Racial and ethnic enrollment disparities in clinical trials of poly(ADP-ribose) polymerase inhibitors for gynecologic cancers.

OBJECTIVES: Disparities persist in the enrollment of racial/ethnic groups in clinical trials for ovarian cancers. We sought to analyze the enrollment rates of patients by race/ethnicity in phase II/III clinical trials involving poly(ADP-ribose) polymerase (PARP) inhibitors for ovarian cancers and compare these to the racial/ethnic prevalence of ovarian cancers in the United States. METHODS: This study was a retrospective review of clinical trials registered with ClinicalTrials.gov. Studies included evaluated PARP inhibitors for the treatment of ovarian, fallopian tube, and primary peritoneal cancers. Enrollment rates for clinical trials were stratified by race/ethnicity and type of cancer. Enrollment fractions (EFs) were calculated using prevalence data from the Surveillance, Epidemiology, and End Results Program. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare racial/ethnic group enrollment rates to Non-Hispanic (NH) White enrollment rates. RESULTS: Forty-eight trials were identified, 15 of which met inclusion criteria. The EFs for included trials, were 1.5% for NH-White, 0.47% for NH-Black, 0.33% for Hispanic, and 2.38% for Asian/Pacific Islander. Patients who identified as NH-Black and Hispanic were significantly underrepresented compared to those who identified as NH-White (OR 0.23, 95% CI [0.18-0.29] and OR 0.3, 95% CI [0.25-0.38] respectively, p < 0.001). CONCLUSIONS: NH-Black and Hispanic patients are significantly underrepresented in clinical trials evaluating PARP inhibitors for ovarian cancers compared to NH-White cohorts. Phase II/III trials assessing PARP inhibitors for ovarian cancers do not accurately represent the populations diagnosed with these malignancies. Enrollment strategies are needed to increase diversity in PARP inhibitor clinical trials for women's cancers.

Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer.

BACKGROUND: Minimally invasive surgery was adopted as an alternative to laparotomy (open surgery) for radical hysterectomy in patients with early-stage cervical cancer before high-quality evidence regarding its effect on survival was available. We sought to determine the effect of minimally invasive surgery on all-cause mortality among women undergoing radical hysterectomy for cervical cancer. METHODS: We performed a cohort study involving women who underwent radical hysterectomy for stage IA2 or IB1 cervical cancer during the 2010-2013 period at Commission on Cancer-accredited hospitals in the United States. The study used inverse probability of treatment propensity-score weighting. We also conducted an interrupted time-series analysis involving women who underwent radical hysterectomy for cervical cancer during the 2000-2010 period, using the Surveillance, Epidemiology, and End Results program database. RESULTS: In the primary analysis, 1225 of 2461 women (49.8%) underwent minimally invasive surgery. Women treated with minimally invasive surgery were more often white, privately insured, and from ZIP Codes with higher socioeconomic status, had smaller, lower-grade tumors, and were more likely to have received a diagnosis later in the study period than women who underwent open surgery. Over a median follow-up of 45 months, the 4-year mortality was 9.1% among women who underwent minimally invasive surgery and 5.3% among those who underwent open surgery (hazard ratio, 1.65; 95% confidence interval [CI], 1.22 to 2.22; P=0.002 by the log-rank test). Before the adoption of minimally invasive radical hysterectomy (i.e., in the 2000-2006 period), the 4-year relative survival rate among women who underwent radical hysterectomy for cervical cancer remained stable (annual percentage change, 0.3%; 95% CI, -0.1 to 0.6). The adoption of minimally invasive surgery coincided with a decline in the 4-year relative survival rate of 0.8% (95% CI, 0.3 to 1.4) per year after 2006 (P=0.01 for change of trend). CONCLUSIONS: In an epidemiologic study, minimally invasive radical hysterectomy was associated with shorter overall survival than open surgery among women with stage IA2 or IB1 cervical carcinoma. (Funded by the National Cancer Institute and others.).

Bone health and osteoporosis screening in gynecologic cancer survivors.

