N.A. Latif

Adjuvant Therapy in Early-Stage Endometrial Cancer: A Systematic Review of the Evidence, Guidelines, and Clinical Practice in the U.S.

Endometrial cancer is the most common gynecologic malignancy in the U.S., with an increasing incidence likely secondary to the obesity epidemic. Surgery is usually the primary treatment for early stage endometrial cancer, followed by adjuvant therapy in selected cases. This includes radiation therapy [RT] with or without chemotherapy, based on stratification of patients into categories dependent on their future recurrence risk. Several prospective trials (PORTEC-1, GOG#99, and PORTEC-2) have shown that the use of adjuvant RT in the intermediate risk (IR) and the high-intermediate risk (HIR) groups decreases locoregional recurrence (LRR) but has no effect on overall survival. The ad hoc analyses from these studies have shown that an even larger LRR risk reduction was seen within the HIR group compared with the IR group. Vaginal brachytherapy is as good as external beam radiotherapy in controlling vaginal relapse where the majority of recurrence occur, and with less toxicity. In the high-risk group, multimodality therapy (chemotherapy and RT) may play a significant role. Although adjuvant RT has been evaluated in many cost-effectiveness studies, high-quality data in this area are still lacking. The uptake of the above prospective trial results in the U.S. has not been promising. Factors that are driving current practices and defining quality-of-care measures for patients with early-stage disease are what future studies need to address.

Incidence of Venous Thromboembolism by Type of Gynecologic Malignancy and Surgical Modality in the National Surgical Quality Improvement Program

Background Women with gynecologic cancer are at higher risk of venous thromboembolism (VTE) due to malignancy, pelvic surgery, increased age, and frequently comorbidities. The rate of VTE among different gynecologic cancers and relative to benign gynecologic surgeries has not been reported in a nationally representative cohort. Methods Using the American College of Surgeons National Surgical Quality Improvement Program database, gynecologic surgeries were identified retrospectively from 2006 to 2012. Clinical characteristics, surgical procedures, and 30-day postoperative complications were abstracted. Multivariable logistic regression models were performed. Results Of all gynecologic surgeries (n = 104,368), 11,427 were performed for malignancy: 2.7% (n = 2800) for ovarian cancer, 6.8% (n = 7114) for uterine cancer, 1.0% (n = 1026) for cervical cancer, and 0.5%(n = 487) for vulvar cancer. 202 (1.8%) patients experienced a VTE. Ovarian cancer had a deep venous thrombosis and pulmonary embolism rates of 1.6% and 1.5% compared with uterine cancer, 0.8% and 0.8%, respectively. Ovarian cancer patients were 1.8 (95% confidence interval [CI], 1.19–2.65) times more likely to have a deep venous thrombosis and 1.7 (95% CI, 1.11–2.51) times more likely to have a pulmonary embolism than patients with uterine cancer. Compared with all gynecologic cancer surgeries, ovarian cancer patients were 1.5 times more likely to have a VTE (95% CI, 1.10–2.16). Patients undergoing minimally invasive surgery were 64% less likely to have a VTE regardless of malignancy site; however, if they had disseminated disease, they remained at higher risk of VTE (odds ratio, 5.96; P = 0.027). Conclusions Of gynecologic cancer surgeries, ovarian cancer patients had the highest rate of VTE. Venous thromboembolism rates were lower in those who had minimally invasive surgery but remained higher in those with disseminated disease.

Post-Surgical Readmissions Among Women Undergoing Benign and Malignant Gynecologic Surgery [17].

