Medicolegal, infrastructural, and financial aspects in gynecologic cancer surgery and their implications in decision making processes: Quo Vadis?

Surgical decision making is complex and involves a combination of analytic, intuitive, and cognitive processes. Medicolegal, infrastructural, and financial factors may influence these processes depending on the context and setting, but to what extent can they influence surgical decision making in gynecologic oncology? This scoping review evaluates existing literature related to medicolegal, infrastructural, and financial aspects of gynecologic cancer surgery and their implications in surgical decision making. Our objective was to summarize the findings and limitations of published research, identify gaps in the literature, and make recommendations for future research to inform policy.

Short-term survival analysis of a risk-adjusted model for ovarian cancer care.

OBJECTIVE: To quantify the impact on short-term ovarian cancer survival associated with treatment at high-performing hospitals using the observed-to-expected ratio (O/E) for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care. METHODS: This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to California Cancer Registry 1996-2017. A fit logistic regression model, risk-adjusted for patient and disease characteristics, was used to calculate O/E for each hospital stratified by hospital annual case volume. Cox proportional hazards model was used for survival analyses at 3, 6, 12, 24 months and stratified according to sociodemographic characteristics. RESULTS: The study population included 35,725 subjects treated at 443 hospitals: Low-O/E - 26.4% of cases; Intermediate-O/E - 55.5% of cases; and High-O/E - 18.1% of cases. Overall median survival by hospital category was: High-O/E = 72.5 months (95% CI = 68.6-78.6 months), Intermediate-O/E = 68.6 months (95% CI = 65.9-71.6 months), Low-O/E = 47.0 months (95% CI = 44.2-49.2 months). Initial treatment at a High-O/E hospital (HR = 1.00) was a statistically significant and independent predictor of improved short-term survival compared to Low-O/E hospitals at 3 months (HR = 1.46, 95% CI = 1.29-1.65), 6 months (HR = 1.35, 95% CI = 1.22-1.50), 12 months (HR = 1.27, 95% CI = 1.17-1.38), and 24 months (HR = 1.19, 95% CI = 1.11-1.27). Significant and independent associations between improved sort-term survival and High/O/E care were observed for Whites, Hispanics, Asian/Pacific Islanders (A/PI), across SES strata, and among all payer categories. CONCLUSION: Ovarian cancer care at a High-O/E hospital is an independent predictor of improved outcome and the survival advantage is disproportionately weighted toward the short-term time horizon following diagnosis.

Sentinel lymphatic mapping for gynecologic malignancies.

PURPOSE OF REVIEW: To summarize the latest data in Gynecologic Oncology for the use of sentinel lymphatic mapping in vulvar, uterine, and cervical cancers. RECENT FINDINGS: To decrease morbidity and improve detection of lymphatic metastasis, lymphatic mapping with sentinel lymph node biopsy is emerging as standard of care over conventional systemic lymphadenectomy in the surgical management of gynecologic malignancies. SUMMARY: Sentinel lymph node mapping with biopsy is one of the most significant advances in cancer surgery. The presence of nodal metastasis is not only a prognostic factor for recurrence and survival in patients with gynecologic malignancies, but also guides assessment for adjuvant treatment. This review article discusses the most recent clinical updates in sentinel lymph node mapping, dissection, and management in vulvar cancer, endometrial cancer, and cervical cancer.

Risk factors for cervical cancer among distinct populations in low-resource countries: feasibility of cervical cancer screen-and-treat program on ukerewe island of lake victoria, Tanzania.