Cancer treatment-induced bone loss is a known side effect of cancer therapy that increases the risk of osteoporosis and bone fracture. Women with gynecologic cancer are at increased risk of bone loss secondary to the combined effect of oophorectomy and adjuvant therapies. Data regarding bone loss in women with gynecologic cancers are overall lacking compared to other cancer populations. Consequently, guidelines for osteoporosis screening in women with cancer are largely based on data generated among non-gynecologic cancer survivors. This article reviews current available data of bone health in women with gynecologic cancer, summarizes best-available guidelines for screening for osteoporosis in women with cancer, and provides guidance for osteoporosis screening in women with gynecologic cancers based on best available evidence.

Universal access to contraception: women, families, and communities benefit.

Universal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.

Increasing NIH funding for academic departments of obstetrics and gynecology: a call to action.

The National Institutes of Health funding for reproductive sciences research, specifically in academic departments of obstetrics and gynecology, is disproportionately low. Research is one of the most important pillars in advancing healthcare. Despite US Congress' vision in providing increased funding to the National Institutes of Health as a whole, underfunding for research in the departments of obstetrics and gynecology remains one of the several critical drivers in the decline in reproductive health and healthcare for women in the United States.

Disparities in the allocation of research funding to gynecologic cancers by Funding to Lethality scores.

PURPOSE: To analyze National Cancer Institute (NCI) funding distributions to gynecologic cancers compared to other cancers from 2007 to 2014. METHODS: The NCI's Surveillance, Epidemiology and End Results (SEER), Cancer Trends Progress Report, and Funding Statistics were used to analyze 18 cancer sites. Site-specific mortality to incidence ratios (MIR) were normalized per 100 cases and multiplied by person-years of life lost to derive cancer-specific lethality. NCI funding was divided by its lethality to calculate Funding to Lethality scores for gynecologic malignancies and compared to 15 other cancer sites. RESULTS: Ovarian, cervical, and uterine cancers ranked 10th (score 0.097, SD 0.008), 12th (0.087, SD 0.009), and 14th (0.057, SD 0.006) for average Funding to Lethality scores. The highest average score was for prostate cancer (score 1.182, SD 0.364). In U.S. dollars per 100 incident cases, prostate cancer received an average of $1,821,000 per person-years of life lost, while ovarian cancer received $97,000, cervical cancer $87,000, and uterine cancer $57,000. Ovarian and cervical cancers had lower average Funding to Lethality scores compared to nine other cancers, while uterine cancer was lower than 13 other cancers (p < 0.01 for all comparisons). Analyses of eight-, five-, and three-year trends for gynecologic cancers showed nearly universal decreasing Funding to Lethality scores. CONCLUSION: Funding to Lethality scores for gynecologic cancers are significantly lower than other cancer sites, indicating a disparity in funding allocation that persists over the most recent eight years of available data. Prompt correction is required to ensure critical discoveries for women with gynecologic cancers.

Trends and comparative effectiveness of inpatient radical hysterectomy for cervical cancer in the United States (2012-2015).

OBJECTIVE: Report the up-to-date trends in surgical approach for cervical cancer and compare outcomes between open and minimally invasive routes. METHODS: Radical Hysterectomy (RH) cases from the National Inpatient Sample (NIS) dataset between 2012 and 2015 were grouped into abdominal (ARH) and Minimally Invasive Surgery (MIS). The MIS group was subdivided as "Laparoscopic", "Robotic", and "Converted". Univariate and multivariable logistic regression were used to analyze differences in complication rates. The National Surgical Quality Improvement Dataset 2015 was used for validation. RESULTS: A total of 7180 cases from NIS were identified. Overall, there was 44% decline in RH cases from 2012 (n = 2220) to 2015 (n = 1255). A proportionate increase in robotic cases from 31.5% in 2012 to 41.4% in 2015 was noted. By intention to treat analysis, the rate of at least one complication for abdominal cases was 24.8% compared to 10% for MIS (p < 0.001). On multivariate analysis, abdominal cases had higher odd of any one complication (aOR 2.9,95% CI 2.12-4.00), medical complication (aOR 3.25,95% CI 2.15-4.19), infectious complication (aOR 3.76,95% CI 2.1-6.1) but not for surgical complications (aOR 1.7,95% CI 0.5-5.6). AH resulted in longer hospital stay compared to MIS (4.3 vs 1.9 days, p < 0.001). Median cost of AH was $12,624, laparoscopic $12,873, robotic $14,029 and converted cases $17,036. NSQIP analysis supplemented the outcomes to 30-days and showed similar findings. CONCLUSIONS: Perioperative complications are significantly lower for MIS procedures. These data should be used for contemporary cost-effective analysis and comprehensive counseling regarding risks and benefits of the surgical approach for cervical cancer.

