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An epidemiologic study that used large cancer databases (National Cancer Database and SEER) showed that minimally invasive hysterectomy was associated with shorter survival than laparotomy among patients with early cervical cancer. A prospective randomized trial and an epidemiologic study that used large cancer databases (National Cancer Database and SEER) both showed that minimally invasive radical hysterectomy was associated with shorter survival in early cervical cancer than open abdominal radical hysterectomy.

The treatment of endometrial cancer has changed substantially in the past decade with the introduction of a new staging system and surgical approaches accompanied by novel adjuvant therapies. Primary surgical treatment is the mainstay of therapy but the effectiveness and extent of lymphadenectomy has been challenged, and its acceptance as a routine procedure varies by country. The role of radiation has evolved and chemotherapy has been incorporated, either alone or combined with radiation, to treat the many patients in whom cancer recurs because of a tumour outside the originally radiated pelvic and lower abdominal area. Use of traditional adjuvant chemotherapeutics has been challenged in clinical trials of new agents with improved side-effect profiles. Novel agents and targeted therapies are being investigated. Research into genetic susceptibility to endometrial cancer and the potential genetic aberrations that might translate into therapeutic interventions continues to increase. Substantial global variability in the treatment of endometrial cancer has led to examination of long-accepted norms, which has resulted in rapidly changing standards. International cooperation in clinical trials will hasten progress in treatment of this ubiquitous cancer.

MIS was associated with an increased locoregional recurrence rate and decreased overall survival.1 Similar findings were noted in a large, observational study and subsequently confirmed in a variety of reports.2 While these data are compelling, the majority of women, including 92% of those enrolled in the LACC trial, had stage IB1 tumors.1 As such, whether these findings apply to women with microscopic (stage IA1 or IA2) cervical cancer remains an area of uncertainty. A multi-institutional observational analysis of 851 patients with stage IA2–IB1 tumors found that MIS was associated with an increased risk of recurrence within the cohort overall, however, in the subset of women who underwent preoperative conization and had no tumor on preoperative assessment prior to radical history there was no increased risk associated with MIS.4 Similarly, a report of 372 women with IB1 tumors who had no grossly visible lesions preoperatively found no difference in survival based on route of surgery.5 The authors of the current report recognize a number of limitations. [...]the data source only captures overall survival and data on recurrences are lacking.

Postmenopausal bleeding (PMB) is a common gynecologic condition. Although it can be a sign of uterine cancer, most patients have benign etiology. However, research on quality of diagnostic evaluation for PMB has been limited to cancer patients. To extend this research, we examined the timeliness of diagnostic evaluation for PMB among patients with benign conditions. Using the 2008-2019 MarketScan Research Databases, we identified 499176 patients (456741 with commercial insurance and 42435 with Medicaid insurance) who presented with PMB but did not have gynecologic cancer. For each patient, we measured the time from their PMB reporting to the date of their first diagnostic procedure. The association between patient characteristics and time to first diagnostic procedure was examined using Cox proportional hazards models (for the overall sample and then stratified by insurance type). Overall, 54.3% of patients received a diagnostic procedure on the same day when they reported PMB and 86.6% received a diagnostic procedure within 12 months after reporting PMB. These percentages were 39.4% and 77.1%, respectively, for Medicaid patients, compared to 55.7% and 87.4%, respectively, for commercially insured patients (p<0.001 for both). Medicaid patients had an 18% lower rate of receiving a diagnostic procedure at any given time point than commercially insured patients (adjusted hazard ratio = 0.82, 95% CI: 0.81-0.83). Meanwhile, older age and non-gynecologic comorbidities were associated with a lower rate whereas concomitant gynecologic conditions and recent use of preventive care were associated with a higher rate of receiving diagnostic procedures. Analysis stratified by insurance type identified additional risk factors for delayed diagnostic procedures (e.g., non-metropolitan versus metropolitan location for commercially insured patients and Black versus White race for Medicaid patients). A sizable proportion of patients did not receive prompt diagnostic evaluation for PMB. Both clinical and non-clinical factors could affect timeliness of evaluation.

