June Y. Hou

Trends in Relative Survival for Ovarian Cancer From 1975 to 2011

OBJECTIVE: To examine relative survival (a metric that incorporates changes in survival within a population) in women with ovarian cancer from 1975 to 2011. METHODS: Women diagnosed with ovarian cancer from 1975 to 2011 and recorded in the National Cancer Institutes Surveillance, Epidemiology, and End Results database were examined. Relative survival, estimated as the ratio of the observed survival of cancer patients (all-cause mortality) to the expected survival of a comparable group from the general population, was matched to the patients with the main factors that are considered to affect patient survival such as age, calendar time, and race. Hazard ratios were adjusted for age, race, year of diagnosis, time since diagnosis, and the interaction of age and years since diagnosis (except for stage II). RESULTS: A total of 49,932 women were identified. For stage I ovarian cancer, the adjusted excess hazard ratio for death in 2006 was 0.51 (95% confidence interval [CI] 0.41–0.63) compared with those diagnosed in 1975. The reduction in excess mortality remained significant when compared with 1980 and 1985. For women with stage III–IV tumors, the excess hazard of mortality was lower in 2006 compared with all other years of study ranging from 0.49 (95% CI 0.44–0.55) compared with 1975 to 0.93 (95% CI 0.87–0.99) relative to 2000. For women aged 50–59 years, 10-year relative survival was 0.85 (99% CI 0.61–0.95) for stage I disease and 0.18 (99% CI 0.10–0.27) for stage III–IV tumors. For women aged 60–69 years, the corresponding 10-year relative survival estimates were 0.89 (99% CI 0.58–0.98) and 0.15 (99% CI 0.09–0.21). CONCLUSION: Relative survival has improved for all stages of ovarian cancer from 1975 to 2011. LEVEL OF EVIDENCE: II

Use of Electric Power Morcellation and Prevalence of Underlying Cancer in Women Who Undergo Myomectomy

IMPORTANCE Myomectomy, the excision of uterine leiomyoma, is now commonly performed via minimally invasive surgery. Electric power morcellation, or fragmentation of the leiomyoma with a mechanical device, may be used to facilitate extraction of the leiomyoma. OBJECTIVE To analyze the prevalence of underlying cancer and precancerous changes in women who underwent myomectomy with and without electric power uterine morcellation. DESIGN, SETTING, AND PARTICIPANTS We used a US nationwide database to retrospectively analyze women who underwent myomectomy at 496 hospitals from January 2006 to December 2012. Use of electric power morcellation at the time of myomectomy was investigated. The prevalence of uterine cancer, uterine neoplasms of uncertain malignant potential, and endometrial hyperplasia were estimated. Multivariable mixed-effects regression models were developed to examine predictors of use of electric power morcellation and factors associated with adverse pathologic outcomes. MAIN OUTCOMES AND MEASURES Use of electric power morcellation at the time of myomectomy was examined. The occurrence of uterine cancer and precancerous uterine lesions was determined. RESULTS The cohort consisted of 41 777 women who underwent myomectomy at 496 hospitals and included 3220 (7.7%) who had electric power morcellation. Uterine cancer was identified in 73 (1 in 528) women who underwent myomectomy without electric power morcellation (0.19%; 95% CI, 0.15%-0.23%) and in 3 (1 in 1073) women who underwent electric power morcellation (0.09%; 95% CI, 0.02%-0.27%). The corresponding rates of any pathologic finding (cancer, tumors of uncertain malignant potential, or endometrial hyperplasia) were 0.67% (n = 257) (95% CI, 0.59%-0.75%) (1 in 150) and 0.43% (n = 14) (95% CI, 0.21%-0.66%) (1 in 230), respectively. Advanced age was the strongest risk factor for uterine cancer. CONCLUSIONS AND RELEVANCE The prevalence of cancers and precancerous abnormalities of the uterus in women who undergo myomectomy with or without electric power morcellation is low overall, but risk increases with age. Electric power morcellation should be used with caution in older women undergoing myomectomy.

Effect of Regional Hospital Competition and Hospital Financial Status on the Use of Robotic-Assisted Surgery.

