R. Spencer

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies.

OBJECTIVE To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery. METHODS Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (<3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value. RESULTS Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels. According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47-2.73, p<0.0001), three or more complications (OR-4.1,CI: 2.31-7.1, p<0.0001), surgical complications (OR-2.39,CI: 1.59-3.58, p<0.0001), thromboembolic complications (OR-2.59,CI: 1.33-5.06, p<0.0001), pulmonary complications (OR-4.06,CI: 2.05-8.03, p<0.0001), or infectious complications (OR-1.84,CI: 1.26-2.69, p<0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51-16.95, p<0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery. In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3g/dl. CONCLUSION Preoperative albumin levels <3g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.

Frailty index predicts severe complications in gynecologic oncology patients

OBJECTIVE The purpose of this study was to quantify the predictive value of frailty index on 30-day Clavien class IV (requiring critical care support) and class V (30-day mortality) complications after gynecologic cancer surgery. METHODS Patients included in the National Surgical Quality Improvement Program (NSQIP) 2008-2011 had a final diagnosis of gynecologic malignancy. Modified frailty index (mFI) was calculated with 11 variables. Higher mFI scores indicated more severe comorbidities. Logistic regression was used to control for known predictors of complications. RESULTS Of the total 6551 patients, 188 (2.9%) of the patients experienced a Clavien IV/V complication. 2958 patients had a score of 0 (45.2%), 2405 patients had a score of 1 (36.7%), 985 patients had a score of 2 (15%), 162 patients had a score of 3 (2.5%) and 41 patients had a score≥4 (0.6%). The rates of Clavien IV/V complications were 2%, 2.7%, 4.4%, 7.4% and 24.4% for mFI scores of 0, 1, 2, 3 and ≥4, respectively (p<0.001). Variables found to be significant for predicting Clavien IV and V complications on logistic regression modeling were preoperative albumin<3g/dL (OR=6.5), operative time (OR=1.003 per min increase), non-laparoscopic surgery (OR=3.3), and frailty index (OR score 0=reference, score 1=1.26, score 2=1.9, score 3=2.33 and score≥4=12.5). Taking the two preoperative factors of albumin and mFI allowed for greater precision in identifying women who are at higher risk for requiring ICU care (>10% risk). CONCLUSIONS Modified frailty index (mFI) is predictive of the need for critical care support and 30-day mortality after surgery for gynecologic cancer.

Predictors of 30-day readmission and impact of same-day discharge in laparoscopic hysterectomy

OBJECTIVE The objective of the study was to identify the predischarge predictors of 30-day readmission and the impact of same-day discharge after laparoscopic hysterectomy. STUDY DESIGN Patients undergoing only laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy participated in the study. RESULTS The 30-day readmission rate was 3.1% (277 of 8890). Factors predictive of higher rates of readmission were diabetes (4.4% vs 3.0%; P = .03), chronic obstructive pulmonary disease (8.5% vs 3.1%; P = .02), disseminated cancer (20% vs 3.1%; P < .001), chronic steroid use (7.1% vs 3.1%; P = .03), daily alcohol use of more than 2 drinks (12.5% vs 2.5%; P = .04), and bleeding disorder (10.8% vs 3%; P = .001). Operative factors included surgical time of 2 hours or greater (3.5% vs 2.7%; P = .014). After surgery, patients had a higher rate of readmission when they experienced any 1 or more complications prior to discharge, (6.9% vs 3.1%; P = .01) as well as any complication after discharge (3.6% vs 1.6%; P = .01). Infections (35.7%) and surgical complications (24.2%) were the most common reasons of readmissions. Of these patients, 20.9% were discharged the same day (n = 1855) and had a similar rate of readmission (2.6% vs 3.2%; P = n.s.). Laparoscopic hysterectomy readmission score (LHRS) can be calculated by assigning 1 point to diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery of 2 hours or longer, and 2 points to any postoperative complication prior to discharge. Readmission rates for the LHRS score were score 1 (2.4%), score 2 (3.3%), score 3 (5.8%), or score 4 (9.5%). CONCLUSION The overall readmission rate after laparoscopic hysterectomy is low. Patients discharged the same day have similar rates of readmission. Higher LHRS is indicative of higher rates of readmission and may identify a population not suitable for same-day discharge and in need of higher vigilance to prevent readmissions.

The risk of squamous cell carcinoma in persistent vulvar ulcers.