PURPOSE OF REVIEW: A mass cervical cancer screening using World Health Organization-endorsed visual inspection with acetic acid (VIA) and cryotherapy triage was conducted over 5 days at Nansio District Hospital on Ukerewe Island, Tanzania in Lake Victoria. The aim was to evaluate the feasibility of a pilot screen-and-treat on a lower resource island and compare the results to previously held screen-and-treats in higher resource mainland settings. RECENT FINDINGS: Two hundred and eight-two women underwent VIA on Ukerewe Island during July 2017. The frequency of abnormal VIA screens was nearly twice that observed on the mainland in 2016 (18.4% vs 10.7%, respectively; P = 0.0091). Island women had lower rates of grand multiparity (19.8% vs 26.8%, P = 0.02) and more island women did not know their HIV status (80% vs 50%, P < 0.0001). Overall, 31% of abnormal VIA screens occurred among women under 30 years between the two sites. Due to the cost of transporting CO2 tanks, cryotherapy was nearly twice as expensive on the island as compared to the mainland. SUMMARY: Although transfer of an entire pilot screen-and-treat program to Ukerewe Island is feasible and well-received, expenses associated with ferrying equipment may be prohibitive to long-term sustainability. Higher VIA positivity rates were observed on the island.

Visual inspection with acetic acid screening for cervical cancer among women receiving anti-retroviral therapy for human immunodeficiency virus infection in northern Tanzania.

AIM: To evaluate visual inspection with acetic acid (VIA) screening for cervical cancer among human immunodeficiency virus (HIV)-positive patients in an East African community. METHODS: During a July 2018 cervical cancer screen-and-treat in Mwanza, Tanzania, participants were offered free cervical VIA screening, cryotherapy when indicated, and HIV testing. Acetowhite lesions and/or abnormal vascularity were designated VIA positive in accordance with current guidelines. The association between VIA results and HIV status was compared using Chi-square and Fisher exact tests. RESULTS: Eight hundred and twenty-four of 921 consented participants underwent VIA screening and 25.0% (n = 206) were VIA positive. VIA-positive nonpregnant women (n = 147) received cryotherapy and 15 (1.8%) with cancerous-appearing lesions were referred to Bugando Hospital. Sixty-six women were HIV-positive and included 25 diagnosed with HIV at the cervical cancer VIA screening and 41 with a prior diagnosis of HIV who were receiving antiretroviral therapy (ART) at the time of cervical cancer VIA screening. Sixty-four of these 66 patients, were screened with VIA. HIV infection was not associated with VIA findings. Abnormal VIA positive screening was observed in 20.3% (n = 13) of HIV-positive patients and in 24.4% (n = 145) of HIV-negative patients (p = 0.508). A nonsignificant trend of higher VIA positive screens among newly diagnosed HIV patients of 26.1% (n = 6) versus patients with preexisting HIV on ART of 17.1% (n = 7) was observed (p = 0.580). CONCLUSION: The unexpected lack of correlation between HIV infection and VIA positivity in a community with access to ART warrants additional research regarding the previously described role of ART in attenuating HPV-mediated neoplasia.

Prioritizing Surgical Services during on-Going Pandemic Response: Modification and Reliability of the Medically Necessary Time Sensitive Surgery (MeNTS) Scoring Tool.