Variation in resource utilization associated with the surgical management of ovarian cancer.

OBJECTIVE: Identify the major factors that drive standardized cost in providing surgical care for women with ovarian cancer, characterize the magnitude of variation in resource utilization between centers, and to investigate the relationship between resource utilization and quality of care provided. METHODS: Retrospective cohort study of hospitals across the United States reporting to the Premier Database who cared for patients with ovarian cancer diagnosed between 2007 and 2014. The primary outcome was standardized total cost of the index hospitalization. To assess the relationship between hospital standardized costs and patient outcomes, we identified four measures of quality: 1) complications, 2) re-operation, 3) length of stay > 15 days, and 4) unplanned readmission. RESULTS: The study population included 15,857 patients treated at 226 hospitals. The median standardized cost for hospitalizations was $13,267 (IQR = $3342). Reoperation was associated with 49% increase (95% CI = 43%-56%), and having minor complication was associated with 10% (95% CI = 8%-12%) increase in standardized cost, a moderate complication was associated with 36% (95% CI = 33%-38%) increase, and a major complication was associated with 83% (95% CI = 76%-89%) increase. The average risk-adjusted hospital standardized costs for hospitals in the highest resource use quartiles was 56% higher than the average hospital costs for hospitals in the lowest quartile ($10,826 vs. $16,933). The largest variation was in operating room standardized cost (45.5% of the total variation in operating room cost is explained by differences in hospital practices) and supplies (41.7%). CONCLUSIONS: We identified significant variation in standardized costs among women who underwent surgery for ovarian cancer, operating room and supply costs are the largest drivers of variation.

The American Gynecological and Obstetrical Society-reinvigorating for the 21st century.

The American Gynecological and Obstetrical Society (AGOS) has the potential to serve as a unifying organization to advocate for women's reproductive health care, education, and research. This report reviews a strategic plan designed to reinvigorate AGOS to address, together with our partner organizations, the ever more pressing issues and challenges in women's reproductive health.

Thirty-day unplanned hospital readmission in ovarian cancer patients undergoing primary or interval cytoreductive surgery: systematic literature review.

OBJECTIVES: Thirty-day readmission rate has been proposed as metric of quality and remains an ongoing clinical concern in the primary treatment of patients with advanced-stage ovarian epithelial ovarian cancer. We conducted a review of the literature to identify rates, risk factors, and predictors for 30-day readmission in this population. METHODS: A 10-year period MEDLINE (PubMed) search of English literature studies published between January 01, 2008-January 01, 2018 was performed to identify appropriate studies for review. RESULTS: Thirty -day readmission rates for ovarian cancer patients undergoing primary treatment ranged from 2.5-19.3%. Neoadjuvant chemotherapy and interval cytoreductive surgery (NACT-ICS) surgery was associated with lower readmission rates, when compared to primary debulking surgery (PDS). The most frequently reported adverse events resulting in readmission include inpatient management of ileus/small bowel obstruction, wound-related complications, and thromboembolic events. Readmission predictors included the presence of other medical comorbidities, re-operation, and major complications occurring after initial hospital discharge. Some studies reported lower rates of readmission and survival in patients treated by NACT-ICS. CONCLUSIONS: Policies and programs should be designed to measure short- and long-term outcomes in this patient population to avoid bias in assigning patients to NACT-ICS to maintain low 30-day readmission rates.

Factors associated with outcomes and inpatient 90-day cost of care in endometrial cancer patients undergoing hysterectomy - implications for bundled care payments.

