Faculty Bibliography

OBJECTIVE:While women with stage III endometrial cancer are often treated with chemotherapy and external beam radiation, the optimal sequence of these modalities is unknown. We examined the association between the sequence of chemotherapy (CT) and external beam radiation therapy (RT) on survival for women with stage IIIC endometrial carcinoma. METHODS:The National Cancer Database was used to identify women with stage IIIC endometrial carcinoma treated with adjuvant CT and RT from 2004 to 2015. Patients were stratified based on the sequence of therapy: RT before CT, CT before RT, or concurrent therapy. The association between treatment sequence and mortality was examined through a weighted propensity score analysis. RESULTS:A total of 6981 patients were identified, including 5116 (73.3%) who received CT before RT, 696 (10.0%) who received RT before CT, and 1169 (16.7%) who received concurrent therapy. The use of CT-RT increased from 39.9% in 2004 to 75.5% in 2015, while use of RT-CT decreased from 34.0% to 4.4% and concurrent therapy decreased from 26.1% to 20.2% over the same period (P < 0.001). Compared to CT-RT, there was no difference in risk of mortality with RT before CT (HR = 1.01; 95% CI, 0.86-1.19) while concurrent therapy was associated with a 47% increased risk of mortality (HR = 1.47; 95% CI, 1.31-1.66). In a sensitivity analysis combining the groups that received RT first (RT before CT or concurrent RT-CT), mortality was 25% higher (HR = 1.25; 95% CI, 1.13-1.39) compared to a strategy of CT followed by RT. CONCLUSION:Among women with stage IIIC endometrial carcinoma treated with combination chemotherapy and external beam radiation, a strategy employing chemotherapy first is associated with improved survival compared to concurrent therapy.

BACKGROUND:Although safety-net hospitals (SNH) provide a valuable role serving vulnerable patients, the quality of gynecologic oncology care at these hospitals remains inadequately documented. We examined the quality of care at SNH for women with gynecologic cancers. METHODS:We used the National Cancer Database to identify hospitals that treated patients with uterine, ovarian, or cervical cancer from 2004 to 2015. Hospitals with the greatest proportion of uninsured patients or Medicaid beneficiaries were defined as SNH. Quality metrics were derived from evidence-based recommendations. Thirty-day mortality, readmission rates, and 5-year survival were calculated. Multivariable models were developed to determine the association between treatment at SNH and outcomes. RESULTS:.05) but were otherwise equivalent. CONCLUSIONS:After adjusting for patient and tumor characteristics, women with gynecologic cancers treated at SNH receive lower-quality surgical care and equivalent medical care and a subset of these patients has modest decreases in survival.

BACKGROUND:Same-day discharge is becoming increasingly common for women who undergo minimally invasive hysterectomy. For women with endometrial cancer, there are limited data to describe the safety of same-day discharge. OBJECTIVE:To examine trends and outcomes of same-day discharge for women with endometrial cancer who underwent minimally invasive hysterectomy. STUDY DESIGN:The National Surgical Quality Improvement Program database was used to identify patients who underwent minimally invasive hysterectomy based for endometrial cancer from 2011 to 2016. The cohort was limited to women discharged on the day of surgery/postoperative day 0 or postoperative day 1. Multivariable models were used to examine clinical, demographic, and procedural characteristics associated with discharge on postoperative day 0. Multivariable models also were developed to examine the association between same-day discharge and readmission. RESULTS:A total of 17,935 patients who underwent minimally invasive hysterectomy were identified. Of those discharged within 1 day, 1828 (12.4%) were discharged on postoperative day 0 and 12,892 (87.6%) were discharged on postoperative day 1 or after. The rate of same-day discharge rose from 5.6% in 2011 to 16.3% in 2016 (P<.001). In a multivariable model, more recent year of surgery was associated with same-day discharge whereas older age (≥70 years old), chronic obstructive pulmonary disease, and hypertension were associated with a decreased likelihood of same-day discharge. Similarly, obese women were 15% less likely to have a same-day discharge than normal-weight women (risk ratio, 0.85; 95% confidence interval, 0.75-0.97). Hispanic women (risk ratio, 1.61; 95% confidence interval, 1.35-1.92 compared with white women) and those who underwent lymphadenectomy (risk ratio, 1.17; 95% confidence interval, 1.07-1.29) were more likely to have a same-day discharge. The readmission rate was 2.3% in those women discharged on the day of surgery compared with 3.1% in women discharged on postoperative day 1 (P=.051). In a multivariable model, there was no association between same-day discharge and readmission (risk ratio, 0.99; 95% confidence interval, 0.71-1.38). Among women discharged on the day of surgery, a longer operative time and the occurrence of a perioperative complication were associated with readmission. CONCLUSION:Same-day discharge for minimally invasive hysterectomy for endometrial cancer is increasing. In selected patients, there is no increased risk of readmission with same day discharge.

