Trends in Use and Survival Associated With Fertility-Sparing Trachelectomy for Young Women With Early-Stage Cervical Cancer.

OBJECTIVE: To assess the trends in use of trachelectomy in the United States and to examine the outcomes of the procedure compared with hysterectomy in young women with cervical cancer. METHODS: Data were analyzed from women younger than 50 years of age with stage IA2-IB2 cervical cancer treated with hysterectomy or trachelectomy from 2004 to 2014 who were registered in the National Cancer Database. After propensity score matching, we used Cox proportional hazard models to examine the association between treatment and survival. RESULTS: We identified 15,150 patients with cervical cancer, including 14,714 (97.1%) who underwent hysterectomy and 436 (2.9%) who underwent trachelectomy. Trachelectomy rates increased from 1.5% in 2004 to 3.8% by 2014 (P<.001). The greatest increase in the rate of trachelectomy was seen in women younger than 30 years of age (4.6% in 2004 to 17.0% in 2014, P<.001). Among women who underwent trachelectomy, 29.6% had tumors greater than 2 cm in diameter. In a multivariable model, younger women and those more recently diagnosed were more likely to undergo trachelectomy, whereas Medicaid recipients (risk ratio 0.39, 95% CI 0.28-0.54) and the uninsured (risk ratio 0.67, 95% CI 0.45-1.00) were less likely to undergo trachelectomy. After propensity score matching, there was no association between trachelectomy and the risk of mortality (hazard ratio 1.24, 95% CI 0.70-2.22) (mortality rate was 6.0% for hysterectomy vs 5.2% for trachelectomy). Similarly, 5-year survival rates were similar between trachelectomy and hysterectomy for all of the stages examined. CONCLUSIONS: Use of trachelectomy for early-stage cervical cancer has increased in the United States, particularly among women younger than 30 years of age. Within this population, survival is similar for trachelectomy and hysterectomy.

Risk of Occult Uterine Sarcoma in Presumed Uterine Fibroids.

Symptomatic fibroids are a common indication for hysterectomy or myomectomy. Although rare, unexpected gynecologic malignancies in presumed fibroids have been documented. In cases where tissue retrieval is performed through morcellation, there is increasing concern that intra-abdominal dispersion of occult uterine malignancies may lead to peritoneal dissemination and worse outcomes. We examined the available literature to determine the prevalence of all uterine cancers in women undergoing hysterectomy or myomectomy for benign uterine disease, with attention to the risk of morcellating occult uterine sarcomas. We also reviewed the available tools for preoperative discrimination between benign and malignant uterine disease.

Economic and Survival Implications of Use of Electric Power Morcellation for Hysterectomy for Presumed Benign Gynecologic Disease.

BACKGROUND: Electric power morcellation during laparoscopic hysterectomy allows some women to undergo minimally invasive surgery but may disrupt underlying occult malignancies and increase the risk of tumor dissemination. METHODS: We developed a state transition Markov cohort simulation model of the risks and benefits of hysterectomy (abdominal, laparoscopic, and laparoscopic with electric power morcellation) for women with presumed benign gynecologic disease. The model considered perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy. We explored the effectiveness from a societal perspective stratified by age (<40, 40-49, 50-59, and ≥60 years). RESULTS: Under all scenarios, modeled laparoscopic hysterectomy without morcellation was the most beneficial strategy. Laparoscopic hysterectomy with morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions than abdominal hysterectomy per 10 000 women. Per 10 000 women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.97 fewer deaths than abdominal hysterectomy. The excess cases of disseminated cancer per 10 000 women with morcellation compared with abdominal hysterectomy increased with age to 47.54 per 10 000 in women age 60 years and older. Compared with abdominal hysterectomy, this resulted in 0.30 (age 40-49 years), 5.07 (age 50-59 years), and 18.14 (age 60 years and older) excess deaths per 10 000 women in the respective age groups. CONCLUSION: Laparoscopic hysterectomy without morcellation is the most beneficial approach of the three methods of hysterectomy studied. In older women, the risks of electric power morcellation may outweigh the benefits of minimally invasive hysterectomy.

Incentivizing HIV/STI testing: a systematic review of the literature.

Suboptimal HIV/STI testing uptake has a profound impact on morbidity and mortality. Incentives have been effective in other areas of medicine and may improve HIV/STI testing uptake rates. This study reviewed the effects of incentives on HIV/STI testing uptake. A systematic search of seven databases was undertaken. Testing uptake was defined as test implementation and/or test result retrieval. Incentives were defined as monetary or non-monetary rewards or free-of-charge testing vouchers. Seven studies were included. All seven studies demonstrated higher rates of uptake in an incentivized group. Incentives offered at a non-clinical setting demonstrated more significant differences in uptake rates compared to incentives offered at a clinical setting. Incentivizing HIV/STI testing uptake, especially testing at a non-clinical setting, may be a useful tool to modify health behavior. Further research is needed to understand how incentives could be an effective component within a comprehensive HIV/STI control strategy.

Microenterprise development interventions for sexual risk reduction: a systematic review.

Comprehensive interventions that address both individual and structural determinants associated with HIV/STI risk are gaining increasing attention over the past decade. Microenterprise development offers an appealing model for HIV prevention by addressing poverty and gender equality. This study systematically reviewed the effects of microenterprise development interventions on HIV/STI incidence and sexual risk behaviors. Microenterprise development was defined as developing small business capacity among individuals to alleviate poverty. Seven eligible research studies representing five interventions were identified and included in this review. All of the studies targeted women, and three focused on sex workers. None measured biomarker outcomes. All three sex worker studies showed significant reduction in sexual risk behaviors when compared to the control group. Non-sex worker studies showed limited changes in sexual risk behavior. This review indicates the potential utility of microenterprise development in HIV risk reduction programs. More research is needed to determine how microenterprise development can be effectively incorporated in comprehensive HIV control strategies.