OBJECTIVE: To investigate the association of obesity and other comorbidities as well as route of surgery with postoperative outcomes, as well as 30- and 90-day inpatient cost of care after hysterectomy for endometrial cancer. METHODS: From the 2013 National Readmission Database release, patients who underwent hysterectomy for endometrial cancer were included. Obesity was classified as non-obese (body mass index [BMI] < 35 kg/m2); class I/II obesity (BMI ≥ 35 but <40 kg/m2 and without obesity related medical condition qualifying it as morbid obesity), class III obesity (BMI ≥ 40 kg/m2 OR BMI ≥ 35 kg/m2 with an obesity-related medical condition). Incremental cost at 30 and 90 days was calculated using cost-to-charge ratio. RESULTS: A total of 27,658 patients were identified. Compared to non-obese patients those with class III obesity had higher rate of any medical (non-surgical) complication (22.3% vs 17.2%, p = 0.004), and higher rate of 30-day readmission (6% vs 4.4%, p = 0.003), but similar rates of surgical complications. There were no significant differences in perioperative outcomes between non-obese patients and those with class I/II obesity. Non-obese patients had higher rates of traditional laparoscopy (8.4% vs 13.6%, p < 0.001) and lower conversion rates from a minimally invasive to abdominal (5.5% vs. 8.2%, p < 0.001) than those with class III obesity. Based on multivariate regression model compared to non-obese patients, class I/II obesity (OR 1.05, 95% CI 1.02-1.09) and class III obesity (OR 1.1, 95% CI 1.1-1.18) were associated with higher cost of care. Other factors increasing cost of care included: comorbidity score per unit increase (OR 1.08, 95% 1.07-1.08), insurance status and route of surgery. CONCLUSIONS: Class III obesity was associated with higher medical (but not surgical) complication rates as well as increased overall inpatient care cost when compared to the non-obese population. Number of comorbidities significantly impacted the cost and outcomes after hysterectomy. As more healthcare initiatives focus on bundled payments, our results suggest that payment packages should adjust for obesity rates and medical comorbidities stratified by region and hospital type in order to fairly compensate for increased costs of care.

Isolated para-aortic lymph node metastasis in FIGO stage IA2-IB2 carcinoma of the cervix: Revisiting the role of surgical assessment.

OBJECTIVES: To investigate the utility of para-aortic lymph node dissection among women undergoing radical hysterectomy and pelvic lymph adenectomy for FIGO Stage IA2-IB2 cervical cancer using the National Cancer Database (NCDB). METHODS: We identified patients with stage IA2-IB2 squamous cell, adenosquamous, or adenocarcinoma of the cervix diagnosed 2011-2014 in the NCDB. The primary outcome was the negative predictive value of histologically assessed pelvic lymph node status for para-aortic lymph node status among women undergoing pelvic and para-aortic lymph node dissection. We calculated probability of para-aortic lymph node metastasis conditional on pelvic lymph node status. Finally, we compared overall survival between patients undergoing para-aortic lymph node dissection and those in whom this procedure was omitted. RESULTS: A total of 3212 patients met study inclusion criteria, of whom 994 (30.9%) underwent para-aortic lymph node dissection. In this group, the risk of isolated para-aortic metastasis was 0.11%. The negative predictive value of surgically assessed pelvic lymph nodes to predict para-aortic lymph node status was 99.9% (95% CI 99.9-99.9). Among 93 patients with pelvic lymph node metastasis, 18 (19.4%) had concurrent para-aortic lymph node metastasis. There was no difference in overall survival between women undergoing pelvic and para-aortic lymph node dissection compared with those undergoing pelvic lymphadenectomy only (p = 0.69). CONCLUSIONS: In patients undergoing radical hysterectomy and pelvic lymphadenectomy for stage IA2-IB2 cervical cancer, para-aortic lymph node dissection is not warranted based on the low risk of isolated metastatic disease, and lack of survival benefit associated with the procedure.

Randomized phase II trial of bevacizumab plus everolimus versus bevacizumab alone for recurrent or persistent ovarian, fallopian tube or peritoneal carcinoma: An NRG oncology/gynecologic oncology group study.