Objective:The standard evaluation for vulvar ulcers includes an office biopsy. There are limited data regarding the false-negative rate of a punch biopsy in detecting squamous cell carcinoma of the vulva. This study reports on pathologic discrepancies between office biopsy and subsequent wide local excision for nonhealing vulvar ulcers. Methods:A retrospective review of the surgical records of 118 consecutive vulvar procedures was performed. Eleven women with persistent vulvar ulcers in the absence of a mass or pigmented lesion were identified. Patient demographics, physical examination, office evaluation, and surgical and pathology reports for these 11 women were reviewed. Results:A persistent vulvar ulcer was the presenting complaint in 11 (13.8%) of 80 women with squamous cell disease. Most women were postmenopausal, with a median age of 72 years. Nine of the 11 women had an office biopsy performed before consultation with a gynecologic oncologist. Five (55%) of these specimens had benign findings on office biopsy but revealed invasive squamous cell carcinoma after subsequent excision. Three of four women with prior diagnosis of lichen sclerosis had ulcers harboring invasive carcinoma. Conclusions:Vulvar ulceration may be the only presenting symptom in women with vulvar squamous cell carcinoma especially in postmenopausal women. Prompt office biopsy should remain part of the standard diagnostic evaluation; however, cancer should be suspected even with a negative biopsy result if ulcerations persist. More extensive tissue sampling in the operating room should be considered for these women.

The use of humor in patients with recurrent ovarian cancer: a phenomenological study.

Objective Humor has been shown to decrease the use of pain medicine, improve mood, and decrease stress. However, the timing and setting for using humor can be perceived differently depending on the patient and the context. Our objective was to better understand how patients with recurrent ovarian cancer experience humor to gain insight into the feasibility of using humor as a therapeutic adjunct. Methods We conducted structured patient interviews with women being treated for recurrent ovarian cancer. The phenomenological method of Colaizzi was used to gain an in-depth understanding of how women with recurrent ovarian cancer use and view humor in relation to their diagnosis. Results Most patients used humor to cope with cancer and felt that humor alleviated their anxiety. The use of humor by physicians and nurses was perceived as appropriate and positive. A previous relationship with a physician was often felt necessary before the use of humor. Humor was often perceived not only in traditional jokes but was also found in humorous anecdotes from the caregiver’s life outside of medicine. Conclusions This study revealed that humor is an often used coping mechanism for women with recurrent ovarian cancer and subjectively helps alleviate anxiety. The use of humor by physicians was found to be universally perceived as appropriate and positive. The waiting area seems to be a place where humorous experiences would be welcomed. These findings provide additional insight into the role that humor plays in the lives of patients with recurrent ovarian cancer.

Association of Hospital Volume With Racial and Ethnic Disparities in Locally Advanced Cervical Cancer Treatment.

OBJECTIVE To evaluate racial-ethnic disparities in guideline-based care in locally advanced cervical cancer and their relationship to hospital case volume. METHODS Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2012 with locally advanced squamous or adenocarcinoma of the cervix undergoing definitive primary radiation therapy. The primary outcome was the race-ethnicity-based rates of adherence to the National Comprehensive Cancer Network guideline-based care. The secondary outcome was the effect of guideline-based care on overall survival. Multivariable models and propensity matching were used to compare the hospital risk-adjusted rates of guideline-based adherence and overall survival based on hospital case volume. RESULTS The final cohort consisted of 16,195 patients. The rate of guideline-based care was 58.4% (95% confidence interval [CI] 57.4-59.4%) for non-Hispanic white, 53% (95% CI 51.4-54.9%) for non-Hispanic black, and 51.5% (95% CI 49.4-53.7%) for Hispanic women (P<.001). From 2004 to 2012, the rate of guideline-based care increased from 49.5% (95% CI 47.1-51.9%) to 59.1% (95% CI 56.9-61.2%) (Ptrend<.001). Based on a propensity score-matched analysis, patients receiving guideline-based care had a lower risk of mortality (adjusted hazard ratio 0.65, 95% CI 0.62-0.68). Compared with low-volume hospitals, the increase in adherence to guideline-based care in high-volume hospitals was 48-63% for non-Hispanic white, 47-53% for non-Hispanic black, and 41-54% for Hispanic women. CONCLUSION Racial and ethnic disparities in the delivery of guideline-based care are the highest in high-volume hospitals. Guideline-based care in locally advanced cervical cancer is associated with improved survival.

Transversus abdominis plane block in robotic gynecologic oncology: A randomized, placebo-controlled trial

OBJECTIVE Although robotic surgery decreases pain compared to laparotomy, postoperative pain can be a concern near the site of a larger assistant trocar site. The aim of this study was to determine the efficacy of transversus abdominis plane (TAP) block on 24-hour postoperative opiate use after robotic surgery for gynecologic cancer. METHODS Sixty-four subjects with gynecologic malignancies who were scheduled to undergo robotic surgery were enrolled into the study. They were randomized to receive a unilateral TAP block to the side of the assistant port via ultrasound guidance. The block was comprised of 30 cc of 0.25% bupivacaine with 3 mcg/mL epinephrine or saline. Opiate use was measured and converted into IV morphine equivalents. Patient-reported pain was measured using the Brief Pain Inventory (BPI) and Visual Analog Scale (VAS). RESULTS The treatment group used a mean of 64.9 mg morphine in the first 24h compared to 69.3mg for controls (primary outcome, p=0.52). After age-adjustment, the treatment group used a mean of 11.1mg morphine less than controls (p=0.09). Postoperative pain scores assessed by the BPI (6.44 vs. 6.97, p=0.37) and the VAS (3.12 vs. 3.61, p=0.30) were equivalent. Block placement was uncomplicated in 98.4% of participants with mean BMI of 35.3 kg/m(2). Linear regression revealed an approximate 8.1mg decrease in morphine equivalents used per additional decade of life (p=0.0008). There was a positive correlation between the amount of opiates and BMI with an additional 8.8 mg of morphine per 10 kg/m(2) increase in BMI (p=0.0012). CONCLUSIONS TAP block is safe and feasible in this patient population with a large proportion of morbid obesity. Preoperative TAP block does not significantly decrease opiate use. However; based on these data, a clinically useful nomogram has been created to aid clinicians in postoperative opiate-dosing for patients based on age and BMI.