Health systems are struggling to manage a fluctuating volume of critically ill patients with COVID-19 while continuing to provide basic surgical services and expand capacity to address operative cases delayed by the pandemic. As we move forward through the next phases of the pandemic, we will need a decision-making system that allows us to remain nimble as clinicians to meet our patient's needs while also working with a new framework of healthcare operations. Here, we present our quality improvement process for the adaptation and application of the Medically Necessary Time-Sensitive (MeNTS) toolto gynecologic surgical services beyond the initial COVID response and into recovery of surgical services; with analysis of the reliability of the modified-MeNTS tool in our multi-site safety net hospital network. This multicenter study evaluated the gynecology surgical case volume at three tertiary acute care safety net institutions within the LA County Department of Health Services: Harbor-UCLA (HUMC), Olive View Medical Center (OVMC), and Los Angeles County + University of Southern California (LAC+USC). We describe our modified-Delphi approach to adapt the MeNTS tool in a structured fashion and its application to gynecologic surgical services. Blinded reviewers engaged in a three-round iterative adaptation and final scoring utilizing the modified tool. The cohort consisted of 392 female consecutive gynecology patients across three Los Angeles County Hospitals awaiting scheduled procedures in the surgical queue.The majority of patients were Latina (74.7%) and premenopausal (67.1%). Over half (52.4%) of the patients had cardiovascular disease, while 13.0% had lung disease, and 13.8% had diabetes. The most common indications for surgery were abnormal uterine bleeding (33.2%), pelvic organ prolapse (19.6%) and presence of an adnexal mass (14.3%). Minimally invasive approaches via laparoscopy, robotic-assisted laparoscopy, or vaginal surgery was the predominant planned surgical route (54.8%). Modified-MeNTS scores assumed a normal distribution across all patients within our cohort (Median 33, Range 18-52). Overall, ICC across all three institutions demonstrated "good" interrater reliability (0.72). ICC within institutions at HUMC and OVMC were categorized as "good" interrater reliability, while LAC-USC interrater reliability was categorized as "excellent" (HUMC 0.73, OVMC 0.65, LAC+USC 0.77). The modified-MeNTS tool performed well across a range of patients and procedures with a normal distribution of scores and high reliability between raters. We propose that the modified-MeNTS framework be considered as it employs quantitative methods for decision-making rather than subjective assessments.

Implementation of human papillomavirus video education for women participating in mass cervical cancer screening in Tanzania.

BACKGROUND: Because the global disease burden of cervical cancer is greatest in Africa, the World Health Organization has endorsed visual inspection with acetic acid screening with cryotherapy triage for the screen-and-treat approach. With the lowest doctor-to-patient ratio worldwide (1:50,000), Tanzania has nearly 10,000 new cases of cervical cancer and 7000 deaths annually. OBJECTIVE: We report on the feasibility of visual inspection with acetic acid in the severely resource-limited Mwanza district and on the impact of intervening education on baseline human papillomavirus and cervical cancer knowledge. STUDY DESIGN: Two 5-day free visual inspection with acetic acid (VIA) clinics in urban Buzuruga and rural Sangabuye on the shores of Lake Victoria were approved by our university institutional review board and local Tanzanian health authorities. Participants completed a demographic survey and a 6-question (1 point per question) multiple choice test written in Kiswahili to assess baseline knowledge. A 15-minute educational video in Kiswahili (MedicalAidFilms: Understanding screening, treatment, and prevention of cervical cancer) was followed by repeated assessment using the same test, visual inspection with acetic acid screening, and optional HIV testing. Pre- and postvideo scores and change of score were analyzed via t test, analysis of variance, and multivariate regression. Significance was considered at P<.05. RESULTS: From July 2, 2018 to July 6, 2018, 825 women were screened, and 207 women (25.1%) were VIA positive (VIA+). One hundred forty-seven VIA+ nonpregnant women received same-day cryotherapy. Seven hundred sixty women participated in an educational intervention-61.6% of whom were from an urban site and 38.2% from a rural site. The mean age was 36.4 (standard deviation, 11.1). Primary languages were Kiswahili (62.2%) and Kisukuma (30.6%). Literacy was approximately 73%, and average education level was equivalent to the seventh grade (United States). Less than 20% of urban and rural women reported access to healthcare providers. Mean score of the participants before watching the video was 2.22 (standard deviation, 1.76) and was not different between VIA+ and VIA negative groups. Mean score of the participants after watching the video was 3.86 (standard deviation, 1.78). Postvideo scores significantly improved regardless of age group, clinic site, primary language, education level, literacy, or access to healthcare provider (P<.0001). Change of score after watching the video was significantly greater in participants from urban areas (1.99±2.07) than in those from rural areas (1.07±1.95) (P<.0001). Multivariate analysis identified urban site as an independent factor in change of score (P=.0211). CONCLUSION: Visual inspection with acetic acid screening for cervical cancer is feasible and accepted in northern Tanzania. Short video-based educational intervention improved baseline knowledge on the consequences of human papillomavirus infection in the studied populations. The impact was greater in the urban setting than in the rural setting.