PURPOSE: Bevacizumab (BV) monotherapy leads to compensatory upregulation of multiple signaling pathways, resulting in mTOR activation. We evaluated combining BV and everolimus (EV), an mTOR kinase inhibitor, to circumvent BV-resistance in women with recurrent or persistent ovarian, fallopian tube or primary peritoneal cancer (OC). PATIENTS AND METHODS: Eligible OC patients had measurable (RECIST1.1) or detectable disease, 1-3 prior regimens, performance status (PS) 0-2, and no prior m-TOR inhibitor. All patients received BV 10 mg/kg IV every 2wks. Patients were randomized (1:1) to oral EV (10 mg daily) or placebo stratified by platinum-free interval (PFI), measurable disease and prior BV. Primary endpoint was progression-free survival (PFS); secondary endpoints included safety and response. RESULTS: 150 patients were randomized to BV with (n = 75) and without (n = 75) EV. Arms were well-balanced for age (median 63: range 28-92), PS (0: 73%, 1-2: 27%), prior regimens (1: 37%, 2: 47%, 3: 16%), prior BV (11%), PFI (<6mos: 65%) and measurable disease (81%). The BV + EV vs BV median PFS was 5.9 vs 4.5 months (hazard ratio [HR] 0.95 (95% CI, 0.66-1.37, p = 0.39)). Median OS was 16.6 vs 17.3 months (HR 1.16 (95% CI, 0.72-1.87, p = 0.55). Objective measurable responses were higher with BV + EV (22% vs 12%). Study removal due to toxicity was higher with BV + EV (29% vs 12%). Toxicity (≥grade 3) from BV + EV were "other GI (mucositis)" (23 vs 1%) and "metabolic/nutrition" (19 vs. 7%); common ≥ grade 2 toxicities with BV + EV were cytopenia, nausea, fatigue and rash. CONCLUSION: The combination regimen (BV + EV) did not significantly reduce the hazard of progression or death relative to BV and was associated with higher rates of adverse events and study discontinuation when compared to BV alone.

Racial and ethnic disparities over time in the treatment and mortality of women with gynecological malignancies.

OBJECTIVE: To examine temporal trends in treatment and survival among black, Asian, Hispanic, and white women diagnosed with endometrial, ovarian, cervical, and vulvar cancer. METHODS: Using the National Cancer Database (2004-2014), we identified women diagnosed with endometrial, ovarian, cervical, and vulvar cancer. For each disease site, we analyzed race/ethnicity-specific trends in receipt of evidence-based practices. Professional societies' recommendations were used to define these practices. Using data from the Surveillance, Epidemiology, and End Results Program (2000-2009) we analyzed trends in 5-year survival. RESULTS: Throughout the study period black (64.8%) and Hispanic (68.3%) women were less likely to undergo lymphadenectomy for stage I ovarian cancer compared to Asian (79.5%) and white patients (74.6%). Black women were the least likely group to undergo lymphadenectomy in all periods. Among patients with stage II-IV ovarian cancer, 76.6% of white and Asian women received both surgery and chemotherapy, compared to 70.8% of black and 73.9% Hispanic women. Hispanic women with deeply invasive or high-grade stage I endometrial cancer underwent lymphadenectomy less frequently (74.5%) than all other groups (80.7%). Black women were less likely to have chemo-radiotherapy for stage IIB-IVA cervical cancer (75.6% versus 80.4% of all others). Black women were also less likely to have a surgical lymph node evaluation for vulvar cancer (58.8% versus 63.5% of all others). Among women diagnosed with ovarian, endometrial, and cervical cancer, black women had lower five-year survival than other groups. CONCLUSION: Significant racial disparities persist in the delivery of evidence-based care. Black women with ovarian, endometrial, and cervical cancer continue to experience higher cancer-specific mortality than other groups.

Estimating potential for savings for low risk endometrial cancer using the Endometrial Cancer Alternative Payment Model (ECAP): A companion paper to the Society of Gynecologic Oncology Report on the Endometrial Cancer Alternative Payment Model.

OBJECTIVE: To design an endometrial cancer (EC) alternative payment (ECAP) model focused on surgical management of EC, as well as identify drivers of cost in order to develop opportunities for cost-savings while maintaining quality of care. METHODS: National practice patterns and reimbursements were compared between private payers (MarketScan data, years 2009-13) and public payers (Medicare, year 2014) of EC patients who underwent hysterectomy. An episode of care for EC included the hysterectomy, stratified by surgical approach (laparotomy versus robotic versus laparoscopy), and in- and outpatient reimbursements from 30days preoperatively to 60days postoperatively. Reimbursements were categorized into cost centers. A decision model informed modifiable components influencing overall reimbursements for EC surgical care. Variations in length of stay (LOS), emergency department (ED visits), and readmissions were analyzed to create an optimal care model. RESULTS: A total of MarketScan (n=29,558) and Medicare (n=377) patients were included. Mean total reimbursement for an episode of care was $19,183 (SD $10,844) for Medicare and $30,839 (SD $19,911) for MarketScan. Mean reimbursements were greatest for abdominal cases in Medicare ($25,553; SD $11,870) and MarketScan ($35,357; SD $21,670), followed by robotic and laparoscopic. Among MarketScan patients, 7.6% of women were readmitted within 60days after surgery and 11.7% had an evaluation in the ED. The median reimbursement per patient for readmission was $14,474 (IQR $8584 to $26,149), and for ED visit was $6327 (IQR $1369 to $29,153). In an optimized care model, increasing the rate of minimally invasive surgery by 5% while reducing LOS by 10% and ED visits/readmissions by 10%, lowered the average case reimbursement by $903 (2.9%) for MarketScan and $1243 (5.9%) for Medicare. CONCLUSION: An ECAP model demonstrates that reimbursements vary by public versus commercial payers in the U.S. for the surgical management of endometrial cancer patients, and that opportunities for cost savings exist. Nominal increases in the rate of minimally invasive surgery and reduction in the rate of ED visits/readmissions and length of stay can result in substantial savings for endometrial cancer care.

