIVES: Lysophosphatidic acid (LPA) has potent growth-regulatory effect in many cell types and has been linked to the in vivo tumor growth and metastasis in several malignancies. The goal of this study was to assess the regulation of (EC) microenvironment by LPA through the examination of its effect on cell proliferation, migration, invasion, uPA activity, and matrix metalloproteinase (MMP) secretion/activation. METHODS: All experiments were performed in vitro using an EC cell line, HEC-1A. Cell proliferation was determined using the Promega MTS proliferation assay following 48 h of exposures to different concentrations of LPA (0.1, 1.0 and 10.0 microM). Cell invasion was assessed using a modified Boyden chamber assay with collagen I coated on the membrane. HEC-1A motility was examined by Boyden chamber migration assay as well as the scratch wound closure assay on type I collagen. MMP secretion/activation in HEC-1A conditioned medium was detected by gelatin zymography. MMP-7 mRNA expression was determined using real-time PCR. uPA activity was measured using a coupled colorimetric assay. RESULTS: LPA, at the concentrations of 0.1 and 1.0 microM, significantly induced the proliferation of HEC-1A cells (p<0.01). At 10 microM, LPA- induced HEC-1A proliferation to a less extent and showed no significant effect on HEC-1A invasion and migration (p>0.05). Gelatin zymogram showed that HEC-1A cells secreted high levels of MMP-7, while MMP-2 and MMP-9 are barely detectable. In addition, LPA significantly enhanced uPA activity in HEC-1A conditioned medium in a concentration-dependent manner. CONCLUSIONS: LPA is a potent modulator of cellular proliferation and invasion for EC cells. It also has the capacity to stimulate the secretion/activity of uPA and MMP-7. Those results suggest that LPA is a bioactive modulator of EC microenvironment and may have a distinct regulation mechanism as observed in epithelial ovarian cancer.