Specialized and high-volume care leads to better outcomes of ovarian cancer treatment in the Netherlands

Association of COVID-19 Pandemic with Colorectal Cancer Screening: Impact of Race/Ethnicity and Social Vulnerability

BACKGROUND

The COVID-19 pandemic disrupted health care delivery, including cancer screening practices. This study sought to determine the impact of the COVID-19 pandemic lockdown on colorectal cancer (CRC) screening relative to social vulnerability.

METHODS

Using the Medicare Standard Analytic File, individuals 65 years old or older who were eligible for guideline-concordant CRC screening between 2019 and 2021 were identified. These data were merged with the Center for Disease Control Social Vulnerability Index (SVI) dataset. Changes in county-level monthly screening volumes relative to the start of the COVID-19 pandemic (March 2020) and easing of restrictions (March 2021) were assessed relative to SVI.

RESULTS

Among 10,503,180 individuals continuously enrolled in Medicare with no prior diagnosis of CRC, 1,362,457 (12.97%) underwent CRC screening between 2019 and 2021. With the COVID-19 pandemic, CRC screening decreased markedly across the United States (median monthly screening: pre-pandemic [n = 76,444] vs pandemic era [n = 60,826]; median Δn = 15,618; p < 0.001). The 1-year post-pandemic overall CRC screening utilization generally rebounded to pre-COVID-19 levels (monthly median screening volumes: pandemic era [n = 60,826] vs post-pandemic [n = 74,170]; median Δn = 13,344; p < 0.001). Individuals residing in counties with the highest SVI experienced a larger decline in CRC screening odds than individuals residing in low-SVI counties (reference, low SVI: pre-pandemic high SVI [OR, 0.85] vs pandemic high SVI [OR, 0.81] vs post-pandemic high SVI [OR, 0.85]; all p < 0.001).

CONCLUSIONS

The COVID-19 pandemic was associated with a decrease in CRC screening volumes. Patients who resided in high social vulnerability areas experienced the greatest pandemic-related decline.

Effect of surgical volume on short-term outcomes of cytoreductive surgery for advanced-stage ovarian cancer: A population-based study from the Dutch Gynecological Oncology Audit

OBJECTIVE

Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted.

METHODS

This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes.

RESULTS

A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment.

CONCLUSIONS

Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.

Regionalizing ovarian cancer cytoreduction to high-volume centers and the impact on patient travel in New York State

OBJECTIVE

To evaluate the theoretical impact of regionalizing cytoreductive surgery for ovarian cancer (OC) to high-volume facilities on patient travel.

METHODS

We retrospectively identified patients with OC who underwent cytoreduction between 1/1/2004-12/31/2018 from the New York State Cancer Registry and Statewide Planning and Research Cooperative System. Hospitals were stratified by low-volume (<21 cytoreductive surgical procedures for OC annually) and high-volume centers (≥21 procedures annually). A simulation was performed; outcomes of interest were driving distance and time between the centroid of the patient's residence zip code and the treating facility zip code.

RESULTS

Overall, 60,493 patients met inclusion criteria. Between 2004 and 2018, 210 facilities were performing cytoreductive surgery for OC in New York; 159 facilities (75.7%) met low-volume and 51 (24.3%) met high-volume criteria. Overall, 10,514 patients (17.4%) were treated at low-volume and 49,979 (82.6%) at high-volume facilities. In 2004, 78.2% of patients were treated at high-volume facilities, which increased to 84.6% in 2018 (P < .0001). Median travel distance and time for patients treated at high-volume centers was 12.2 miles (IQR, 5.6-25.5) and 23.0 min (IQR, 15.2-37.0), and 8.2 miles (IQR, 3.7-15.9) and 16.8 min (IQR, 12.4-26.0) for patients treated at low-volume centers. If cytoreductive surgery was centralized to high-volume centers, median distance and time traveled for patients originally treated at low-volume centers would be 11.2 miles (IQR, 3.8-32.3; P < .001) and 20.2 min (IQR, 13.6-43.0; P < .001).

CONCLUSIONS

Centralizing cytoreductive surgery for OC to high-volume centers in New York would increase patient travel burden by negligible amounts of distance and time for most patients.

Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study

OBJECTIVES

To study the association between hospital volume and outcomes in patients with invasive epithelial ovarian cancer (EOC).

METHODS

This study included 3988 patients diagnosed with invasive EOC between 2014 and 2018, selected from the population-based database of the Belgian Cancer Registry (BCR), and coupled with health insurance and vital status data. The associations between hospital volume and observed survival since diagnosis were assessed with Cox proportional hazard models, while volume associations with 30-day post-operative mortality and complicated recovery were evaluated using logistic regression models.

RESULTS

Treatment for EOC was very dispersed with half of the 100 centres treating fewer than six patients per year. The median survival of patients treated in centres with the highest-volume quartile was 2.5 years longer than in those with the lowest-volume quartile (4.2 years versus 1.7 years). When taking the case-mix of hospitals into account, patients treated in the lowest volume centres had a 47% higher hazard to die than patients treated in the highest volume centres (HR: 1.47, 95% CI: 1.11-1.93, p = 0.006) over the first five years after incidence. A similar association was found when focussing on the surgical volume of the hospitals and considering only operated patients with invasive EOC. Lastly, the 30-day post-operative mortality decreased significantly with increasing surgical volume.

CONCLUSIONS

The large dispersion of care and expertise within Belgium and the volume-outcome associations observed in this study support the implementation of the concentration of care for patients with invasive EOC in reference centres.

Current uptake and barriers to wider use of the International Ovarian Tumor Analysis (IOTA) models in Dutch gynaecological practice

OBJECTIVE

Correct referral of women with an ovarian tumor to an oncology department remains challenging. The International Ovarian Tumor Analysis (IOTA) consortium has developed models with higher diagnostic accuracy than the alternative Risk of Malignancy Index (RMI). This study explores the uptake of the IOTA models in Dutch hospitals and factors that impede or promote implementation. Optimal implementation is crucial to improve pre-operative classification of ovarian tumors, which may lead to better patient referral to the appropriate level of care.

STUDY DESIGN

In February 2021, an electronic questionnaire consisting of 37 questions was sent to all 72 hospitals in the Netherlands. One pre-selected gynaecologist per hospital was asked to respond on behalf of the department.

RESULTS

The study had a response rate of 93% (67/72 hospitals). All respondents (100%) were familiar with the IOTA models with 94% using them in practice. The logistic regression 2 (LR2)-model, Simple ultrasound-based rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model were used in respectively 40%, 67% and 73% of these hospitals. Respondents rated the models overall with an 8.2 (SD 1.8), 8.3 (SD 1.6) and 8.9 (SD 1.3) respectively for LR2, SR and ADNEX on a scale from 1 to 10. Moreover, 89% indicated to have confidence in the results of the IOTA models. The most important factors to improve further implementation are more training (43%), research on sensitivity, specificity and cost-effectiveness in the Dutch health care system (27%), easier usability (24%) and more consultation time (19%).

CONCLUSION

The IOTA ultrasound models are adopted in the majority of Dutch hospitals with the ADNEX model being used the most. While Dutch gynecologists have a strong familiarity and confidence in the models, the uptake varies in reality. Areas that warrant improvement in the Dutch context are more uniformity, education and more research. These findings can be helpful for other countries considering adopting the IOTA models.