Preoperative obstructive sleep apnea screening in gynecologic oncology patients.

BACKGROUND: Women with a gynecologic cancer tend to be older, obese, and postmenopausal, characteristics that are associated with an increased risk for obstructive sleep apnea. However, there is limited investigation regarding the condition's prevalence in this population or its impact on postoperative outcomes. In other surgical populations, patients with obstructive sleep apnea have been observed to be at increased risk for adverse postoperative events. OBJECTIVE: We sought to estimate the prevalence of obstructive sleep apnea among gynecologic oncology patients undergoing elective surgery and to investigate for a relationship between obstructive sleep apnea and postoperative outcomes. STUDY DESIGN: Patients referred to an academic gynecologic oncology practice were approached for enrollment in this prospective, observational study. Patients were considered eligible for study enrollment if they were scheduled for a nonemergent inpatient surgery and could provide informed consent. Enrolled patients were evaluated for a preexisting diagnosis of obstructive sleep apnea. Those without a prior diagnosis were screened using the validated, 4-item STOP questionnaire (ie, Snore loudly, daytime Tiredness, Observed apnea, elevated blood Pressure). All patients who screened positive for obstructive sleep apnea were referred for polysomnography. The primary outcome was the prevalence of women with obstructive sleep apnea or those who screened at high risk for the condition. Secondary outcomes examined the correlation between body mass index (kg/m2) with obstructive sleep apnea and assessed for a relationship between obstructive sleep apnea and postoperative outcomes. RESULTS: Over a 22-month accrual period, 383 eligible patients were consecutively approached to participate in the study. A cohort of 260 patients were enrolled. A total of 33/260 patients (13%) were identified as having a previous diagnosis of obstructive sleep apnea. An additional 66/260 (25%) screened at risk for the condition using the STOP questionnaire. Of the patients who screened positive, 8/66 (12%) completed polysomnography, all of whom (8/8 [100%]) were found to have obstructive sleep apnea. The prevalence of previously diagnosed obstructive sleep apnea or screening at risk for the condition increased as body mass index increased (P < .001). Women with untreated obstructive sleep apnea and those who screened at risk for the condition were found to have an increased risk for postoperative hypoxemia (odds ratio, 3.5; 95% confidence interval, 1.8-4.7; P = .011) and delayed return of bowel function (odds ratio, 2.1; 95% confidence interval, 1.3-4.5; P = .009). CONCLUSION: The prevalence of obstructive sleep apnea or screening at risk for the condition is high among women presenting for surgery with a gynecologic oncologist. Providers should consider evaluating a patient's risk for obstructive sleep apnea in the preoperative setting, especially when risk factors for the condition are present.

Minimally Invasive Staging Surgery in Women with Early-Stage Endometrial Cancer: Analysis of the National Cancer Data Base.