INTRODUCTION: To compare 30 day postoperative readmission rates and risk factors for readmission between women following benign and malignant gynecologic surgery. METHODS: We identified patients following benign and malignant gynecologic surgery in the National Surgical Quality Improvement Program database from 2006–2012. Data collected included surgical procedure, operative time, 30-day readmission, co-morbidities, pre-operative condition and serious postoperative morbidity. Standard statistical analyses were performed. RESULTS: 5% (654/13,093) versus 1.75% (375/21,331) of patients who underwent surgery for malignant and benign indications, respectively, were readmitted (P<.001). Compared with benign patients, those with uterine cancer (OR 2.41, CI 2.07–2.81), ovarian cancer (OR 4.04, CI 3.38–4.81), cervical cancer (OR 2.41, CI 1.93–3) and other gynecologic malignancies (OR 3.10, CI 2.38–4.04) were more likely to be readmitted. Patients with gynecologic cancers were more likely to have comorbidities, worse preoperative condition and major complications (P<.01). Independent factors for readmission for gynecologic cancer surgery included worse preoperative condition (OR 1.33, CI 1.14–1.54), complex surgery (OR 1.67, CI 1.23–2.25) and major complications (OR 2.71, CI 2.44–3.01), all P less than or equal to .001. In comparison, independent factors for readmission for benign surgery included presence of co-morbid conditions (OR 1.26, CI 1.09–1.46) and major complications (OR 9.26, CI 7.81–10.99), all P less than or equal to .002. CONCLUSION/IMPLICATIONS: Women with gynecologic malignancies are more likely to have a 30 day post-surgical readmission than their benign counterparts. Future studies are needed to identify the role of perioperative care in reducing post-surgical readmissions.

Abstract 3726: Race-based disparities in loss of functional independence after uterine cancer

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Introduction Racial disparities in uterine cancer-related outcomes have been reported. Black uterine cancer patients are more likely to have worse clinical outcomes, which are not fully explained by number of comorbidities. Few studies have investigated the factors that may influence functional independence following surgery for uterine cancer. The goal of this study was to determine if race, preoperative body mass index (BMI) and medical comorbidities are predictors of loss of functional independence. Method: Data from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) were used. All patients were identified by post-operative ICD-9 code. Functional independence was defined as: the patient not requiring assistance from another person for any activities of daily living preoperatively. Loss of independence was defined as requiring discharge to a post-care facility or death, in the immediate postoperative period following hysterectomy. Demographic factors, comorbidities, BMI, intraoperative and postoperative outcomes and discharge status were captured within 30 days of surgery. Statistical analyses included multivariate logistic regression and Wald tests for interaction. Results: 4115 patients were identified with a diagnosis of uterine cancer and were functionally independent preoperatively: 310 (7.5%) were Black and 3805 (92.5%) were non-black. Compared with non-black, Black uterine cancer patients were notable for greater BMI (median 35.4 vs. 32.3, P<0.001), more likely to have one or more comorbidities (76.9% vs. 59.8%, P<0.001), and longer operative time (179.9 mins vs. 159.5 mins, P<0.001). After adjusting for BMI, age, number of comorbidities, pre-operative conditions, major complications, disseminated cancer and days of hospitalization prior to surgery, Black women were not significantly more likely to lose functional independence during the postoperative period than non-Black women. However, a significant interaction (OR 1.14 per 1-unit BMI increase, P<0.001) was found between Black and BMI on loss of functional independence. Interaction plots revealed worse functional outcomes per unit increase in BMI for Black women but not in non-Blacks. Conclusions: The significant interaction between Black race and BMI suggests a 14% increased odds of losing functional independence for each unit of BMI increase for Black uterine cancer patients, meaning that a 10-point increase in BMI would confer a 140% increase in odds of losing functional independence. Black uterine cancer patients with high BMIs may especially benefit from weight loss or interventions to optimize physical function and comorbidity profiles prior to and following surgery, in order to reduce the likelihood of losing functional independence after surgery. Together these efforts may improve disease specific as well as overall health outcomes in Black women with uterine cancer. Citation Format: Lorraine Dean, Xiaochen Zhang, Nawar Latif, Ashley Haggerty, Robert Giuntoli, Sarah Kim, David Shalowitz, Caitlin Stashwick, Mark Morgan, Emily Ko, Kathryn Schmitz. Race-based disparities in loss of functional independence after uterine cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3726. doi:10.1158/1538-7445.AM2015-3726