Ultrasound examination, MRI, or ROMA for discriminating between inconclusive adnexal masses as determined by IOTA Simple Rules: a prospective study

OBJECTIVE

To determine the best second-step approach for discriminating benign from malignant adnexal masses classified as inconclusive by International Ovarian Tumour Analysis Simple Rules (IOTA-SR).

METHODS

Single-center prospective study comprising a consecutive series of patients diagnosed as having an adnexal mass classified as inconclusive according to IOTA-SR. All women underwent Risk of Ovarian Malignancy Algorithm (ROMA) analysis, MRI interpreted by a radiologist, and ultrasound examination by a gynecological sonologist. Cases were clinically managed according to the result of the ultrasound expert examination by either serial follow-up for at least 1 year or surgery. Reference standard was histology (patient was submitted to surgery if any of the tests was suspicious) or follow-up (masses with no signs of malignancy after 12 months were considered benign). Diagnostic performance of all three approaches was calculated and compared. Direct cost analysis of the test used was also performed.

RESULTS

Eighty-two adnexal masses in 80 women (median age 47.6 years, range 16 to 73 years) were included. Seventeen patients (17 masses) were managed expectantly (none had diagnosis of ovarian cancer after at least 12 months of follow-up) and 63 patients (65 masses) underwent surgery and tumor removal (40 benign and 25 malignant tumors). Sensitivity and specificity for ultrasound, MRI, and ROMA were 96% and 93%, 100% and 81%, and 24% and 93%, respectively. The specificity of ultrasound was better than that for MRI (p=0.021), and the sensitivity of ultrasound was better than that for ROMA (p<0.001), sensitivity was better for MRI than for ROMA (p<0.001) and the specificity of ROMA was better than that for MRI (p<0.001). Ultrasound evaluation was the most effective and least costly method as compared with MRI and ROMA.

CONCLUSION

In this study, ultrasound examination was the best second-step approach in inconclusive adnexal masses as determined by IOTA-SR, but the findings require confirmation in multicenter prospective trials.

Ovarian Cancer in a Northern Italian Province and the Multidisciplinary Team

Ovarian cancer represents one of the most aggressive female cancers in the world, remaining a tumor with high lethality. This study aims to present how a multidisciplinary team (MDT) approach can improve the prognosis in terms of recurrence and death of patients. In total, 448 ovarian cancer cases registered in an Italian Cancer Registry between 2012 and 2020 were included. Information on age, morphology, stage, and treatment was collected. Recurrence and death rates were reported 1 and 2 years after diagnosis, comparing MDT vs. non-MDT approaches. Ninety-three percent had microscopic confirmation, and most showed cystic-mucinous morphology. In total, 50% were older than 65 years old. The distribution by stage was 17.6%, 4%, 44.9%, and 32.6% for stages I, II, III, and IV, respectively. The women followed by the MDT were 24.1%. Disease-free survival 1-year post-diagnosis, recurrences, recurrences-deaths, and deaths were 67.5%, 14.5%, 8.4%, and 9.6%, respectively, better than the non-MDT group (46.2%, 13.2%, 20.8 %, and 19.8%, respectively) (p < 0.01). The same positive results were confirmed two years after diagnosis, particularly for stages III and IV. Albeit small numbers, the study confirms a better prognosis for women managed by MDT with fewer recurrences and deaths, especially within the first 24 months of diagnosis.

Psychological impact of referral to an oncology hospital on patients with an ovarian mass

OBJECTIVES

In patients with an ovarian mass, a risk of malignancy assessment is used to decide whether referral to an oncology hospital is indicated. Risk assessment strategies do not perform optimally, resulting in either referral of patients with a benign mass or patients with a malignant mass not being referred. This process may affect the psychological well-being of patients. We evaluated cancer-specific distress during work-up for an ovarian mass, and patients' perceptions during work-up, referral, and treatment.

METHODS

Patients with an ovarian mass scheduled for surgery were enrolled. Using questionnaires we measured (1) cancer-specific distress using the cancer worry scale, (2) patients' preferences regarding referral (evaluated pre-operatively), and (3) patients' experiences with work-up and treatment (evaluated post-operatively). A cancer worry scale score of ≥14 was considered as clinically significant cancer-specific distress.

RESULTS

A total of 417 patients were included, of whom 220 (53%) were treated at a general hospital and 197 (47%) at an oncology hospital. Overall, 57% had a cancer worry scale score of ≥14 and this was higher in referred patients (69%) than in patients treated at a general hospital (43%). 53% of the patients stated that the cancer risk should not be higher than 25% to undergo surgery at a general hospital. 96% of all patients were satisfied with the overall work-up and treatment. No difference in satisfaction was observed between patients correctly (not) referred and patients incorrectly (not) referred.

CONCLUSIONS

Relatively many patients with an ovarian mass experienced high cancer-specific distress during work-up. Nevertheless, patients were satisfied with the treatment, regardless of the final diagnosis and the location of treatment. Moreover, patients preferred to be referred even if there was only a relatively low probability of having ovarian cancer. Patients' preferences should be taken into account when deciding on optimal cut-offs for risk assessment strategies.

Using Genomic Variation to Distinguish Ovarian High-Grade Serous Carcinoma from Benign Fallopian Tubes

The preoperative diagnosis of pelvic masses has been elusive to date. Methods for characterization such as CA-125 have had limited specificity. We hypothesize that genomic variation can be used to create prediction models which accurately distinguish high grade serous ovarian cancer (HGSC) from benign tissue.

METHODS

In this retrospective, pilot study, we extracted DNA and RNA from HGSC specimens and from benign fallopian tubes. Then, we performed whole exome sequencing and RNA sequencing, and identified single nucleotide variants (SNV), copy number variants (CNV) and structural variants (SV). We used these variants to create prediction models to distinguish cancer from benign tissue. The models were then validated in independent datasets and with a machine learning platform.

RESULTS

The prediction model with SNV had an AUC of 1.00 (95% CI 1.00-1.00). The models with CNV and SV had AUC of 0.87 and 0.73, respectively. Validated models also had excellent performances.

CONCLUSIONS

Genomic variation of HGSC can be used to create prediction models which accurately discriminate cancer from benign tissue. Further refining of these models (early-stage samples, other tumor types) has the potential to lead to detection of ovarian cancer in blood with cell free DNA, even in early stage.

Variation in ovarian cancer care in Australia: An analysis of patterns of care in diagnosis and initial treatment in New South Wales

OBJECTIVE

Ovarian cancer has the highest mortality of all gynaecological cancers. This study aimed to identify the extent to which women across New South Wales experienced variation in their care in diagnosis and initial treatment for ovarian cancer against the national optimal care pathway for ovarian cancer.

METHOD

Clinical audit methodology was utilised to explore variations for women with primary ovarian cancer; 171 eligible cases were identified through by the NSW Cancer Registry for the period of 1 March 2017 to 28 February 2018.

RESULTS

Limited variation was detected with 86% of women being reviewed by a specialist gynaecological oncology multidisciplinary team; 54% of women received their first treatment within 28 days of their first specialist appointment, 66% of women having their first surgery completed by a gynaecological oncologist and 45% of women received their first treatment in a specialist gynaecological oncology hospital.