OBJECTIVE:To examine the rate of opioid use for gynecologic surgical procedures and to investigate persistent opioid use among those women who received an initial opioid prescription. METHODS:A retrospective cohort study using the MarketScan database was performed. MarketScan is a claims-based data source that captures claims from more than 50 million privately insured patients and 6 million Medicaid enrollees from 12 states. We identified women who underwent major and minor gynecologic surgery from 2009 to 2016. Among women who received an opioid prescription, new persistent opioid use was defined as receipt of one or more opioid prescriptions from 90 to 180 days after surgery with no intervening additional procedures or anesthesia. Multivariable models were used to examine associations between clinical characteristics and any use and new persistent use of opioids. RESULTS:A total of 729,625 patients were identified. Overall, 60.0% of patients received a perioperative opioid prescription. Receipt of an opioid prescription ranged from 36.7% in those who underwent dilation and curettage to 79.5% of patients who underwent minimally invasive hysterectomy. Among patients who received a perioperative opioid prescription, the rate of new persistent opioid use overall was 6.8%. The rate of new persistent opioid use was 4.8% for myomectomy, 6.6% for minimally invasive hysterectomy, 6.7% for abdominal hysterectomy, 6.3% for endometrial ablation, 7.0% for tubal ligation, and 7.2% for dilation and curettage (P<.001). In a multivariable model, patients who underwent dilation and curettage and endometrial ablation were at highest risk for new persistent opioid use. Younger patients, Medicaid recipients, and patients with depression, anxiety, and substance use disorder more commonly had new persistent opioid use (P<.001 for all). Among women who received an opioid prescription, the rate of new persistent opioid use decreased over time from 7.0% in 2010 to 5.5% in 2016 (P<.001). CONCLUSION:The rate of new persistent opioid use after major and minor gynecologic procedures is substantial.

OBJECTIVE:Long-term outcomes for women with ovarian cancer are improved when they are treated at high volume hospitals by high volume surgeons. We examined changes over time in surgeon and hospital procedural volume for ovarian cancer and explored the association between volume and perioperative outcomes. METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to examine women with ovarian cancer who underwent surgery from 2000 to 2014. Annualized surgeon and hospital procedural volume were estimated and each grouped into quartiles. Changes over time in the annual number of surgeons and hospitals rendering care were estimated. The association between surgeon and hospital volume and perioperative morbidity and mortality were analyzed. RESULTS:We identified 25,044 patients treated by 2728 surgeons at 213 hospitals. The number of surgeons decreased from 598 surgeons with 1737 patients (mean cases = 3) in 2000, to 278 surgeons who operated on 1503 patients (mean cases = 5) (P < 0.001) in 2014, while the mean hospital volume rose from 10 cases to 15 cases over the same time period (P < 0.001). There was no difference in morbidity based on surgeon volume (RR = 0.99 for high vs .low volume; 95% CI, 0.91-1.07) while perioperative mortality rates decreased with increasing surgeon volume quartile from 2.6% to 1.9%, 1.3% and 1.3%, respectively (P < 0.001). Similarly, there was no association between hospital volume and morbidity (RR = 1.00; 95% CI, 0.88-1.15). In contrast, the mortality rate declined with volume quartile from 2.5% in the lowest volume quartile to 0.9% in the highest volume quartile (P < 0.001). CONCLUSION:The surgical care of women with ovarian cancer has been concentrated to a smaller number of surgeons and hospitals over time. There was a modest association between increased surgeon and hospital volume and decreased perioperative mortality.

OBJECTIVE:To examine the prognostic performance of the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging schema. METHODS:We used the National Cancer Database to identify women with cervical cancer diagnosed from 2004 to 2015. Using clinical and pathologic data, each patient's stage was classified using three staging schemas: American Joint Committee on Cancer 7th edition, FIGO 2009 and FIGO 2018. The FIGO 2018 revised staging classifies stage IB tumors into three substages based on tumor size (IB1-IB3) and classifies patients with positive lymph nodes (pathologically or clinically detected) as stage IIIC1 (positive pelvic nodes) or IIIC2 (positive para-aortic nodes). Five-year survival rates were estimated for each stage grouping. We sought to determine whether the 2018 FIGO staging system was able to offer improved 5-year survival rate differentiation compared with older staging schemas. RESULTS:A total of 62,212 women were identified. The classification of stage IB tumors into three substages improved discriminatory ability. Five-year survival in the FIGO 2018 schema was 91.6% (95% CI 90.4-92.6%) for stage IB1 tumors, 83.3% (95% CI 81.8-84.8%) for stage IB2 neoplasms, and 76.1% (95% CI 74.3-77.8%) for IB3 lesions. In contrast, for women with stage III tumors, higher FIGO staging was not consistently associated with worse 5-year survival rates: stage IIIA (40.7%, 95 CI 37.1-44.3%), stage IIIB (41.4%; 95% CI 39.9-42.9%), stage IIIC1 (positive pelvic nodes) was 60.8% (95% CI 58.7-62.8%) and stage IIIC2 37.5% (95% CI 33.3-41.7%). CONCLUSION:The FIGO 2018 staging schema provides improved discriminatory ability for women with stage IB tumors; however, classification of all women with positive lymph nodes into a single stage results in a very heterogeneous group of patients with highly variable survival rates.

