Utility Scores for Risk-Reducing Mastectomy and Risk-Reducing Salpingo-Oophorectomy: Mapping to EQ-5D.

BACKGROUND: Risk-reducing mastectomy (RRM) and risk-reducing salpingo-oophorectomy (RRSO) are the most effective breast and ovarian cancer preventive interventions. EQ-5D is the recommended tool to assess the quality of life and determine health-related utility scores (HRUSs), yet there are no published EQ-5D HRUSs after these procedures. These are essential for clinicians counselling patients and for health-economic evaluations. METHODS: We used aggregate data from our published systematic review and converted SF-36/SF-12 summary scores to EQ-5D HRUSs using a published mapping algorithm. Study control arm or age-matched country-specific reference values provided comparison. Random-effects meta-analysis provided adjusted disutilities and utility scores. Subgroup analyses included long-term vs. short-term follow-up. RESULTS: Four studies (209 patients) reported RRM outcomes using SF-36, and five studies (742 patients) reported RRSO outcomes using SF-12/SF-36. RRM is associated with a long-term (>2 years) disutility of -0.08 (95% CI -0.11, -0.04) (I2 31.4%) and a utility of 0.92 (95% CI 0.88, 0.95) (I2 31.4%). RRSO is associated with a long-term (>1 year) disutility of -0.03 (95% CI -0.05, 0.00) (I2 17.2%) and a utility of 0.97 (95% CI 0.94, 0.99) (I2 34.0%). CONCLUSIONS: We present the first HRUSs sourced from patients following RRM and RRSO. There is a need for high-quality prospective studies to characterise quality of life at different timepoints.

Venous thromboembolism in women with ovarian cancer undergoing neoadjuvant chemotherapy prior to cytoreductive surgery: A retrospective study.

INTRODUCTION: Ovarian cancer is associated with a venous thromboembolism risk of at least 7.2% by 2 years from diagnosis, and although patients undergoing surgery benefit from routine thromboprophylaxis, those undergoing neoadjuvant chemotherapy do not. This study aims to determine the venous thromboembolism incidence in patients with ovarian cancer undergoing neoadjuvant chemotherapy, and explore whether any subset is at higher risk, in order to evaluate whether thromboprophylaxis is justified in some or all of these patients. MATERIAL AND METHODS: This was a retrospective review of all women undergoing neoadjuvant chemotherapy for FIGO radiological stages III and IV primary ovarian, fallopian tube, and primary peritoneal cancer, between 2000 and 2015, in a London tertiary cancer center. The primary outcome was venous thromboembolism rate among women undergoing neoadjuvant chemotherapy. The secondary outcomes were patient or treatment factors associated with venous thromboembolism risk, including age, body mass index, smoking status, performance status, and tumor stage. RESULTS: We identified 278 eligible women from the ovarian cancer database. Fifty-eight women (20.9%) developed venous thromboembolism between initial presentation and the immediate postoperative period, of which 45 (77.6%) developed a pulmonary embolism. In all, 15.1% of women developed venous thromboembolism from the start of neoadjuvant chemotherapy. Age, body mass index, smoking, or other comorbidities were not significantly associated with venous thromboembolism risk. One woman died from massive pulmonary embolism, 27 women underwent inferior vena cava filter insertion, and 10 had surgery delayed. CONCLUSIONS: This study demonstrates an unacceptably high rate of avoidable venous thromboembolism including pulmonary embolism in these women, which complicates and delays treatment. Thromboprophylaxis during neoadjuvant chemotherapy should now be assessed prospectively.

Commentary on "duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study".

Decisions about the appropriate termination of resuscitation attempts are among the most important that teams must face, yet there have been very few studies looking into the issue. Many national guidelines refer only to advance decisions to prevent the initiation of resuscitation, such as DNAR orders,(1-3) and yet the decision to continue or abort on-going treatment is a clinical one, which should be evidence based like any other. This observational study(4) is one of the largest to examine the relationship between length of resuscitation efforts in hospital and outcome, and provides novel, powerful, and highly relevant results. The authors tested the hypothesis that hospitals with longer attempted duration of resuscitation in patients who don't survive would correlate with higher hospital survival outcomes, both immediate and to discharge. They assessed whether higher survival rates were associated with poor neurological status; additionally they directly estimated risk ratios for various at-risk groups, including breakdowns by cardiac rhythm. Hospital data was collected from 'Get With The Guidelines - Resuscitation'; the largest world-wide in-hospital resuscitation registry, managed by the American Heart Association.(5) Between 2000-2008, 64,339 cardiac arrests were considered that lasted at least 2 minutes (to exclude 'partial arrests') in 435 hospitals in the USA, each with a minimum experience of at least 10 arrests over 8 years. Exclusions were made for Emergency Departments, operating theatres, postoperative areas, procedure areas, rehabilitation areas, and arrests with area unknown, to avoid the 'distinct circumstances' of arrests in those settings. The median value for each hospital was calculated, and hospitals were divided into quartiles based on median length of resuscitation in non-survivors, with corresponding lengths of 16, 19, 22, and 25 minutes. Median resuscitation times overall were 17 minutes (IQR 10-26), with a breakdown of 12 minutes (IQR 6-21) for immediate survivors and 20 minutes (IQR 14-30) for non-survivors.(4).