CONCLUSION

Deviation from effective ovarian cancer care is apparent particularly in the location and timeliness of first treatment, with implications for the quality of care received and care outcomes. Understanding factors that contribute to variation is critical to ensure optimal and appropriate ovarian cancer care and to tackle systemic barriers to the provision of effective care.

Detection and localization of early- and late-stage cancers using platelet RNA

Cancer patients benefit from early tumor detection since treatment outcomes are more favorable for less advanced cancers. Platelets are involved in cancer progression and are considered a promising biosource for cancer detection, as they alter their RNA content upon local and systemic cues. We show that tumor-educated platelet (TEP) RNA-based blood tests enable the detection of 18 cancer types. With 99% specificity in asymptomatic controls, thromboSeq correctly detected the presence of cancer in two-thirds of 1,096 blood samples from stage I-IV cancer patients and in half of 352 stage I-III tumors. Symptomatic controls, including inflammatory and cardiovascular diseases, and benign tumors had increased false-positive test results with an average specificity of 78%. Moreover, thromboSeq determined the tumor site of origin in five different tumor types correctly in over 80% of the cancer patients. These results highlight the potential properties of TEP-derived RNA panels to supplement current approaches for blood-based cancer screening.

New Analytical Approach for the Alignment of Different HE4 Automated Immunometric Systems: An Italian Multicentric Study

Human epididymal secretory protein 4 (HE4) elevation has been studied as a crucial biomarker for malignant gynecological cancer, such us ovarian cancer (OC). However, there are conflicting reports regarding the optimal HE4 cut-off. Thus, the goal of this study was to develop an analytical approach to harmonize HE4 values obtained with different laboratory resources. To this regard, six highly qualified Italian laboratories, using different analytical platforms (Abbott Alinity I, Fujirebio Lumipulse G1200 and G600, Roche Cobas 601 and Abbott Architett), have joined this project. In the first step of our study, a common reference calibration curve (designed through progressive HE4 dilutions) was tested by all members attending the workshop. This first evaluation underlined the presence of analytical bias in different devices. Next, following bias correction, we started to analyze biomarkers values collected in a common database (1509 patients). A two-sided p-value < 0.05 was considered statistically significant. In post-menopausal women stratified between those with malignant gynecological diseases vs. non-malignant gynecological diseases and healthy women, dichotomous HE4 showed a significantly better accuracy than dichotomous Ca125 (AUC 0.81 vs. 0.74, p = 0.001 for age ≤ 60; AUC 0.78 vs. 0.72, p = 0.024 for age > 60). Still, in post-menopausal status, similar results were confirmed in patients with malignant gynecological diseases vs. patients with benign gynecological diseases, both under and over 60 years (AUC 0.79 vs. 0.73, p = 0.006; AUC 0.76 vs. 0.71, p = 0.036, respectively). Interestingly, in pre-menopausal status women over 40 years, HE4 showed a higher accuracy than Ca125 (AUC 0.73 vs. 0.66, p = 0.027), thus opening new perspective for the clinical management of fertile patients with malignant neoplasms, such as ovarian cancer. In summary, this model hinted at a new approach for identifying the optimal cut-off to align data detected with different HE4 diagnostic tools.

Stacking Machine Learning Algorithms for Biomarker-Based Preoperative Diagnosis of a Pelvic Mass

Simple Summary

It is critical for women who are diagnosed with a pelvic mass, or an ovarian cyst to be accurately assessed for their risk of having an ovarian malignancy. Accurate risk stratification for these women will allow for appropriate triage and referral to centers best equipped to treat women diagnosed with ovarian cancer. In this study, machine learning (ML) algorithms were used to determine the optimal combination of biomarkers for prediction of malignancy in women presenting with a pelvic mass. Nine unique ML algorithms were employed to evaluate age, menopausal status, race, and levels of 67 biomarkers from serum, urine, and plasma samples prospectively collected in a cohort 140 women with a variety of pelvic mass diagnoses benign and malignant. A complex statistical algorithm using serum levels of CA125, HE4 and transferrin provided greater than 93% sensitivity and specificity for the preoperative prediction of malignancy in women presenting with a pelvic mass.

Abstract

Objective: To identify the most predictive parameters of ovarian malignancy and develop a machine learning (ML) based algorithm to preoperatively distinguish between a benign and malignant pelvic mass. Methods: Retrospective study of 70 predictive parameters collected from 140 women with a pelvic mass. The women were split into a 3:1 “training” to “testing” dataset. Feature selection was performed using Gini impurity through an embedded random forest model and principal component analysis. Nine unique ML classifiers were assessed across a variety of model-specific hyperparameters using 25 bootstrap resamples of the training data. Model predictions were then combined into an ensemble stack by LASSO regression. The final ensemble stack and individual classifiers were then applied to the testing dataset to assess model performance. Results: Feature selection identified HE4, CA125, and transferrin as three predictive parameters of malignancy. Assessment of the ensemble stack on the testing dataset outperformed all individual ML classifiers in predicting malignancy. The ensemble stack demonstrated an accuracy of 97.1%, a receiver operating characteristic (ROC) area under the curve (AUC) of 0.951, and a sensitivity of 93.3% with a specificity of 100%. Conclusions: Combining the measurement of three distinct biomarkers with the stacking of multiple ML classifiers into an ensemble can provide valuable preoperative diagnostic predictions for patients with a pelvic mass.

Folate Transport and One-Carbon Metabolism in Targeted Therapies of Epithelial Ovarian Cancer

New therapies are urgently needed for epithelial ovarian cancer (EOC), the most lethal gynecologic malignancy. To identify new approaches for targeting EOC, metabolic vulnerabilities must be discovered and strategies for the selective delivery of therapeutic agents must be established. Folate receptor (FR) α and the proton-coupled folate transporter (PCFT) are expressed in the majority of EOCs. FRβ is expressed on tumor-associated macrophages, a major infiltrating immune population in EOC. One-carbon (C1) metabolism is partitioned between the cytosol and mitochondria and is important for the synthesis of nucleotides, amino acids, glutathione, and other critical metabolites. Novel inhibitors are being developed with the potential for therapeutic targeting of tumors via FRs and the PCFT, as well as for inhibiting C1 metabolism. In this review, we summarize these exciting new developments in targeted therapies for both tumors and the tumor microenvironment in EOC.

Association of gynecologic oncology versus medical oncology specialty with survival, utilization, and spending for treatment of gynecologic cancers

BACKGROUND

We examined the association of gynecologic oncology (GYO) versus medical oncology (MEDONC) based care with survival, health care utilization and spending outcomes in women undergoing chemotherapy for advanced gynecologic cancers.

METHODS

Women with newly diagnosed stage III-IV uterine, ovarian, and cervical cancers from 2000 to 2015 were identified in SEER-Medicare. We assessed the association of provider specialty with overall survival, emergency department utilization, admissions, and spending. Outcomes were assessed using unadjusted and Inverse Treatment Probability Weighted propensity-score applied, multi-variable cox modeling, Poisson regression, and generalized models of log-transformed data.

