Faculty Bibliography

Objective: While the incidence of cervical cancer has declined in the United States, cervical cancer continues to be a significant source of morbidity and mortality among specific subsets of women. In a recent study published in Cancer, black women over the age of 85[1] were found to have the greatest mortality from cervical cancer. Importantly, cervical cancer screening guidelines do not extend to this age group, highlighting the importance of gaining a comprehensive understanding of these at risk populations. The objective of this study was to define the characteristics, risk factors and clinical course of patients treated for cervical cancer at a large urban public hospital. [1] Beavis, AL, Gravitt, P Rositch, A, Hysterectomy Corrected Cervical Cancer Mortality Rates;Cancer:2017:-1044-50. Design: A review of patients treated for cervical cancer by gynecologic oncologists at Bellevue Hospital between 2007- 2015. Results: One-hundred and fifty-nine patients were treated for cervical cancer by gynecologic oncologists at an urban academic institution during the specified time period. The median age at diagnosis was 51 years (range 28- 80), with 26 (16.4%) patients over 65 years. Sixty-nine (43.4%) patients identified as Hispanic or Latina, 36 (22.6%) as Black or African-American, 25 (15.7%) as Asian, 17 (10.7%) as Caucasian, and 12 (7.5%) were unknown. Seventy-six (47.8%) patients originated from the United States, while 57 (36%) patients reported their region of origin elsewhere - 24 (15.1%) from Asia, 16 (10.1%) South America, 5 (3.1%) Africa, 12 (7.5%) Europe, and 26 (16.4%) were unknown. The vast majority of patients had public insurance (71.1%), or were uninsured (20.8%). One hundred and seven (67%) patients presented with stage IB2 or higher disease, and the predominant stage at diagnosis was IIB (40, 24.2%). Only 34 (21.4%) patients had a known history of dysplasia, with HSIL being the most common cervical cytology prior to diagnosis. Forty-two (26.4%) patients were smokers, only 1 (0.6%) patient was HIV positive on antiretroviral therapy, and 5 (3.1%) had a history of radiation or chemotherapy from a prior cancer diagnosis. One hundred and eighteen (74.2%) underwent chemotherapy and radiation, while 55 (34.6%) were treated surgically, and 3 (1.9%) did not undergo treatment. At the most recent encounter, 85 (53.5%) patients had no evidence of disease, 67 (42.1%) were alive with disease, and 6 (3.8%) had died of their disease. Conclusion: Despite advances in detection and treatment, cervical cancer remains a significant women's health care issue among at-risk patient populations in the United States. These findings draw attention to how the new screening guidelines may affect the care of women over 65 years of age

Objective Preterm birth is a leading cause of perinatal morbidity and mortality. Prevention strategies rarely focus on preconception care. We sought to create a preconception nomogram that identifies nonpregnant women at highest risk for preterm birth using the Pregnancy Risk Assessment Monitoring System (PRAMS) surveillance data. Methods We used PRAMS data from 2004 to 2009. The odds ratios (ORs) of preterm birth for each preconception variable was estimated and adjusted analyses were conducted. We created a validated nomogram predicting the probability of preterm birth using multivariate logistic regression coefficients. Results 192,208 cases met inclusion criteria. Demographic/maternal health characteristics and associations with preterm birth and ORs are reported. After validation, we identified the following significant predictors of preterm birth: prior history of preterm birth or low birth weight baby, prior spontaneous or elective abortion, maternal diabetes prior to conception, maternal race (e.g., non-Hispanic black), intention to get pregnant prior to conception (i.e., did not want or wanted it sooner), and smoking prior to conception (p < 0.05). Overall, our preconception preterm risk model correctly classified 76.1 % of preterm cases with a negative predictive value (NPV) of 76.7 %. A nomogram using a 0-100 scale illustrates our final preconception model for predicting preterm birth. Conclusion This preconception nomogram can be used by clinicians in multiple settings as a tool to help predict a woman's individual preterm birth risk and to triage high-risk non-pregnant women to preconception care. Future studies are needed to validate the nomogram in a clinical setting.

Objective Antenatal testing has been implemented for advanced maternal age (AMA) women given their increased stillbirth risk. Our objective was to evaluate cesarean delivery and induction rates after the start of antenatal testing at our institution. Study Design A retrospective cohort study of AMA women (>/= 40 years) who delivered at our institution was performed. Testing for AMA began in 2005. AMA women who delivered before (unexposed) and after (exposed) the implementation were compared. Our primary outcome was cesarean delivery and secondary outcome was induction. Chi-square compared categorical variables and multivariable logistic regression calculated odds ratio (OR) and controlled for confounders. Results A total of 276 women were included (147 unexposed and 129 exposed). The cesarean rate was higher in the exposed group (53 vs. 39%, OR 1.76 [1.09-2.84]). The increased risk of cesarean remained after adjusting for race, previous cesarean, multiple gestations, and parity (adjusted OR 1.85 [1.05-3.28]). When excluding those with previous cesareans, the risk of primary cesarean was not significant (OR 1.57 [0.89-2.76]). The induction rate was not different (38 vs. 33%, p = 0.4). Conclusions While overall cesareans increased, there was no difference in primary cesarean and induction rates for AMA women after implementation of antenatal testing for AMA.

To examine the association between actual and perceived overweight/obese status and excess gestational weight gain (GWG). As part of an infant feeding trial, multi-ethnic lower and moderate income women-completed a checklist of current health conditions, including "overweight/obesity," "asthma," and "hypertension" while pregnant. Odds of excessive GWG per the Institute of Medicine guidelines in 'accurate' versus 'inaccurate' reporters, by overweight status were analyzed with multivariate logistic regression for women with pre-or early pregnancy BMIs of >/=18.5. 775 women met study criteria. Just 21 % (n = 107) of overweight/obese women accurately identified their weight status, compared to >90 % accurate report of documented hypertension or asthma. Compared to normal-weight accurate reporters, the adjusted odds of excessive GWG in overweight/obese women was 2.3 (95 % CI 1.4, 3.7) in accurate reporters, and 2.5 (95 % CI 1.7, 3.4) in inaccurate reporters. Overweight/obesity is associated with excessive GWG, but this risk is not modified by inaccurate reporting/perception of weight-status.