IMPORTANCE Despite the lack of efficacy data, robotic-assisted surgery has diffused rapidly into practice. Marketing to physicians, hospitals, and patients has been widespread, but how this marketing has contributed to the diffusion of the technology remains unknown. OBJECTIVE To examine the effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery for 5 commonly performed procedures. DESIGN, SETTING, AND PARTICIPANTS A cohort study of 221 637 patients who underwent radical prostatectomy, total nephrectomy, partial nephrectomy, hysterectomy, or oophorectomy at 1370 hospitals in the United States from January 1, 2010, to December 31, 2011, was conducted. The association between hospital competition, hospital financial status, and performance of robotic-assisted surgery was examined. MAIN OUTCOMES AND MEASURES The association between hospital competition was measured with the Herfindahl-Hirschman Index (HHI), hospital financial status was estimated as operating margin, and performance of robotic-assisted surgery was examined using multivariate mixed-effects regression models. RESULTS We identified 221 637 patients who underwent one of the procedures of interest. The cohort included 30 345 patients who underwent radical prostatectomy; 20 802, total nephrectomy; 8060, partial nephrectomy; 134 985, hysterectomy; and 27 445, oophorectomy. Robotic-assisted operations were performed for 20 500 (67.6%) radical prostatectomies, 1405 (6.8%) total nephrectomies, 2759 (34.2%) partial nephrectomies, 14 047 (10.4%) hysterectomies, and 1782 (6.5%) oophorectomies. Use of robotic-assisted surgery increased for each procedure from January 2010 through December 2011. For all 5 operations, increased market competition (as measured by the HHI) was associated with increased use of robotic-assisted surgery. For prostatectomy, the risk ratios (95% CIs) for undergoing a robotic-assisted procedure were 2.20 (1.50-3.24) at hospitals in moderately competitive markets and 2.64 (1.84-3.78) for highly competitive markets compared with noncompetitive markets. For hysterectomy, patients at hospitals in moderately (3.75 [2.26-6.25]) and highly (5.30; [3.27-8.57]) competitive markets were more likely to undergo a robotic-assisted surgery. Increased hospital profitability was associated with use of robotic-assisted surgery only for partial nephrectomy in facilities with medium-high (1.67 [1.13-2.48]) and high (1.50 [0.98-2.29]) operating margins. With analysis limited to patients treated at a hospital that had performed robotic-assisted surgery, there was no longer an association between competition and use of robotic-assisted surgery. CONCLUSIONS AND RELEVANCE Patients undergoing surgery in a hospital in a competitive regional market were more likely to undergo a robotic-assisted procedure. These data imply that regional competition may influence a hospitals decision to acquire a surgical robot.

Trends in Use and Outcomes of Women Undergoing Hysterectomy With Electric Power Morcellation.

Over several years, there has been increasing concern that use of electric power morcellation during hysterectomy for benign conditions may result in the spread of undetected malignancies. This concern led the US Food and Drug Administration (FDA) to issue a safety communication in April 2014 discouraging use of morcellation and, in November 2014, to recommend against use of this procedure in perimenopausal and postmenopausal women. However, some clinicians believe that avoiding morcellation would lead to a greater number of hysterectomies via laparotomy, with an increased risk of surgical complications. Trends in the route of hysterectomy, use of electric power morcellators, and prevalence of abnormal pathology were compared before and after the FDA’s safety warning in 2014. The Perspective database was used to identify women aged 18 to 95 years who underwent hysterectomy from 2013 to the first quarter of 2015. This database includes more than 500 hospitals across the United States and 15% of hospitalized patients. A total of 203,520 women were identified, including 117,653 women (57.8%) who underwent minimally invasive hysterectomy. Among these minimally invasive hysterectomies, power morcellation was used in 13.5% in the first quarter of 2013, peaked at 13.7% by the last quarter of 2013, and declined sharply to 2.8% by the first quarter of 2015 (P< 0.001). During the same time, use of abdominal hysterectomy increased from 27.1% of procedures in early 2013 to 31.8% by the first quarter in 2015 (P = 0.004). Despite increased use of abdominal hysterectomy, the complication rate did not change over time (8.3% during the first quarter of 2013 and 8.4% during the last in 2015: difference, 0.1%; P = 0.53 for trend). The rate of complications during abdominal hysterectomy decreased from 18.4% in the first quarter of 2103 to 17.6% in the first quarter of 2015 (difference, −0.9%; P < 0.001 for trend). Complications were stable during minimally invasive hysterectomy (4.4% in 2013 and 4.1% in 2015: difference, −0.4%; P = 0.71 for trend) and vaginal hysterectomy (4.7% in 2013 and 4.2% in 2015: difference, −0.6%; P = 0.45 for trend). Over the study period, the prevalence rates of uterine cancer, endometrial hyperplasia, other gynecologic cancers, and uterine tumors of indeterminate behavior were unchanged among women who underwent minimally invasive hysterectomy with power morcellation. These data show that use of electric power morcellation declined after the FDAwarning, and use of abdominal hysterectomy increased. The FDAwarnings may result in a lower prevalence of cancer because of greater scrutiny on patient selection in women who undergo morcellation. However, the high rates of abnormal pathology after the warnings demonstrate the difficulty in the preoperative detection of uterine pathology.

