Effects of Endometrial Ablation on Treatment Planning in Women With Endometrial Cancer.

To evaluate effects of endometrial ablation on the staging and treatment planning of postablation endometrial cancer. After authorization from the institutional review board, we performed a retrospective chart review of patients with a history of endometrial ablation and a subsequent diagnosis of endometrial cancer from July 2006 to December 2013. The information obtained included patient's age at time of cancer diagnosis, pre-ablation endometrial biopsy histology, dilation and curettage histology at time of ablation, endometrial biopsy-to-ablation interval, ablation-to-hysterectomy interval, final pathologic diagnosis, Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) staging, and treatment recommendations for adjuvant therapy. The histopathology was examined by a gynecologic pathologist. The National Comprehensive Cancer Network guidelines were applied to determine need for adjuvant therapy. Six of 490 (1.2%) patients with endometrial cancer were identified to have an antecedent ablation. Mean patient age was 48.2 years (range: 40-53). The time interval from office pre-ablation endometrial sampling to ablation ranged from 1 to 17 months. Four patients (67%) had an undetected endometrial cancer at the time of ablation, despite having benign pre-ablation histology. Following surgical staging, 4 patients (67%) had no evidence of residual carcinoma, and 2 (33%) had evidence of endometrial adenocarcinoma grades 1 to 2. There was no evidence of myometrial invasion in all cases, and a FIGO stage of IA was assigned. No adjuvant therapies were indicated. There have been no documented cancer recurrences, with a follow-up range from 16 to 52 months (average 30.2). Endometrial ablation artifact does not appear to hinder evaluation and treatment planning in the presence of endometrial cancer.

Robotic Surgery Training in an OB/GYN Residency Program: A Survey Investigating the Optimal Training and Credentialing of OB/GYN Residents.

OBJECTIVE: Many community hospital gynecologic surgery training programs now include robotics.At St. Francis Hospital and Medical Center, we have integrated robotic surgical training since 2006. This study is designed to assess the success in training gynecology residents in robotic surgery. DESIGN: An anonymous web-based survey tool (www. survey monkey. com) was sent to all Ob/Gyn residency graduates from 2007-2010 (n = 17). From 2011-2014, we emailed three reevaluation questions to all 2007-2014 graduates (N = 32). Design Classification: II-3. RESULTS: The response rate was 95%, and 11 of 17 initial graduates (65%) indicated that they had received adequate robotic training. Currently, 24 of 32 (75%) graduates practice in hospitals with robotic availability. Twenty of the 32 graduates (63%) are using robotics in their surgical practices. Nine of these 20 graduates (45%) were fully credentialed following their residency. The other 11 graduates (55%)required further proctoring to obtain full robotic credentials. CONCLUSION: Robotic surgical training is a component of modern gynecologic surgical training. Postresidency robotic credentialing is a realistic graduation goal for residents who plan to practice gynecologic surgery.

Ovarian cancer in the United States: contemporary patterns of care associated with improved survival.

BACKGROUND: Ovarian cancer (OC) requires complex multidisciplinary care with wide variations in outcome. We sought to determine the impact of institutional and process of care factors on overall survival (OS) and delivery of guideline care nationally. METHODS: This was a retrospective cohort study of primary OC diagnosed from 1998 to 2007 using the National Cancer Data Base (NCDB) capturing 80% of all U.S. cases. Patient- (demographics, comorbidities, stage/grade), process of care (adherence to guidelines) and institutional- (facility type, case volume) factors were evaluated. Primary outcomes were OS and delivery of guideline therapy. Multivariable logistic regression and Cox proportional hazards models were used for analysis. RESULTS: We analyzed 96,802 consecutive cases. Five-year OS was 84%, 66.3%, 32% and 15.7% for stages I, II, III and IV, respectively. The annual mean facility case volumes varied by cancer center type (range: 5.7 to 26.7), with 25% of cases spread over 65% of centers--all treating fewer than 8 cases. Overall, 56% of cases received non-guideline care. Low facility case volume and higher comorbidity index independently predicted non-guideline care; high volume centers were less likely to deliver non-guideline care (OR: 0.44, 95% CI: 0.41-0.47). Delivery of non-guideline care (OR: 1.4, 95% CI: 1.36-1.44), and higher facility case volume (OR: 0.91, 95% CI: 0.86-0.96) were both independent predictors of OS. CONCLUSIONS: Delivery of guideline care and facility case volume are important drivers of overall survival. Most cancer centers treat very few women with OC. National efforts should focus on improved access to centers with expertise in OC and ensuring delivery of guideline care.