BackgroundSurvival outcomes in metastatic breast cancer (MBC) have improved due to novel agents such as CDK4/6 inhibitors (CDK4/6i). Nevertheless, Black patients and patients with lower socioeconomic status (SES) continue to bear a disproportionate mortality burden.MethodsWe conducted a retrospective analysis of EHR-derived data from the Flatiron Health Database (FHD). A dataset was constructed to include Black/African-American (Black/AA) and White patients with hormone receptor (HR)-positive, HER2-negative MBC. Outcomes included CDK4/6i use (overall and first-line), and rates of leukopenia, dose reduction, and time on treatment for first-line CDK4/6i. Multivariable logistic regression was used to evaluate factors associated with use and outcomes.ResultsA total of 6802 patients with MBC were included, of which 5187 (76.3%) received CDK4/6i. Of those, 3186 (61.4%) received CDK4/6i first-line. Overall, 86.7% of patients were categorized as White and 13.3% as Black/AA; 22.4% were > 75 years old; 12.6% were treated at an academic site; 3.3% had Medicaid insurance. In addition to advanced age and poorer performance status, lower use of CDK4/6i was associated with Black/AA vs White race (72.9% vs 76.8%; OR 0.83, 95% CI 0.70–0.99, p = 0.04) and Medicaid vs commercial insurance (69.6% vs 77.4%; OR: 0.68, 95% CI 0.49–0.95, p = 0.02). Odds of CDK4/6i use were twofold higher for patients treated at an academic center (p < 0.001). Rates of CDK4/6i-induced leukopenia and dose reductions did not differ significantly by race, insurance type, or treatment site. Time on CDK4/6i was significantly lower among Medicaid patients (395 days) than patients with commercial insurance (558 days) or Medicare (643 days) (p = 0.03).ConclusionThis analysis of real-world data suggests that Black race and lower SES are associated with decreased CDK4/6i use. However, among patients treated with CDK4/6i, subsequent toxicity outcomes are similar. Efforts to ensure access to these life-prolonging medications are warranted.

BackgroundData regarding the prognostic significance of lymphovascular space invasion (LVSI) for stage IA1 and IA2 cervical cancer are limited. Specifically, the role of LVSI as an independent risk factor for mortality in stage IA disease has not been shown.ObjectiveWe examined the association between LVSI and nodal metastases and survival for women with stage IA1 and IA2 cervical cancer.Study DesignWe used the National Cancer Database to identify patients with stage IA adenocarcinoma or squamous carcinoma of the cervix from January 2010 through December 2015 for whom LVSI status was known. Mixed-effect log-Poisson models were used to identify predictors of LVSI. Cox proportional hazard models and Kaplan-Meier curves were used to compare all-cause mortality.ResultsWe identified 3239 patients with stage IA1 and 1049 patients with stage IA2 carcinoma of the cervix. Among patients with stage IA1 and IA2 disease, 10.5% and 18.8% had LVSI, respectively. Less than 1% of patients with stage IA1 disease without LVSI had positive nodes compared with 7.8% of those with LVSI (p<0.001). Lymphatic metastases were identified in 1.7% of stage IA2 cases without LVSI versus 14.6% for those with LVSI (p<0.001). Among both stage IA1 and IA2 patients, squamous histology, grade 3 tumor differentiation, and white race were associated with LVSI (p<0.05 for all). In a univariable model, the hazard ratio for death associated with LVSI was 1.05 (95% CI 0.45 to 2.45) for women with stage IA1 tumors and 2.36 (95% CI 1.04 to 5.33) for those with IA2 neoplasms.ConclusionsLVSI is associated with lymph node metastases in patients with stage IA cervical cancer. LVSI is associated with decreased survival for women with stage IA2 cervical cancer.