RESULTS

We identified 7930 gynecologic cancer patients (4360 ovarian, 2934 uterine, 643 cervix). 37% were treated by GYO and 63% by MEDONC. For ovarian patients, GYO care was associated with improved OS (median OS 3.3 v. 2.9 years; HR 0.85, 95%CI 0.80, 0.91, p < .0001) and similar mean spending per month ($4015 v. $4316, mean ratio 0.97 (95% CI 0.93, 1.02), p = .19), compared to MEDONC in adjusted analyses. For uterine patients, GYO care was associated with similar OS, but decreased spending ($3573 v. $4081, mean ratio 0.87 (95% CI.81, 0.93), p < .0001), and decreased ED utilization (RR 0.76, 95% CI 0.69, 0.85, p < .0001). For cervical patients, GYO care was associated with similar OS, and similar spending. Admissions were more likely in ovarian (RR 1.23, 95%CI 1.11, 1.37, p = .0001) and cervical patients (RR 1.26, 95% CI 1.05, 1.51, p = .015) treated by GYO, in adjusted analyses.

CONCLUSIONS

GYO based care was associated with improved OS and equal spending for patients with advanced stage ovarian cancer. Uterine and cervix patients had similar OS, and less or equal spending respectively, when treated by GYO compared to MEDONC.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

The diagnostic accuracy of human epididymis protein 4 (HE4) for discriminating between benign and malignant pelvic masses: a systematic review and meta-analysis

INTRODUCTION

Many women with benign pelvic masses, suspected of ovarian cancer, are unnecessarily referred for treatment at specialized centers. There is an unmet clinical need to improve diagnostic assessment in these patients. Our objective was to obtain summary estimates of the accuracy of human epididymis protein (HE4) for diagnosing ovarian cancer and to compare the performance of HE4 with that of cancer antigen 125 (CA125).

MATERIAL AND METHODS

We searched PubMed, Ovid and Scopus using search terms for "pelvic masses" and "HE4", to identify studies that evaluated HE4 for diagnosing malignant ovarian masses, in adult women presenting with a pelvic mass, suspected of ovarian cancer, and with diagnosis confirmed by histopathology. Screening, data extraction and Risk of Bias assessment with the QUADAS-2 tool were done independently by two authors. We performed a meta-analysis of the accuracy of HE4 and CA125 using a random-effects bivariate logit-normal model. A study protocol was registered at PROSPERO (CRD42020158073).

RESULTS

In the 17 eligible studies, which included 3404 patients, ovarian cancer prevalence ranged from 15% to 71%. Overall, the studies were heterogeneous. All studies seemed to have recruited patients in specialized settings. A meta-analysis of seven HE4 studies resulted in a mean sensitivity of 79.4% (95% confidence interval [CI] 74.1%-83.8%) and a mean specificity of 84.1% (95% CI 79.6%-87.8%), for cut-off values of 67-72 pmol/L. Based on eight studies, the mean sensitivity of CA125 was 81.4% (95% CI 74.6%-86.2%) and the mean specificity was 56.8% (95% CI 47.9%-65.4%), at a cut-off of 35 U/ml. Given a 40% ovarian cancer prevalence, the positive predictive value (PPV) for HE4 would be 76.9% (71.9%-81.2%) versus 55.6% (50.2%-60.9%) for CA125. The negative predictive value (NPV) would be 85.9 (82.8%-88.6%) and 81.9% (76.2%-86.4%), respectively. At a 15% prevalence, the NPV would be 95.8% (95% CI 94.4%-96.7%) for HE4 and 94.4% (95% CI 92.3%-96.0%) for CA125. The PPV would be 46.9% (40.4%-53.4%) and 24.9% (21.1%-29.2%), respectively.

CONCLUSIONS

HE4 had higher specificity and similar sensitivity compared with CA125. At high prevalence, PPV was also higher for HE4, but at low prevalence, it had a similar NPV to CA125. The field would benefit from studies conducted in general settings.

A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review)

Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.

The Volume-Outcome Paradigm for Gynecologic Surgery: Clinical and Policy Implications

Studies over the past decade have clearly demonstrated an association between high surgeon and hospital volume and improved outcomes for women undergoing gynecologic surgical procedures. In contrast to procedures associated with higher morbidity, the association between higher volume and improved outcomes is often modest for gynecologic surgeries. The lower magnitude of this association has limited actionable policy changes for gynecologic surgery. These data have been driving initiatives such as regionalization of care, targeted quality improvement at low volume centers and volume-based credentialing in gynecology.

Effect of surgeon volume on long-term quality of life outcomes following tension-free vaginal tape surgery

INTRODUCTION AND HYPOTHESIS

The role of the general obstetrician/gynaecologist completing routine urogynaecology procedures is controversial, and some research has suggested that these patients should be referred to high-volume subspecialists. In response to recent public and regulatory scrutiny of vaginal mesh procedures, credentialling guidelines have been released in Australia requiring surgeons to demonstrate a minimum caseload prior to performing tension-free vaginal tape (TVT) surgery for incontinence. Hence, a retrospective cohort study was conducted to evaluate the long-term quality of life outcomes of TVT procedures for high- and low-volume surgeons.

METHODS

One hundred seventy patients who had undergone TVT surgery between 1 May 2011 and 1 May 2016 in the Sunshine Coast health district were invited to complete the UDI-6 (Urinary Distress Inventory) and IIQ-7 (Incontinence Impact Questionnaire) surveys. Perioperative information was accessed from available health records. Mean UDI-6 and IIQ-7 scores were compared for high- and low-volume groups, and the groups were assessed for confounding factors.

RESULTS

Of the 170 patients eligible, 83 completed the surveys (47.2%). No differences in UDI-6 or IIQ-7 scores were found between high- and low-volume surgeons (p > 0.05). High-volume surgeons completed more concomitant procedures amongst survey respondents (p < 0.05), though this was not reproduced when considering all 170 patients eligible for the study. There were no significant differences in age, ASA (American Society of Anaesthesiologists) score or complication rate amongst survey respondents.

CONCLUSIONS

Amongst the patients surveyed, high- and low-volume surgeons had similar long-term quality of life outcomes for TVT surgery, without any significant difference in complication rate.

Outcomes after the regionalization of care for high-grade endometrial cancers: a population-based study

BACKGROUND

In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that gynecologic oncologists at tertiary care centers manage the treatment of patients with high-grade endometrial cancers. This study examines the effects of this regionalization of care on patient outcomes.

OBJECTIVE

This study aimed to evaluate the impact of the regionalization of surgery for high-grade endometrial cancer on patient and treatment outcomes.

STUDY DESIGN

In this retrospective cohort study, patients diagnosed with nonendometrioid high-grade endometrial cancer from 2003 to 2017 were identified using province-wide administrative databases. To allow 6 months for knowledge translation, 2 periods were defined, with January 1, 2014, as the cutoff. Methods for segmented regression were used to test the effect of the guidelines. Multivariable Cox proportional hazards regression was used to evaluate whether regionalization of care had an impact on patient survival.