Disparities in ovarian cancer care quality and survival according to race and socioeconomic status.

BACKGROUND: The relationship between racial and socioeconomic status (SES) disparities and the quality of epithelial ovarian cancer care and survival outcome are unclear. METHODS: A population-based analysis of National Cancer Data Base (NCDB) records for invasive primary epithelial ovarian cancer diagnosed in the period from 1998 to 2002 was done using data from patients classified as white or black. Adherence to National Comprehensive Cancer Network (NCCN) guideline care was defined by stage-appropriate surgical procedures and recommended chemotherapy. The main outcome measures were differences in adherence to NCCN guidelines and overall survival according to race and SES and were analyzed using binomial logistic regression and multilevel survival analysis. RESULTS: A total of 47 160 patients (white = 43 995; black = 3165) were identified. Non-NCCN-guideline-adherent care was an independent predictor of inferior overall survival (hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.38 to 1.47). Demographic characteristics independently associated with a higher likelihood of not receiving NCCN guideline-adherent care were black race (odds ratio [OR] = 1.36, 95% CI = 1.25 to 1.48), Medicare payer status (OR = 1.20, 95% CI = 1.12 to 1.28), and not insured payer status (OR = 1.33, 95% CI = 1.19 to 1.49). After controlling for disease and treatment-related variables, independent racial and SES predictors of survival were black race (HR = 1.29, 95% CI = 1.22 to 1.36), Medicaid payer status (HR = 1.29, 95% CI = 1.20 to 1.38), not insured payer status (HR = 1.32, 95% CI = 1.20 to 1.44), and median household income less than $35 000 (HR = 1.06, 95% CI = 1.02 to 1.11). CONCLUSIONS: These data highlight statistically and clinically significant disparities in the quality of ovarian cancer care and overall survival, independent of NCCN guidelines, along racial and SES parameters. Increased efforts are needed to more precisely define the patient, provider, health-care system, and societal factors leading to these observed disparities and guide targeted interventions.

Surgically (laparotomy/laparoscopy) guided placement of high dose rate interstitial irradiation catheters (LG-HDRT): technique and outcome.

OBJECTIVE: To describe and evaluate the technique and the clinical outcome of a new modality for the treatment of women with persistent or recurrent pelvic malignancies utilizing surgically (laparotomy or laparoscopic) guided high dose rate (HDR) catheters to complete high dose rate interstitial irradiation therapy (LG-HDRT). METHODS: Between 6/2000 and 6/2004, 14 women with histologic evidence of postradiation persistent (3 patients) or recurrent (11 patients) pelvic disease underwent LG-HDRT. Five patients (36%) received treatment for a 2nd, 3rd or 4th recurrence. Preoperative clinical and radiologic evaluation to exclude evidence of extrapelvic disease was routine. Initial intraoperative evaluation included intraabdominal inspection and or biopsy to determine the extent of disease. A two "team" approach was used to place the 100 cm Teflon after loading HDR catheters. Each catheter had its open ends closed with bone wax prior to placement. Using a 14 gauge intravenous catheter as a guide, each HDR catheter was individually placed transvaginally. The tumor bed (treatment volume) was marked circumferentially with clips to facilitate treatment planning. Dosimetry was typically completed on the day of surgery and HDR therapy was started within the initial 24 postoperative hours. The catheters were removed transvaginally, without anesthesia following completion of therapy. RESULTS: Mean patient age was 63.1 years and weight was 138.2 lb. Squamous cell cancer of the vagina or cervix was the most common (64%) diagnosis. The mean time from initial diagnosis to LG-HDRT was 67.9 months. The procedure was completed laparoscopically in 71% of patients, with 4 patients requiring laparotomy (3 conversions from laparoscopy). The mean duration of surgery was 94.9 min and the mean hospital stay was 4.8 days. Only 2 patients (14%) were discharged prior to the completion of therapy. The mean number of catheters placed was 6.1 and the mean dose delivered was 20 Gy over a mean of 5 fractions. There were no major intraoperative complications. Postradiation complications were limited to DVT (1), bladder bleeding (1),

Poly(L-lactide/glycolide) suture: the effect of acute radiation.