In this nationwide cross-sectional study of 4,055,462 hospital admissions with a diagnosis of coronavirus disease 2019 (COVID-19) from April 2020 to December 2021 identified in the Agency of Healthcare Research and Quality’s Healthcare Cost and Utilization Project National Inpatient Sample in the United States, a total of 489,390 (12.1%) patients experienced endotracheal intubation and mechanical ventilation, with the highest peak in August 2021 (48,735 endotracheal intubations and mechanical ventilation), followed by January 2021 (47,100 endotracheal intubations and mechanical ventilation) and December 2021 (43,835 endotracheal intubations and mechanical ventilation). During the 3-month long large surge from November 2020 to January 2021, a total of 104,750 endotracheal intubations and mechanical ventilation occurred among 1,069,874 COVID-19 admissions. Shock (adjusted-odds ratio 24.21, 95% confidence interval 23.93–24.49) and respiratory failure (adjusted-odds ratio 14.09, 95% confidence interval 13.80–14.38) were the two strongest factors associated with endotracheal intubation and mechanical ventilation. A total of 266,585 (6.6%) patients received non-invasive respiratory support alone without endotracheal intubation and mechanical ventilation during the study period with the highest peak in August 2021 (30,725 cases), followed by January 2021 (28,035 cases), and December 2021 (26,200 cases). The utilization of non-invasive respiratory support without endotracheal intubation and mechanical ventilation increased by nearly three-fold during the 21-month study period (adjusted-odds ratio for the fourth year-quarter of 2021 compared to the second year-quarter of 2020 2.94, 95% confidence interval 2.88–3.00). A total of 515,800 (12.7%) deaths occurred during COVID-19 hospitalization, with highest in the peak of multi-month lasting largest surge (January 2021, 56,775 deaths), followed by August 2021 (47,535 deaths) and December 2021 (46,880 deaths). Among those who deceased following endotracheal intubation and mechanical ventilation, the median time from admission to death was 14 days (interquartile range 7–21). COVID-19 admissions, respiratory intervention approach, and COVID-19 case fatality differed across the nine U.S. census divisions during the study period. In conclusion, these statistics may be useful to inform the national-level preparedness of global pandemic from respiratory illness in the future, possibly exceeding 48,000 endotracheal intubations and mechanical ventilation across the country in a month and 100,000 endotracheal intubations and mechanical ventilation in three months when encountering long-lasting surge with one-million admissions.

ObjectiveThe aim of this study was to examine the survival effect of adjuvant therapy in stage II–III endometrial cancer based on peritoneal cytology results.MethodsThe National Cancer Institute’s Surveillance, Epidemiology, and End Results Program was retrospectively queried to examine 7467 women with stage II–III endometrial cancer who underwent hysterectomy, and with available peritoneal cytology results, from 2010 to 2016. A Cox proportional hazard regression model was fitted to assess the association between adjuvant therapy and all-cause mortality stratified by peritoneal cytology results.ResultsMalignant peritoneal cytology was reported in 1662 (22.3%) women and was associated with non-endometrioid histology, higher tumor stage, and nodal metastasis (p < 0.05). In a propensity score-weighted model, malignant peritoneal cytology was associated with increased all-cause mortality compared with negative peritoneal cytology (hazard ratio 1.35, 95% confidence interval 1.23–1.48). Adjuvant therapy types varied based on histology and peritoneal cytology results. In non-endometrioid histology, the combination of chemotherapy and whole pelvic radiotherapy (WPRT) was associated with improved overall survival compared with chemotherapy or WPRT alone irrespective of the peritoneal cytology results (p < 0.05). The combination of chemotherapy and WPRT was also associated with improved overall survival in women with endometrioid histology and malignant peritoneal cytology (p = 0.026). Women with endometrioid histology and negative peritoneal cytology represented the most common subpopulation (46.5%), and overall survival was similar regardless of which of the three adjuvant therapy modalities was used (p = 0.319).ConclusionsMalignant peritoneal cytology is prevalent and prognostic in stage II–III endometrial cancer. This study found that the surgeon’s choice and benefit of adjuvant therapy for women with stage II–III endometrial cancer differed depending on the status of peritoneal cytology.