PURPOSE: The aim of this study was to determine factors associated with the adoption of minimally invasive surgery (MIS) compared with laparotomy in the treatment of endometrial cancer and to compare surgical outcomes and survival between these two surgical modalities. METHODS: We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with presumed early-stage endometrial cancer between 2010 and 2012. We also identified factors associated with the performance of MIS and utilized propensity score matching to create a matched cohort of women who underwent minimally invasive staging surgery or laparotomy for surgical staging. RESULTS: Overall, 20,346 women were eligible for inclusion in the study; 12,604 (61.9%) had MIS, while 7742 (38.1%) had a laparotomy. African American race (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.49-0.60], Hispanic ethnicity (OR 0.70, 95% CI 0.61-0.80), Charlson score >2 (OR 0.79, 95% CI 0.69-0.91), high-grade histology (OR 0.63, 95% CI 0.59-0.68), presumed clinical stage II disease (OR 0.53, 95% CI 0.46-0.60), and surgery at a community cancer program (OR 0.46, 95% CI 0.39-0.55) or in the Midwest region (OR 0.70, 95% CI 0.64-0.76) were associated with a decreased likelihood of having MIS, while private insurance (OR 1.69, 95% CI 1.45-1.97) and highest quartile median household income (OR 1.13, 95% CI 1.03-1.24) were associated with an increased likelihood of having MIS. After propensity score matching, there was no association between minimally invasive staging surgery and 3-year overall survival (hazard ratio 1.03, 95% CI 0.92-1.16). CONCLUSION: There are notable racial, ethnic, socioeconomic, and geographic variations in the utilization of MIS for endometrial cancer staging in the US. After controlling for the aforementioned factors, MIS had a similar 3-year survival compared with laparotomy in women undergoing staging surgery for endometrial cancer.

Management of menopausal symptoms in women with gynecologic cancers.

OBJECTIVE: Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients. METHODS: MEDLINE was searched for studies on menopause management published in English through December of 2016. RESULTS: Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking. CONCLUSIONS: Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.

Disparities in receipt of care for high-grade endometrial cancer: A National Cancer Data Base analysis.

PURPOSE: To examine patterns of care and survival for Hispanic women compared to white and African American women with high-grade endometrial cancer. METHODS: We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear cell carcinoma and papillary serous carcinoma between 2003 and 2011. The effect of treatment on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS: 43,950 women were eligible. African American and Hispanic women had higher rates of stage III and IV disease compared to white women (36.5% vs. 36% vs. 33.5%, p<0.001). African American women were less likely to undergo surgical treatment for their cancer (85.2% vs. 89.8% vs. 87.5%, p<0.001) and were more likely to receive chemotherapy (36.8% vs. 32.4% vs. 32%, p<0.001) compared to white and Hispanic women. Over the entire study period, after adjusting for age, time period of diagnosis, region of the country, urban or rural setting, treating facility type, socioeconomic status, education, insurance, comorbidity index, pathologic stage, histology, lymphadenectomy and adjuvant treatment, African American women had lower overall survival compared to white women (Hazard Ratio 1.21, 95% CI 1.16-1.26). Conversely, Hispanic women had improved overall survival compared to white women after controlling for the aforementioned factors (HR 0.87, 95% CI 0.80-0.93). CONCLUSIONS: Among women with high-grade endometrial cancer, African American women have lower all-cause survival while Hispanic women have higher all-cause survival compared to white women after controlling for treatment, sociodemographic, comorbidity and histopathologic variables.

The impact of physician burnout on clinical and academic productivity of gynecologic oncologists: A decision analysis.

OBJECTIVE: Physician burnout is associated with mental illness, alcohol abuse, and job dissatisfaction. Our objective was to estimate the impact of burnout on productivity of gynecologic oncologists during the first half of their career. METHODS: A decision model evaluated the impact of burnout on total relative value (RVU) production during the first 15years of practice for gynecologic oncologists entering the workforce from 2011 to 2015. The SGO practice survey provided physician demographics and mean annual RVUs. Published data were used to estimate probability of burnout for male and female gynecologic oncologists, and the impact of depression, alcohol abuse, and early retirement. Academic productivity was defined as annual PubMed publications since finishing fellowship. RESULTS: Without burnout, RVU production for the cohort of 250 gynecologic oncologists was 26.2 million (M) RVUs over 15years. With burnout, RVU production decreased by 1.6 M (5.9% decrease). Disproportionate rates of burnout among females resulted in 1.1 M lost RVUs for females vs. 488 K for males. Academic production without burnout was estimated at 9277 publications for the cohort. Burnout resulted in 1383 estimated fewer publications over 15years (14.9%). CONCLUSIONS: The impact of burnout on clinical and academic productivity is substantial across all specialties. As health care systems struggle with human resource shortages, this study highlights the need for effective burnout prevention and wellness programs for gynecologic oncologists. Unless significant resources are designated to wellness programs, burnout will increasingly affect the care of our patients and the advancement of our field.