Yu-Shiang Lu

Prognostic significance of adenocarcinoma histology in women with cervical cancer

OBJECTIVES We performed a population-based analysis to determine the effect of histology on survival for women with invasive cervical cancer. METHODS The Surveillance, Epidemiology and End Results database was used to identify women with stage IB-IVB cervical cancer treated from 1988 to 2005. Patients were stratified by histology (squamous, adenocarcinoma, and adenosquamous). Clinical characteristics, patterns of care, and outcomes were analyzed using multivariable logistic regression and Cox proportional hazards models. RESULTS A total of 24,562 patients were identified including 18,979 (77%) women with squamous cell carcinomas, 4103 (17%) with adencarcinomas, and 1480 (6%) with adenosquamous tumors. Women with adenocarcinomas were younger, more often white, and more frequently married than patients with squamous cell tumors (p<0.0001 for all). Patients with adenocarcinomas were more likely to present with early-stage disease (p<0.0001). At diagnosis, 26.7% of women with adenocarcinomas had stage IB1 tumors compared to 16.9% of those with squamous cell carcinomas. Among women with early-stage (IB1-IIA) tumors, patients with adenocarcinomas were 39% (HR=1.39; 95% CI, 1.23-1.56) more likely to die from their tumors than those with squamous cell carcinomas. For patients with advanced-stage disease (stage IIB-IVA) women with adenocarcinomas were 21% (HR=1.21; 95% CI, 1.10-1.32) more likely to die from their tumors than those with squamous neoplasms. Five-year survival for stage IIIB neoplasms five-year survival was 31.3% (95% CI, 29.2-33.3%) for squamous tumors vs. 20.3% (95% CI, 14.2-27.1%) for adenocarcinomas. CONCLUSION Cervical adenocarcinomas are more common in younger women and white patients. Adenocarcinoma histology negatively impacts survival for both early and advanced-stage carcinomas.

Comparative effectiveness of minimally invasive and abdominal radical hysterectomy for cervical cancer

OBJECTIVE We analyzed the uptake, morbidity, and cost of laparoscopic and robotic radical hysterectomies for cervical cancer. METHODS We identified women recorded in the Perspective database with cervical cancer who underwent radical hysterectomy (abdominal, laparoscopic, robotic) from 2006 to 2010. The associations between patient, surgeon, and hospital characteristic and use of minimally invasive hysterectomy as well as complications and cost were estimated using multivariable logistic regression models. RESULTS We identified 1894 patients including 1610 (85.0%) who underwent abdominal, 217 (11.5%) who underwent laparoscopic, and 67 (3.5%) who underwent robotic radical hysterectomy were analyzed. In 2006, 98% of the procedures were abdominal and 2% laparoscopic; by 2010 abdominal radical hysterectomy decreased to 67%, while laparoscopic increased to 23% and robotic radical hysterectomy was performed in 10% of women (p<0.0001). Patients treated at large hospitals were more likely to undergo a minimally invasive procedure (OR=4.80; 95% CI, 1.28-18.01) while those with more medical comorbidities (OR=0.60; 95% CI, 0.41-0.87) were less likely to undergo a minimally invasive surgery. Perioperative complications were noted in 15.8% of patients who underwent abdominal surgery, 9.2% who underwent laparoscopy, and 13.4% who had a robotic procedure (p=0.04). Both laparoscopic and robotic radical hysterectomies were associated with lower transfusion requirements and shorter hospital stays than abdominal hysterectomy (p<0.05). Median costs were

Effect of surgical volume on outcomes for laparoscopic hysterectomy for benign indications.

9618 for abdominal,

An economic analysis of robotically assisted hysterectomy.

11,774 for laparoscopic, and

Trends in surgical mesh use for pelvic organ prolapse from 2000 to 2010.

10,176 for robotic radical hysterectomy (p<0.0001). CONCLUSION Uptake of minimally invasive radical hysterectomy for cervical cancer has been slow. Both laparoscopic and robotic radical hysterectomies are associated with favorable morbidity profiles.

Effect of Radical Cytoreductive Surgery on Omission and Delay of Chemotherapy for Advanced-stage Ovarian Cancer

OBJECTIVE: To estimate the influence of surgical volume on outcome and resource utilization for laparoscopic hysterectomy for benign indications. METHODS: Patients who underwent laparoscopic hysterectomy from 2000 to 2010 and recorded in a commercial database were analyzed. Patients were stratified into tertiles according to the number of procedures performed by their surgeons and at their hospital. The influence of surgeon and hospital volume on perioperative morbidity and resource utilization was examined using multivariable regression models. RESULTS: A total of 124,615 patients were identified. The overall complication rate decreased from 6.2% for low-volume surgeons to 4.2% for high-volume surgeons (P<.001). Patients operated on by high-volume surgeons were 25% (risk ratios [RRs] 0.75, 95% confidence interval [CI] 0.68–0.82) less likely to experience a complication. In multivariable models intraoperative complications, surgical-site complications, medical complications, prolonged hospitalization, and transfusion rates were lower for high-volume surgeons. Overall morbidity was 5.8% for women treated at low-volume hospitals compared with 4.7% at high-volume centers (P<.001). Women treated at high-volume centers were 18% (RR 0.82, 95% CI 0.75–0.90) less likely to experience a complication. Procedure costs for high-volume surgeons were

Deviations from guideline-based therapy for febrile neutropenia in cancer patients and their effect on outcomes.

867 lower than for low-volume surgeons, and treatment at a high-volume center reduced costs by

Feasibility and economic impact of same-day discharge for women who undergo laparoscopic hysterectomy

966 per procedure. CONCLUSION: Performance of laparoscopic hysterectomy by high-volume surgeons and at high-volume hospitals is associated with modest reductions in morbidity and lower costs. LEVEL OF EVIDENCE: II

Patterns of care and treatment outcomes for elderly women with cervical cancer

OBJECTIVE: To perform an econometric analysis to examine the influence of procedure volume, variation in hospital accounting methodology, and use of various analytic methodologies on cost of robotically assisted hysterectomy for benign gynecologic disease and endometrial cancer. METHODS: A national sample was used to identify women who underwent laparoscopic or robotically assisted hysterectomy for benign indications or endometrial cancer from 2006 to 2012. Surgeon and hospital volume were classified as the number of procedures performed before the index surgery. Total costs as well as fixed and variable costs were modeled using multivariable quantile regression methodology. RESULTS: A total of 180,230 women, including 169,324 women who underwent minimally invasive hysterectomy for benign indications and 10,906 patients whose hysterectomy was performed for endometrial cancer, were identified. The unadjusted median cost of robotically assisted hysterectomy for benign indications was

Underuse of postcesarean thromboembolism prophylaxis.

8,152 (interquartile range [IQR]