ObjectiveThe International Federation of Gynecology and Obstetrics (FIGO) revised the vulvar cancer staging schema in 2021. Previous stage IIIA–B diseases were reclassified based on nodal size (≤5 mm for stage IIIA compared with >5 mm for stage IIIB), and previous stage IVA1 disease based on non-osseous organ extension was reclassified to stage IIIA whereas osseous extension remained as stage IVA. This study sought to validate the 2021 FIGO vulvar cancer staging schema.MethodsThis retrospective cohort study examined 889 women with stage III–IV vulvar cancer from 2010 to 2015 in the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. Stage shift and overall survival were assessed by comparing the 2021 and 2009 FIGO staging schemas.ResultsStage shift occurred in 229 (25.8%) patients (upstaged 17.7% and downstaged 8.1%). When comparing the new and previous staging schemas, 5 year overall survival rates were 45.6% versus 48.9% for stage IIIA, 47.0% versus 44.2% for stage IIIB, and 13.9% versus 25.1% (interval change −11.2%) for stage IVA diseases. According to the revised staging schema, 5 year overall survival rates were similar for stage IVA and IVB diseases (13.9% vs 14.5%) and for stage IIIA and IIIB disease (45.6% vs 47.0%). For new stage IIIA disease, 5 year overall survival rates differed significantly based on the staging factors (nodal involvement vs non-nodal organ involvement, 48.9% vs 38.7%, difference 10.2%, p=0.038).ConclusionThe 2021 FIGO staging schema results in one in four cases of advanced vulvar cancer being reclassified. Survival rates of patients with new stage IVA disease worsened significantly whereas those of patients with new stage IIIA disease were heterogenous based on the staging factors. The discriminatory ability of the revised 2021 FIGO staging schema for 5 year overall survival rate between patients with stage IIIA and IIIB tumors and those with IVA and IVB tumors is limited in this study population.

ObjectiveSurgery for placenta accreta spectrum is associated with significant maternal morbidity and mortality. The role of gynecologic oncologists in the surgical management of placenta accreta spectrum is currently under investigation. This study examined the practices, experiences, and interests of gynecologic oncologists in placenta accreta spectrum surgeries.MethodsThe intervention was an anonymous, cross-sectional, 20-question survey sent to 1084 members of the Society of Gynecologic Oncology in the USA.ResultsA total of 184 gynecologic oncologists responded to the survey (response rate 17.0%). Most participating gynecologic oncologists have been practicing for >10 years after fellowship (53.2%), practice in urban-teaching hospitals (84.8%) with delivery volumes ≥3000/year (54.3%), and have a multidisciplinary approach (82.5%). Three-quarters (78.7%) feel that the rate of placenta accreta spectrum is increasing over time. One-third (35.5%) perform ≥6 hysterectomies for placenta accreta spectrum yearly. Less than half (45.5%) practice conservative management. Approximately half are involved from the beginning of the case (49.7%) and perform the surgery in the main operating room (59.4%). Almost three-quarters (71.6%) have experienced surgical blood loss >5 L and one-third (36.6%) have experienced cases with blood loss >10 L. About half (50.3%) of participants are interested in placenta accreta spectrum surgery for future practice. Gynecologic oncologists engaging in a multidisciplinary approach are more likely to practice in an urban-teaching hospital, have higher surgical volume, be involved from the beginning of the case, and be interested in placenta accreta spectrum surgery. Those >10 years post-training and in the Southern US region are more likely to practice conservative management or delayed hysterectomy.ConclusionThis society-based cross-sectional survey suggests that gynecologic oncologists are actively involved in the surgical management of placenta accreta spectrum in the USA. Nearly half of gynecologic oncologists who responded to the survey expressed interest in surgery for placenta accreta spectrum.