Comparative Effectiveness of Minimally Invasive Hysterectomy for Endometrial Cancer

PURPOSE Despite the potential benefits of minimally invasive hysterectomy for uterine cancer, population-level data describing the procedures safety in unselected patients are lacking. We examined the use of minimally invasive surgery and the association between the route of the procedure and long-term survival. METHODS We used the SEER-Medicare database to identify women with stage I-III uterine cancer who underwent hysterectomy from 2006 to 2011. Patients who underwent abdominal hysterectomy were compared with those who had minimally invasive hysterectomy (laparoscopic and robot-assisted). Perioperative morbidity, use of adjuvant therapy, and long-term survival were examined after propensity score balancing. RESULTS We identified 6,304 patients, including 4,139 (65.7%) who underwent abdominal hysterectomy and 2,165 (34.3%) who underwent minimally invasive hysterectomy; performance of minimally invasive hysterectomy increased from 9.3% in 2006 to 61.7% in 2011. Robot-assisted procedures accounted for 62.3% of the minimally invasive operations. Compared with women who underwent abdominal hysterectomy, minimally invasive hysterectomy was associated with a lower overall complication rate (22.7% v 39.7%; P < .001), and lower perioperative mortality (0.6% v 1.1%), but these women were more likely to receive adjuvant pelvic radiotherapy (34.3% v 31.3%) and brachytherapy (33.6% v 31.0%; P < .05). The complication rate was higher after robot-assisted hysterectomy compared with laparoscopic hysterectomy (23.7% v 19.5%; P = .03). There was no association between the use of minimally invasive hysterectomy and either overall (HR, 0.89; 95% CI, 0.75 to 1.04) or cancer-specific (HR, 0.83; 95% CI, 0.59 to 1.16) mortality. CONCLUSION Minimally invasive hysterectomy does not appear to compromise long-term survival for women with endometrial cancer.

Factors associated with 30-day hospital readmission after hysterectomy.

OBJECTIVE: To analyze factors associated with 30-day readmission among women who underwent hysterectomy for uterine cancer and benign indications. METHODS: We used the National Surgical Quality Improvement Project database to perform a cohort study of women who underwent hysterectomy from 2011 to 2012. Patients were stratified by surgical indication (uterine cancer or benign indications). Multivariable logistic regression models were constructed to determine factors associated with 30-day readmission. Model fit statistics were used to evaluate the importance of demographic factors, preoperative comorbidities, and postoperative complications on readmission. RESULTS: The rate of 30-day readmission was 6.1% among 4,725 women with uterine cancer and 3.4% after hysterectomy for benign gynecologic disease in 36,471 patients. In a series of multivariable models, postoperative complications including wound complications, infections, and pulmonary emboli and myocardial infarctions were the factors most strongly associated with readmission. Compared with women without a complication, complications increased the readmission rate from 2.5 to 20.3% for women with uterine cancer and from 1.5 to 15.1% for those without cancer. Among women with uterine cancer, postoperative complications explained 34.3% of the variance in readmission compared with 5.9% for demographic factors and 2.2% for preoperative comorbidities. For patients with benign diseases, complications accounted for 32.1%, preoperative conditions 1.2%, and demographic factors 2.5% of the variance in readmission. CONCLUSION: Efforts to reduce readmission should be directed at initiatives to reduce complications and improve the care of women who experience a complication. LEVEL OF EVIDENCE: II