UNLABELLED: The physical properties of Poly(L-lactide/glycolide) indicate that the suture retains approximately 80% of its original strength at 3 months and 60% of its original strength at 6 months. This new long-term synthetic absorbable suture offers postoperative fascial strength for an extended period when compared to other available absorbables. Importantly, many women with gynecologic cancer will undergo radiation therapy during this interval. This report is intended to evaluate the effects of ionizing radiation on this suture. METHODS: One lot (op strands) of size 1 PLG suture was used. Ten (10) strands were used for baseline study of out of package tensile strength. Eighty (80) strands were placed in a buffer solution (pH approximately 9.0) and incubated in an in vitro water bath approximately 48 h at 55 degrees C to simulate 4 weeks in vitro residence time. Following this in vitro hydrolysis 20 strands were tested. Sixty strands were placed beneath a piece of fresh full thickness porcine skin and subcutaneous tissue and exposed to 3, 30, and 70 Gy. All samples were evaluated for breaking strength and elongation-at-break using an Instron tensiometer. RESULTS: Analysis of variance performed at the different exposure level revealed no significant effect on tensile properties (p>0.1). CONCLUSION: The tensile properties of PLG suture are not adversely affected by ionizing radiation. This long-term absorbable suture is an alternative for fascial closure when extended periods of support are necessary in patients destined to receive therapeutic ionizing radiation.

Stage IC adenocarcinoma of the endometrium: survival comparisons of surgically staged patients with and without adjuvant radiation therapy.

OBJECTIVE: The goal of this study was to determine the outcomes of stage IC endometrial carcinoma patients who are managed with and without adjuvant radiation therapy after comprehensive surgical staging. METHODS: Patients with FIGO stage IC adenocarcinoma of the endometrium diagnosed from 1988 to 1999 were identified from tumor registry databases at four institutions. A retrospective chart review identified 220 women who underwent comprehensive surgical staging including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic/paraaortic lymphadenectomy, and peritoneal cytology. RESULTS: Of the 220 stage IC patients, 56 (25%) patients received adjuvant brachytherapy (BT), 19 (9%) received whole-pelvis radiation (WPRT), and 24 (11%) received both WPRT and BT. One hundred twenty-one patients (55%) did not receive adjuvant radiation. There were 6 recurrences (6%) in the radiated group and 14 (12%) in the observation group (P = 0.20). Seven of fourteen recurrences in the observation group were local, and all local recurrences were salvaged with radiation therapy. Two of seven distant recurrences in this group were also salvaged with surgery and chemotherapy. The overall salvage rate for the observation group was 64%. There was a statistical difference in 5-year disease-free survival between the radiated and observation groups (93% vs 75%, P = 0.013). However, the 5-year overall survival was similar in the two groups (92% vs 90%, P = 0.717). CONCLUSION: Adjuvant radiation therapy improves disease-free survival in surgical stage IC patients; however, overall survival is not improved with adjuvant radiation therapy since the majority of local recurrences in conservatively managed patients can be salvaged with radiation therapy.

Health literacy, cervical cancer risk factors, and distress in low-income African-American women seeking colposcopy.

OBJECTIVES: To describe the relationship between health literacy, distress, and cervical cancer risk factors in women at high risk for developing cervical cancer. DESIGN: Cross-sectional, prospective cohort design. SETTING: Two university-based gynecological oncology colposcopy clinics and 3 Planned Parenthood community dinics. PATIENTS/PARTICIPANTS: One hundred-thirty English-speaking African-American women > or = 18 years referred for colposcopy following abnormal Pap testing. MAIN OUTCOME MEASURES: Avoidance and Intrusion subscales of the Impact of Events Scale (IES), Rapid Estimate of Adult Literacy in Medicine (REALM), and demographics. RESULTS: Forty-five percent of women had a low level of health literacy (< 9th grade). Low health literacy was related to fewer risk factors (P < .01) and higher levels of distress on the Impact of Events avoidance subscale (P < .05) after controlling for covariates. Forty-three percent of women with low literacy had excessive levels of distress as compared to 25% in women with high literacy (P < .05). CONCLUSIONS: A low level of health literacy is associated with increased levels of distress among women at high risk for developing cervical cancer. To the extent that distress serves as a barrier to treatment, culturally informed, effective interventions are needed.