Trends in hospice discharge, documented inpatient palliative care services and inpatient mortality in ovarian carcinoma

OBJECTIVE To investigate the trends in discharge to hospice, documented inpatient palliative care services, and inpatient mortality in metastatic ovarian cancer (mOvCa) patients. METHODS Patients≥18years with mOvCa and a non-elective admission between January 1, 2006 and December 31, 2011 were identified from the National Inpatient Sample (NIS). The primary outcome of interest was the temporal trend in the annual proportion of hospitalizations for mOvCa where discharge destination was hospice. Secondary outcomes included temporal trend of inpatient mortality and documented palliative care services. Multivariable logistic regression models were used to ascertain independent factors predictive of hospice discharge and documented palliative services across the clusters of hospitals. RESULTS A total of 106,203 non-elective hospitalizations were identified. The rate of hospice discharge increased from 9.2% in 2004 to 11.1% in 2011 (ptrend<0.001). Similarly, the rate of documented palliative care services increased from 2.7% in 2004 to 10.4% in 2011 (ptrend<0.001). The inpatient mortality decreased from 9.6% in 2004 to 7.4% in 2011 (ptrend<0.001). In a subset of hospitalizations with extreme risk of dying, 22% were discharged to hospice and 11% received documented palliative care services. One fifth of the patients who died in the hospital received documented palliative care services. CONCLUSIONS The use of hospice as a discharge destination and documented palliative care services is relatively low but appears to be increasing over time for mOvCa patients. Monitoring this data is vital to plan educational programs regarding palliative care approaches in this at-risk population.

Disparities in receipt of care for high-grade endometrial cancer: A National Cancer Data Base analysis

PURPOSE To examine patterns of care and survival for Hispanic women compared to white and African American women with high-grade endometrial cancer. METHODS We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear cell carcinoma and papillary serous carcinoma between 2003 and 2011. The effect of treatment on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS 43,950 women were eligible. African American and Hispanic women had higher rates of stage III and IV disease compared to white women (36.5% vs. 36% vs. 33.5%, p<0.001). African American women were less likely to undergo surgical treatment for their cancer (85.2% vs. 89.8% vs. 87.5%, p<0.001) and were more likely to receive chemotherapy (36.8% vs. 32.4% vs. 32%, p<0.001) compared to white and Hispanic women. Over the entire study period, after adjusting for age, time period of diagnosis, region of the country, urban or rural setting, treating facility type, socioeconomic status, education, insurance, comorbidity index, pathologic stage, histology, lymphadenectomy and adjuvant treatment, African American women had lower overall survival compared to white women (Hazard Ratio 1.21, 95% CI 1.16-1.26). Conversely, Hispanic women had improved overall survival compared to white women after controlling for the aforementioned factors (HR 0.87, 95% CI 0.80-0.93). CONCLUSIONS Among women with high-grade endometrial cancer, African American women have lower all-cause survival while Hispanic women have higher all-cause survival compared to white women after controlling for treatment, sociodemographic, comorbidity and histopathologic variables.

Risk factors for early-occurring and late-occurring incisional hernias after primary laparotomy for ovarian cancer.

OBJECTIVE: To evaluate a cohort of gynecologic oncology patients to discover risk factors for early- and late-occurring incisional hernia after midline incision for ovarian cancer. METHODS: We collected retrospective data from patients undergoing primary laparotomy for ovarian cancer at the University of Wisconsin Hospitals and Clinics from 2001 to 2007. Patient characteristics and potential risk factors for hernia formation were noted. Physical examination, abdominal computerized assisted tomography scans, or both were used to detect hernias 1 year after surgery (early hernia) and 2 years after surgery (late hernia). RESULTS: There were 265 patients available for the 1-year analysis and 189 patients for the 2-year analysis. Early and late hernia formation occurred in 9.8% (95% confidence interval [CI] 6.2–12%) and an additional 7.9% (95% CI 4.1–12%) of patients, respectively. Using multiple logistic regression, poor nutritional status (albumin less than 3 g/dL) and suboptimal cytoreductive surgery (1 cm or greater residual tumor) were significantly associated with the formation of early incisional hernia after midline incision (P<.001 for both). Late hernia formation was associated only with age 65 years or older (P=.01). CONCLUSION: The formation of early incisional hernias after midline incision is associated with poor nutritional status and suboptimal cytoreductive surgery, whereas late hernia formation is associated with advanced age. LEVEL OF EVIDENCE: II