RESULTS

There were 3518 patients with nonendometrioid high-grade endometrial cancer identified. The case mix as represented by patient comorbidities and the disease stage distribution did not differ significantly between the 2 regionalization periods. There was a significant increase (69%-85%; P<.001) in the proportion of primary surgeries performed by gynecologic oncologists after regionalization, which was not explained by secular trends. After regionalization, the proportion of patients who had surgical staging (50%-63%; P<.001) and the proportion of patients who received adjuvant treatment (65%-71%; P<.001) increased significantly. After adjusting for age, stage, and comorbidities, there was a decrease in the hazard of mortality (hazard ratio, 0.85 [95% confidence interval, 0.73-0.99]; P=.04) after regionalization.

CONCLUSION

The publication of a regionalization policy for the treatment of high-grade endometrial cancers in Ontario led to an increase in the proportion of surgeries performed by gynecologic oncologists. This also translated into a significant improvement in patient survival.

Multidisciplinary Surgical Approach to Increase Complete Cytoreduction Rates for Advanced Ovarian Cancer in a Tertiary Gynecologic Oncology Center

BACKGROUND

Surgical resection remains the cornerstone of ovarian cancer management. In 2017, the authors implemented a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper gastrointestinal (GI) surgeons to increase gross macroscopic resection rates. This report aims to describe changes in complete cytoreduction rates and morbidity after the implementation of a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper GI surgeons in a tertiary gynecologic oncology unit.

METHODS

The study used two cohorts. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients initiated in 2017. A multidisciplinary approach to preoperative medical optimization, intraoperative management, and postoperative care was implemented in 2017. The patients in cohort B with upper abdominal disease were offered primary cytoreduction with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Before 2017, the patients with upper abdominal disease received neoadjuvant chemotherapy (cohort A).

RESULTS

This study included 146 patients in cohort A (2006-2015) and 93 patients in cohort B (2017-2019) with stages 3 or 4 ovarian cancer. The overall complete macroscopic resection rate (CC0) increased from 58.9 in cohort A to 67.7% in cohort B. The rate of primary cytoreductive surgery (CRS) increased from 38 (55/146) in cohort A to 42% (39/93) in cohort B. The CC0 rate for the patients who underwent primary CRS increased from 49 in cohort A to 77% in cohort B. Major morbidity remained stable throughout both study periods (2006-2019).

CONCLUSIONS

The study data demonstrate that implementation of a multidisciplinary team intraoperative approach and a meticulous approach to preoperative optimization resulted in significantly improved complete resection rates, particularly for women offered primary CRS.

Differential blood count as triage tool in evaluation of pelvic masses

OBJECTIVE

Triaging patients with presumptive ovarian cancer to the appropriate specialist may improve survival. Therefore, there is increasing interest in complementary diagnostic markers to the standard serum CA125. In patients with pelvic masses, we examined the ability of epidemiologic variables and preoperative differential blood counts to improve detection of ovarian cancer over CA125 alone.

METHODS

From pathology reports, patients were classified as having: epithelial ovarian cancer (n=743), including fallopian tube and primary peritoneal cancer, non-epithelial ovarian cancers (n=46), non-ovarian cancers (n=122), or benign disease (1,129). From women with epithelial ovarian cancer, we excluded those who received prior neoadjuvant chemotherapy (n=19). Women were also excluded if they did not have a serum CA125 or complete blood count measured within 180 days prior to surgery (n=1099) or did not have both tests within 90 days of each other (n=13). Categorizing patients by menopausal status, we calculated Pearson correlations between differential counts or ratios and CA125, and used t tests to identity univariate predictors of malignancy and stepwise logistic regression and likelihood ratio tests to create models best distinguishing epithelial ovarian cancer from benign disease.

RESULTS

337 women with epithelial ovarian cancer and 365 with benign disease were included in the analysis. Compared with cancers, women with benign disease had lower average: age, 52.5 versus 58.4 years (p<0.0001); serum CA125, 20 versus 239 U/mL (p<0.0001), neutrophil-to-lymphocyte ratio, 2.4 versus 3.5 (p<0.0001); and platelet-to-lymphocyte ratio, 158 versus 222 (p<0.0001); but greater average body mass index, 28.5 versus 26.8 kg/m² (p=0.004), and lymphocyte-to-monocyte ratio, 5.6 versus 3.9 (p<0.0001). Correlations between counts and ratios and serum CA125 were seen in both epithelial ovarian cancer and benign disease groups and differed by menopausal status. In premenopausal women, a multivariate model including serum CA125, smoking, family history, lymphocytes, and monocytes performed similarly to the model with lymphocyte-to-monocyte ratio replacing counts. In postmenopausal women, a model including body mass index, parity, monocytes, and basophils performed similarly to the model replacing counts with platelet-to-lymphocyte ratio and lymphocyte-to-monocyte ratio. Models including epidemiologic variables and either counts or ratios were better at fitting data than models with serum CA125 and menopausal status alone. A single model applying to all women overstated performance for premenopausal women and understated performance for postmenopausal women.

CONCLUSIONS

Epidemiologic variables and differential counts or ratios better distinguished between benign and malignant disease when compared with serum CA125 alone using separate models for pre- and postmenopausal women.

Travel distance, hospital volume and their association with ovarian cancer short- and long-term outcomes

OBJECTIVE

To examine patterns of patient travel among women with ovarian cancer and to explore the association between travel distance and short and long-term outcomes.

METHODS

Women with stage II-IV epithelial ovarian cancer diagnosed from 2004 to 2016 who underwent primary surgery were identified in the National Cancer Database. Mixed-effect log-linear models and proportional hazards models were developed to evaluate the association between travel distance and short and long-term outcomes after propensity score weighting. A further analysis was performed to compare patients who traveled a short distance to a low volume center (Local) to patients who traveled farther to a high volume hospital (Travel).

RESULTS

We identified 56,834 patients treated in 1201 hospitals. Hispanic women were 58% and black women 64% less likely than white women to travel to a center in the greatest distance quartile for care. Similarly, Medicaid recipients (vs. commercially insured) were less likely to travel to a quartile four hospital (compared to Q1 of distance traveled). Of all patients, 90-day mortality was significantly lower in patients who traveled farther (Q4 vs. Q1; P < 0.0001). Compared to women in the Local group, patients in the Travel group had a decreased 30-day readmission rate. There was no difference in 30-day, 90-day, or 5-year mortality when comparing the Local to the Travel group.

CONCLUSIONS

Travel distance for ovarian cancer surgery has increased over time. While there may be some short-term benefits in traveling to a regional center for care, there was little difference in long term outcomes based on travel distance.

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer

BACKGROUND

Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice.

METHODS

Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives.

RESULTS

Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes.

DISCUSSION

Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Breech deliveries in OLVG, the Netherlands: A retrospective cohort study of seven years

BACKGROUND

The clinical dilemma on the preferred mode of delivery for breech position still exists. Elective caesarean delivery (CD) could be safer for neonates, whereas vaginal breech delivery (VBD) remains a safe option when conducted by an experienced person. Besides successful VBD is beneficial for mothers and subsequent pregnancies.

OBJECTIVES

To evaluate breech deliveries on mode of delivery, maternal and neonatal outcomes.