Influence of Lymphadenectomy on Survival for Early-stage Endometrial Cancer

OBJECTIVE: To use a number of methods to control for confounding and selection bias to examine the association between lymphadenectomy and survival in a large cohort of women with endometrial cancer. METHODS: A retrospective cohort study using the National Cancer Data Base was performed to identify women with endometrioid adenocarcinoma of the endometrium who underwent hysterectomy with or without lymphadenectomy from 1998 to 2011. Traditional regression analysis, propensity score, and an instrumental variable using regional variation in the rate of lymphadenectomy as an instrument were used to examine the association between lymphadenectomy and survival. RESULTS: A total of 151,089 women treated at 1,336 hospitals were identified; 99,052 (65.6%) patients underwent lymphadenectomy, whereas 52,037 (34.4%) did not. In a multivariable regression model, lymphadenectomy was associated with a 16% reduction in mortality (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.81–0.87). The results were similar after adjustment for adjuvant therapy (HR 0.85, 95% CI 0.82–0.87). The results were largely unchanged and suggested that lymphadenectomy was associated with improved survival after application of a propensity score analysis. In contrast, in the instrumental variable analysis, there was not a statistically significant association between lymphadenectomy and survival (HR 0.75, 95% CI 0.53–1.06), even after adjustment for adjuvant treatment (HR 0.76, 95% CI 0.54–1.06). The results were unchanged for women with T1A and T1B tumors. CONCLUSION: Lymphadenectomy is associated with a modest, if any, effect on survival for women with endometrial cancer.

Measurement and validation of frailty as a predictor of outcomes in women undergoing major gynaecological surgery.

Frailty is the loss of physical or mental reserve that impairs function, often in the absence of a defined comorbidity. Our aim was to determine whether a modified frailty index (mFI) correlates with morbidity and mortality in patients undergoing hysterectomy.

Vulvar and vaginal melanoma: A unique subclass of mucosal melanoma based on a comprehensive molecular analysis of 51 cases compared with 2253 cases of nongynecologic melanoma

Optimal treatments for vulvar and vaginal melanomas (VVMs) have not been identified. Herein, the authors compare molecular profiles between VVM and nongynecologic melanoma (NGM) subtypes with the objective of identifying novel, targetable biomarkers.

Risk stratification and outcomes of women undergoing surgery for ovarian cancer

OBJECTIVE Cytoreduction for ovarian cancer is associated with substantial morbidity. We examined the outcome of patients undergoing surgery for ovarian cancer to determine if there are sub-groups of patients who may benefit from alternative treatments. METHODS The National Surgical Quality Improvement Program database was used to identify women who underwent surgery for ovarian cancer from 2005-2012. Multivariable logistic regression models were used to examine the effect of age, race, functional status, ASA class, preoperative albumin and performance of extended cytoreductive procedures on morbidity, mortality and resource utilization. RESULTS A total of 2870 women were identified. The perioperative complication rate increased from 9.5% in women <50years, to 13.4% in those age 60-69years, and 14.6% in women ≥70years (P<0.0001). Similarly, complications rose from 7.3% in those who did not require any extended procedures to 12.9% after 1 procedure, 28.4% for those who had 2, and 30.0% in women who underwent ≥3 extended procedures (P<0.0001). In a series of multivariable models, the number of extended cytoreductive procedures performed and preoperative albumin were the factors most consistently associated with morbidity. Using a series of model fit statistics, compared to chance alone, the ability to predict any complication increased by 27.4% when procedure score was analyzed, 22.0% with preoperative albumin, 11% with age, and 4% with functional status. CONCLUSIONS While preoperative clinical and demographic factors may help predict the risk of adverse outcomes for women undergoing surgery for ovarian cancer, performance of extended cytoreductive procedures is the strongest risk factor for complications.