Socially determined cervical cancer care navigation: An effective step toward health care equity and care optimization.

BACKGROUND: Despite being the standard of care for patients with locoregional cervical cancer, many patients do not complete all components of primary chemoradiotherapy (pCRT): external beam radiotherapy, chemosensitization, and brachytherapy. Incomplete or protracted pCRT is associated with worse survival. The authors implemented a socially determined cervical cancer care navigation program at a public safety-net hospital to improve treatment adherence. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 to IVA cervical cancer who underwent pCRT from 2012 to 2016 were prospectively enrolled into this navigation program spanning the medical, financial, and psychosocial aspects of care. This patient cohort was compared with a similar cohort of consecutive nonnavigated patients who were treated from 1998 to 2008. Patient characteristics, treatment data, and patient outcomes were collected. A database of navigation encounters was maintained prospectively. RESULTS: A total of 46 patients composed the navigated cohort and 85 patients composed the nonnavigated cohort. After implementation of the cervical cancer care navigation program, the percentage of patients receiving ≥5 cycles of weekly cisplatin increased from 74% to 93% (P < .01) and rates of the initiation of brachytherapy during external beam radiotherapy increased from 49% to 78% (P < .01). The median treatment time was reduced from 67 days in the nonnavigated patients to 55 days in the navigated patients (P < .01). Approximately 95% of navigated patients who completed pCRT did so within 63 days, compared with 52% of nonnavigated patients (P < .01). Treatment completion within 63 days was associated with significantly improved overall survival. CONCLUSIONS: Socially informed cervical cancer care navigation can significantly improve the timeliness of guideline-based care, enhance access to resources for underserved minority patients receiving pCRT, and may improve overall patient outcomes.

Implementation of a human papillomavirus screen-and-treat model in Mwanza, Tanzania: training local healthcare workers for sustainable impact.

Background: The purpose of this study is to evaluate the development of a 1-wk screening campaign and efforts towards the implementation of a sustainable system that addresses cervical cancer in Mwanza, Tanzania with a screen-and-treat model utilizing visual inspection of the cervix with acetic acid (VIA) and cryotherapy. Methods: In partnership with CureCervicalCancer (CCC), a non-profit organization based in Los Angeles, CA, USA, 11 medical students at the University of California, Irvine School of Medicine established a model for sustainable human papillomavirus screening practices in Mwanza, Tanzania. This study both quantitatively and qualitatively assesses the successes and limitations of the program model. Results: During the 5-day training, a total of 614 women attended the screenings and 556 women were screened with VIA, of whom 10.6% (n=59) were VIA positive and 89.4% (n=499) were VIA negative. Of those who were VIA positive, 83.1% (n=49) received cryotherapy while 16.9% (n=10) did not due to suspicion of advanced cancer (n=7), refusal to receive cryotherapy (n=2) or pregnancy (n=1). Conclusions: The screen-and-treat model for the identification and treatment of precancerous cervical lesions is an effective public health intervention with the potential to impact women by providing the tools and education needed by local healthcare professionals. However, limitations common to resource-poor settings, such as continuity of funding, loss to follow-up and transportation costs, remain barriers to sustainability.

Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter.

BACKGROUND: Over 90% of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment. METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study. RESULTS: The sensitivities for malaria diagnosis were 66.7% and 58.3% for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9% for spleen length and the acceptable specificity of 75.0% for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value. CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.

Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter / 世界急诊医学杂志（英文）

@#BACKGROUND: Over 90％ of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment. METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study. RESULTS: The sensitivities for malaria diagnosis were 66.7％ and 58.3％ for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9％ for spleen length and the acceptable specificity of 75.0％ for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value. CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.