STUDY DESIGN

A single center, retrospective, cohort study was performed of women who delivered a singleton fetus in breech position from 32 weeks' gestation onwards from January 2011 to December 2017. Primary outcome measure was mode of delivery defined as an elective CD and planned VBD. Secondary outcome measures were neonatal and maternal outcome. For neonatal outcome, we used neonatal mortality and a composite measure neonatal morbidity. Maternal outcome included maternal mortality and maternal morbidity divided in severe and non-severe complications. We subcategorized for preterm (32 weeks to 37 weeks of gestation) and term pregnancies (from 37 weeks of gestation onwards).

RESULTS

1.774 women delivered a child in breech position, 73 % opted for an elective CD. Of the 484 women that had a planned VBD (preterm 38 % (n = 59), term 26 % (n = 425)) 71 % were successful. Neonatal mortality occurred twice in the VBD cohort. Preterm neonatal morbidity occurred in the elective CD and VBD cohort equally (both 66 %), at term significantly more in the VBD cohort (12 % v 4%, OR 3.2, 95 % CI 2.1-4.8). For the total cohort, severe maternal postpartum complications occurred more often in the elective CD compared to successful VBD (2% v 0.3 %, OR 6.0, 95 % CI 0.80-44.3).

CONCLUSION

A high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal postpartum complications were more frequent in the elective CD group compared to the VBD group. Future research should focus alternations in the management of breech presentation.

Well-trained gynecologic oncologists can perform bowel resection and upper abdominal surgery safely

Objective

This study was performed to examine the safety of bowel resection and upper abdominal surgery in patients with advanced ovarian cancer performed by gynecologic oncologists after training in a monodisciplinary surgical team.

Methods

We implemented a monodisciplinary surgical team consisting of specialized gynecologic oncologist for advanced ovarian cancer. In the initial learning period in 65 patients with International Federation of Gynecology and Obstetrics (FIGO) III/IV, a gynecologic oncologist who had a certification as a general surgeon trained 2 other gynecologic oncologists in bowel resection and upper abdominal surgery for 4 years. After the initial learning period, the trained gynecologic oncologists performed surgeries without the certificated general surgeon in 195 patients with FIGO III/IV. The surgical outcomes and perioperative complications during the 2 periods were evaluated.

Results

The rates of achieving no gross disease after cytoreductive surgery were 80.0% in the initial learning period and 83.6% in the post-learning period (p=0.560). The incidence of anastomotic leakage after rectosigmoid resection, symptomatic pleural effusion or pneumothorax after right diaphragm resection, and pancreatic fistula after splenectomy with distal pancreatectomy in the 2 periods were 2 of 34 (6.0%), 1 of 33 (3.0%), and 3 of 15 (20.0%) patients in the initial learning period, and 12 of 147 (8.2%), 1 of 118 (0.8%), and 11 of 84 (13.1%) patients in the post-learning period, respectively. There were no significant differences between the 2 groups (p=0.270, p=0.440, p=0.520, respectively).

Conclusion

Bowel resection and upper abdominal surgery can be performed safely by gynecologic oncologists.

Failure to Rescue and Mortality Following Resection of Intracranial Neoplasms

BACKGROUND

There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications.

OBJECTIVE

To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms.

METHODS

We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication).

RESULTS

A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]).

CONCLUSION

While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.

European Society of Gynaecological Oncology (ESGO) Guidelines for Ovarian Cancer Surgery

METHODS

The European Society of Gynaecological Oncology council nominated an international multidisciplinary development group made of practicing clinicians who have demonstrated leadership and interest in the care of ovarian cancer (20 experts across Europe). To ensure that the statements are evidence based, the current literature identified from a systematic search has been reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group (expert agreement). The guidelines are thus based on the best available evidence and expert agreement. Before publication, the guidelines were reviewed by 66 international reviewers independent from the development group including patients representatives.

RESULTS

The guidelines cover preoperative workup, specialized multidisciplinary decision making, and surgical management of diagnosed epithelial ovarian, fallopian tube, and peritoneal cancers. The guidelines are also illustrated by algorithms.

Clair CM, Hou JY, Khoury-Collado FMD, Ananth CV, Neugut AI, Hershman DL. Potential Consequences of Minimum-Volume Standards for Hospitals Treating Women With Ovarian Cancer

OBJECTIVE

To assess the potential effects of implementing minimum hospital volume standards for ovarian cancer on survival and access to care.

METHODS

We used the National Cancer Database to identify hospitals treating women with ovarian cancer from 2005 to 2015. We estimated the number of patients treated by each hospital during the prior year. Multivariable models were used to estimate the ratio of observed/expected 60-day, and 1-, 2- and 5-year mortalities. The mean predicted observed/expected ratio of hospitals was plotted based on prior year volume. The number of hospitals that would be restricted if minimum-volume standards were implemented was modeled.

RESULTS

A total of 136,196 patients treated at 1,321 hospitals were identified. Increasing hospital volume was associated with decreased 60-day (P=.004), 1-year (P<.001), 2-year (P<.001) and 5-year (P=.008) mortality. In 2015, using a minimum-volume cutpoint of one case in the prior year would eliminate 144 (13.6%) hospitals (treated 2.6% of all patients); a cutpoint of three would eliminate 364 (34.5%) hospitals (treated 7.7% of the patients). The mean observed/expected ratios for hospitals with a prior year volume of 1 was 1.14 for 60-day mortality, 1.06 for 1-year mortality, 1.12 for 2-year mortality, and 1.08 for 5-year mortality. Among hospitals with a prior year volume of one, 49.2% had an observed/expected ratio for 2-year mortality of at least 1 (indicating worse than expected performance), and 50.8% had an observed/expected ratio of less than 1 (indicating better than expected performance). The mean observed/expected ratios for hospitals with a prior year volume of two or less were 1.11 for 60-day mortality, 1.09 for 1-year mortality, 1.08 for 2-year mortality, and 1.07 for 5-year mortality. Implementing a minimum-volume standard of one case in the prior year would result in one fewer death for every 198 patients at 60 days, for every 613 patients at 1 year, and for every 62 patients at 5 years.

CONCLUSION

Implementation of minimum hospital volume standards could restrict care at a significant number of hospitals, including many centers with better-than-predicted outcomes.

Impact of hospital surgical volume on complete gross resection (CGR) rates following primary debulking surgery for advanced stage epithelial ovarian carcinoma

BACKGROUND

To investigate the impact of hospital surgical volume on the rate of complete gross resection for patients with advanced stage epithelial ovarian carcinoma undergoing primary debulking surgery.

METHODS

The National Cancer Data Base was used to identify patients undergoing between 2010 and 2014 for an advanced stage (III-IV) epithelial ovarian cancer. For analyses purposes facility surgical volume was divided into tertiles (high, intermediate and low). Patients with bulky stage III disease who underwent primary debulking surgery with known residual disease status were selected for further analysis.

RESULTS

A total of 8894 patients with macroscopic peritoneal disease were included. Rates of complete gross resection for patients managed in low, intermediate and high-volume centers were 41.0%, 41.6% and 43.3% respectively (p = 0.20). After controlling for year of diagnosis, age, insurance status, presence of co-morbidities, histology, size of peritoneal implants, stage, and complexity of surgery, patients undergoing primary debulking surgery at low (OR: 0.85, 95% CI: 0.74, 0.97, p = 0.013) and intermediate (OR: 0.90, 95% CI: 0.82, 0.99, p = 0.043) volume centers had a lower likelihood of achieving complete gross resection compared to those managed in high volume centers.