OBJECTIVE:To compare the outcomes of women with stage III uterine cancer treated with chemotherapy alone, external beam radiation alone, and combination chemotherapy and radiation. METHODS:The National Cancer Database was used to identify women with stage III endometrioid, serous, and clear cell uterine cancer treated with either chemotherapy (with or without vaginal brachytherapy) alone, external beam radiation (with or without brachytherapy), or combination chemotherapy and external beam radiation (with or without vaginal brachytherapy) from 2004 to 2015. Survival was estimated using Cox proportional hazards models and adjusted survival curves after propensity score analysis using inverse probability of treatment weighting to balance the clinical and demographic characteristics between the cohorts. RESULTS:Of the 20,873 patients identified, 9,456 (45.3%) received chemotherapy alone, 2,417 (11.6%) were treated with radiation alone, and 9,000 (43.1%) received chemotherapy in combination with external beam radiation. Use of combination therapy was 33.0% in 2004, and then rose to 50.5% in 2015. The mortality of the cohort was 33.1% and median survival was 115 months. Within the cohort, combination therapy was associated with a 23% reduction in mortality (hazard ratio [HR]=0.77; 95% CI 0.73-0.80) compared with chemotherapy alone. Similar findings of decreased mortality were noted in subgroup analyses for both stage IIIA (HR=0.81; 95% CI 0.68-0.98) and stage IIIC (HR=0.79; 95% CI 0.75-0.84) tumors. Similarly, when compared with radiation alone, combination therapy was accompanied by a 19% decrease in mortality (HR=0.81; 95% CI 0.73-0.89). Combination chemoradiation was associated with decreased mortality across all of the histologic subtypes. CONCLUSION:Among women with stage III uterine cancer, combination chemotherapy and external beam radiation is associated with decreased mortality compared with chemotherapy or radiation alone.

OBJECTIVE:To assess the potential effects of implementing minimum hospital volume standards for ovarian cancer on survival and access to care. METHODS:We used the National Cancer Database to identify hospitals treating women with ovarian cancer from 2005 to 2015. We estimated the number of patients treated by each hospital during the prior year. Multivariable models were used to estimate the ratio of observed/expected 60-day, and 1-, 2- and 5-year mortalities. The mean predicted observed/expected ratio of hospitals was plotted based on prior year volume. The number of hospitals that would be restricted if minimum-volume standards were implemented was modeled. RESULTS:A total of 136,196 patients treated at 1,321 hospitals were identified. Increasing hospital volume was associated with decreased 60-day (P=.004), 1-year (P<.001), 2-year (P<.001) and 5-year (P=.008) mortality. In 2015, using a minimum-volume cutpoint of one case in the prior year would eliminate 144 (13.6%) hospitals (treated 2.6% of all patients); a cutpoint of three would eliminate 364 (34.5%) hospitals (treated 7.7% of the patients). The mean observed/expected ratios for hospitals with a prior year volume of 1 was 1.14 for 60-day mortality, 1.06 for 1-year mortality, 1.12 for 2-year mortality, and 1.08 for 5-year mortality. Among hospitals with a prior year volume of one, 49.2% had an observed/expected ratio for 2-year mortality of at least 1 (indicating worse than expected performance), and 50.8% had an observed/expected ratio of less than 1 (indicating better than expected performance). The mean observed/expected ratios for hospitals with a prior year volume of two or less were 1.11 for 60-day mortality, 1.09 for 1-year mortality, 1.08 for 2-year mortality, and 1.07 for 5-year mortality. Implementing a minimum-volume standard of one case in the prior year would result in one fewer death for every 198 patients at 60 days, for every 613 patients at 1 year, and for every 62 patients at 5 years. CONCLUSION:Implementation of minimum hospital volume standards could restrict care at a significant number of hospitals, including many centers with better-than-predicted outcomes.

BACKGROUND:The ovaries can be the site for various primary tumors and also the presenting site of metastatic disease. Quick and correct intraoperative diagnosis is crucial for the patient's further management. The aim of this study was to demonstrate the advantages of the combined diagnostic method - ovarian frozen sections in conjunction with cytologic smears. METHODS:From June 2016 to June 2017, we prospectively prepared additional two cytologic smears with Diff-Quik stain on ovarian frozen sections comprised of two hematoxylin and eosin sections. For quality assurance purposes, we compared the results of frozen section discrepancies and deferrals with those that of the previous year from June 2015 to June 2016. RESULTS:With the introduction of cytologic smears to ovarian frozen sections, the number of discrepancies and deferrals combined decreased from 13.75% to 7.85%. The most benefit of smears was observed in primary ovarian malignancies. CONCLUSIONS:In the setting where all the members of the pathology group render cytologic evaluations routinely, smears play an important complementary role.