CONCLUSIONS

After controlling for multiple potential confounders, patients receiving surgery in high volume centers had a higher likelihood of complete gross resection following primary debulking surgery for advanced-stage epithelial ovarian cancer.

Variation in the time to treatment for stage III and IV non-small cell lung cancer patients for hospitals in the Netherlands

OBJECTIVES

Increased emphasis on molecular diagnostics can lead to increased variation in time to treatment (TTT) for patients with stage III and IV non-small cell lung cancer. This article presents the variation in TTT for advanced NSCLC patients observed in Dutch hospitals before the widespread use of immunotherapy. The aim of this article was to explore the variation in TTT between patients, as well as between hospitals.

MATERIAL AND METHODS

Based on the Netherlands Cancer Registry, we used patient-level data (n = 4096) from all 78 hospitals that diagnosed stage III or IV NSCLC in the Netherlands in 2016. To investigate how patient characteristics and hospital-level effects are associated with TTT (from diagnosis until start treatment), we interpreted regression model results for five common patient profiles to analyze the influence of age, gender, tumor stage, performance status, histology, and referral status as well as hospital-level characteristics on the TTT.

RESULTS AND CONCLUSIONS

TTT varies substantially between and within hospitals. The median TTT was 28 days with an inter-quartile range of 22 days. The hospital-level median TTT ranges from 17 to 68 days. TTT correlates significantly with tumor stage, performance status, and histology. The hospital-level effect, unrelated to hospital volume and type, affected TTT by several weeks at most. For most patients, TTT is within range as recommended in current guidelines. Variation in TTT seems higher for patients receiving either radiotherapy or targeted therapy, or for patients referred to another hospital and we hypothesize this is related to the complexity of the diagnostic pathway. With further advances in molecular diagnostics and precision oncology we expect variation in TTT to increase and this needs to be considered in designing optimal cancer care delivery.

Multiple biomarker algorithms to predict epithelial ovarian cancer in women with a pelvic mass: Can additional makers improve performance?

INTRODUCTION

Management of a woman with a pelvic mass is complicated by difficulty in discriminating malignant from benign disease. Many serum biomarkers have been examined to determine their sensitivity for detecting malignancy. This study was designed to evaluate if the addition of biomarkers to HE4 and CA125, as used in the Risk of Malignancy Algorithm (ROMA), can improve the detection of EOC.

METHODS

This was an IRB approved, prospective clinical trial examining serum obtained from women diagnosed with a pelvic mass who subsequently underwent surgery. Serum biomarker levels for CA125, HE4, YKL-40, transthyretin, ApoA1, Beta-2-microglobulin, transferrin, and LPA were measured. Logistic regression analysis was performed for various marker combinations, ROC curves were generated, and the area under the curves (AUCs) were determined.

RESULTS

A total of 184 patients met inclusion criteria with a median age of 56 years (Range 20-91). Final pathology revealed there were 103 (56.0%) benign tumors, 4 (2.2%) LMP tumors, 61 EOC (33.1%), 2 (1.1%) non-EOC ovarian cancers, 6 (3.3%) gynecologic cancers with metastasis to the ovary and 8 (4.3%) non-gynecologic cancers with metastasis to the ovary. The combination of HE4 and CA125 (i.e. ROMA) achieved an AUC of 91.2% (95% CI: 86.0-96.4) for the detection of EOC vs benign disease. The combination of CA125, HE4, YKL-40, transthyretin, ApoA1, Beta 2 microglobulin, transferrin, LPA and menopausal status achieved the highest AUC of 94.6% (95% CI: 90.1-99.2) but this combination was not significantly better than the HE4 and CA125 combination alone (p = 0.078).

CONCLUSIONS

The addition of select further serum biomarkers to HE4 and CA125 does not add to the performance of the dual marker combination for the detection of ovarian cancer.

[Epithelial ovarian cancer and elderly patients. Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

In ovarian, tubal and primary peritoneal cancers, older adults have an over-mortality due to more aggressive disease (NP4), surgical and chemotherapy under treatment (NP4) and co-morbidities (NP4). Older age is at higher risk for postoperative morbidity and mortality (NP4). Surgery is more often incomplete in this elderly population (NP4). Older age is a risk factor for lower dose intensity in adjuvant chemotherapy (NP4) and incomplete chemotherapy (NP4). Nevertheless, the benefit of a complete surgery remains identical to that of the younger population (NP2). Preoperative functional assessment identifies patients at risk for postoperative complications (NP4). The perioperative risk depends on three variables, the ASA score, the age and the complexity score of the surgery (NP4). It is recommended to perform cytoreduction surgery in an expert centre (grade C) and on the basis of geriatric expertise analysing functional and physical performance (grade C). The benefit/risk balance of surgery should be assessed on a case-by-case basis for the most at-risk (NP4) populations defined by: (i) age≥80 years, especially if albuminemia≤37g/L; (ii) age≥75 years and FIGO stage IV; (iii) age≥75 years, stage FIGO III and≥1 comorbidity. A comprehensive geriatric assessment is recommended prior to the management of an elderly person with primary ovarian, tubal or peritoneal cancer (grade C). The GVS (Geriatric Vulnerability Score) is used to identify vulnerable elderly patients (NP2). In fit elderly patients, it is recommended to perform intravenous chemotherapy identical to that of younger patients (ie platinum-based dual therapy) (grade B). In vulnerable elderly patients, various adapted chemotherapy regimens have been prospectively evaluated in non-comparative trials, and seem feasible considering specific and nonspecific toxicities: carboplatin monotherapy (NP2), carboplatin AUC2+paclitaxel 60mg/m² 3 weeks/4 (NP2), carboplatin AUC 4-5+paclitaxel 135mg/m²/3 weeks (NP2), carboplatin AUC5/3 weeks+paclitaxel 60mg/m²/week (NP3). In the absence of comparative data, no recommendation can be made in this population. Primary chemotherapy decreases the complexity of the surgical procedure and perioperative morbidity and mortality during interval surgery (NP1). It should be considered after 70 years in cases of comorbidities and/or peritoneal carcinomatosis sufficient for complex initial surgery (NP4).

Neoadjuvant therapy in gynaecological malignancies: What pathologists need to know

In recent times, there has been a growing tendency to treat advanced gynaecological malignancies with neoadjuvant chemotherapy (NACT), with the goal of reducing tumour volume and enhancing operability resulting in optimal cytoreduction. This approach is used in particular for patients with advanced high-grade serous carcinoma of the ovary, fallopian tube or peritoneum. Pathology plays a crucial role in the management of these patients, both before and after NACT. Prior to initiation of NACT, a biopsy should be performed, usually of the omental cake, to confirm that a malignancy is present, to identify the site of origin of the tumour and to type and grade the tumour. Histopathologists must be aware of the resultant morphological effects of NACT when examining specimens following interval cytoreduction surgery. Tumour typing and grading, and even the identification of residual neoplasia, are particular challenges. Immunohistochemistry, when used judiciously, can be a useful adjunct in certain scenarios. A pathological assessment of the response to chemotherapy, and the pathological stage should be provided in the pathology report, as these may inform prognosis and subsequent management. We present a comprehensive overview of the relevant clinical and pathological aspects pertaining to NACT for gynaecological malignancies for the practicing surgical pathologist.

Exploring the impact of income and race on survival for women with advanced ovarian cancer undergoing primary debulking surgery at a high-volume center

OBJECTIVE

To evaluate patients with advanced ovarian cancer (OC) undergoing primary debulking surgery (PDS) at a high-volume center (HVC), to determine whether socio-demographic disparities in PDS outcome and overall survival (OS) were present.

METHODS

All patients with stages IIIB-IV high-grade OC undergoing PDS at our institution from 1/2001-12/2013 were identified. Patients self-identified race/ethnicity as non-Hispanic White (NHW), non-Hispanic Black (NHB), Asian (A), or Hispanic (H). Income level for the entire cohort was estimated using the census-reported income level for each patient's zip code as a proxy for SES. Main outcome measures were PDS outcome and median OS. Cox proportional hazards model was used to examine differences in OS by racial/ethnic and income category, controlling for selected clinical factors.

RESULTS

963 patients were identified for analysis: 855 NHW; 43 A, 34H, 28 NHB, and 3 unknown. PDS outcome was not significantly different among NHB and H as compared to NHW. Compared to NHW, Asians were more likely to have >1cm residual (AOR 2.32, 95%CI 1.1-4.9, p=0.03). Median income for the entire cohort was $85,814 (range $10,926-$231,667). After adjusting for significant prognostic factors, there were no significant differences in PDS outcome between income groups (p=0.7281). Median OS was 55.1mos (95%CI 51.8-58.5) with no significant differences in OS between the income (p=0.628) or racial/ethnic (p=0.615) groups.

CONCLUSION

Statistically significant socio-demographic disparities in PDS and survival outcomes were not observed among women with advanced OC treated at this HVC. Increased efforts are needed to centralize care to and increase the diversity of pts treated at HVCs.

Is Ovarian Cancer Being Managed According to Clinical Guidelines? Evidence From a Population-Based Clinical Audit

BACKGROUND

In the northwestern Italian region of Piedmont, current statistics on hospitalizations show that surgical treatment for ovarian cancer (OC) is taking place in many small hospitals, as opposed to a more centralized approach. A population-based clinical audit was promoted to investigate whether OC is being managed according to clinical guidelines, identify determinants of lack of adherence to guidelines, and evaluate the association between adherence to guidelines and survival.

PATIENTS AND METHODS

Residents diagnosed with OC in 2009 were identified in the regional hospital discharge records database. All hospitalizations within 2 years from diagnosis were reviewed. Patients were classified according to their initial pattern of care, defined as "with curative intent" (CIPC) if including debulking surgery aimed at maximal cytoreduction. Adherence to guidelines for surgery and chemotherapy and the effects of this adherence on OC survival were investigated with logistic regression and Cox models.

RESULTS

The final study sample consisted of 344 patients with OC, 215 (62.5%) of whom received CIPC. Increasing age, comorbidities, and metastases were negatively associated with receiving CIPC. In the CIPC group, surgical treatment was adherent to guidelines in 35.2%, whereas chemotherapy was adherent in 87.8%. Surgical treatment that was adherent to guidelines [hazard ratio (HR), 0.72; 95% confidence interval (CI), 0.45-1.15] and absence of residual tumor (HR, 0.55; 95% CI, 0.32-0.94) were associated with better survival in the CIPC group, and chemotherapy that was adherent to guidelines was associated with a significant reduction in the risk of death (HR, 0.49; 95% CI, 0.28-0.87).

CONCLUSIONS

Results support the need to reorganize the clinical pathway of patients with OC in the Piedmont Region and the need for better adherence to current guidelines.

Being treated in higher volume hospitals leads to longer progression-free survival for epithelial ovarian carcinoma patients in the Rhone-Alpes region of France

BACKGROUND

To investigate the relationship between hospital volume activities and the survival for Epithelial Ovarian Carcinoma (EOC) patients in France.

METHODS

This retrospective study using prospectively implemented databases was conducted on an exhaustive cohort of 267 patients undergoing first-line therapy during 2012 in the Rhone-Alpes Region of France. We compared Progression-Free Survival for Epithelial Ovarian Carcinoma patients receiving first-line therapy in high- (i.e. ≥ 12 cases/year) vs. low-volume hospitals. To control for selection bias, multivariate analysis and propensity scores were used. An adjusted Kaplan-Meier estimator and a univariate Cox model weighted by the propensity score were applied.

RESULTS

Patients treated in the low-volume hospitals had a probability of relapse (including death) that was almost two times (i.e. 1.94) higher than for patients treated in the high-volume hospitals (p < 0.001).

CONCLUSION

To our knowledge, this is the first study conducted in this setting in France. As reported in other countries, there was a significant positive association between greater volume of hospital care for EOC and patient survival. Other factors may also be important such as the quality of the surgical resection.

Centralization of ovarian cancer in the Netherlands: Hospital of diagnosis no longer determines patients' probability of undergoing surgery

OBJECTIVE

Surgical care for advanced stage epithelial ovarian cancer (EOC) patients has been centralized in the Netherlands since 2012. We evaluated whether the likelihood for patients to undergo surgery depends on the hospital of initial diagnosis before and after centralization of surgical care.

METHODS

Patients with EOC FIGO stage IIB-IV, diagnosed in the Netherlands between 2000 and 2015, were identified from the Netherlands Cancer Registry. Multilevel multivariate logistic regression was used to study the association between hospital of diagnosis and patients' likelihood of undergoing surgery in subsequent time periods. Furthermore, changes in overall survival were analyzed by multivariable Cox regression models.

RESULTS

15,314 EOC patients were selected from the NCR. Hospital of diagnosis was identified as a significant level for patients' likelihood of undergoing surgery in 2000-2005 (LR test p<0.001), as well as in 2006-2011 (LR test p=0.002) but not in 2012-2015 (LR test p=0.127). Patients who underwent surgery in 2012-2015 had a better survival when compared to 2006-2011 (HR 0.90(0.84-0.96)).

CONCLUSION

This study shows that centralization of surgical care resolved the variation between hospitals in the probability to undergo cytoreductive surgery for patients with advanced EOC. Since centralization was established in 2012, the decision to operate patients seems solely attributable to patient and tumor characteristics. This supports the growing evidence in favor of centralizing (surgical) treatment for complex and heterogeneous diseases such as EOC.

Association of Hospital Volume and Quality of Care With Survival for Ovarian Cancer

OBJECTIVE

To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer.

METHODS

We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01-5, 5.01-9, 9.01-19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics.

RESULTS

A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5-66.4%) at low-volume to 77.4% (95% CI 77.0-77.8%) at high-volume centers and from 66.5% (95% CI 65.5-67.5%) at low-quality to 77.3% (95% CI 76.8-77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4-64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2-70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals.

CONCLUSION

Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.

Ninety-Day Mortality as a Reporting Parameter for High-Grade Serous Ovarian Cancer Cytoreduction Surgery

OBJECTIVE

To evaluate the utility of using 90-day as an adjunct to 30-day mortality rates after surgical cytoreduction for serous ovarian cancer and to compare them across hospitals of differing case volumes over time.

METHODS

We performed a retrospective cohort study using the National Cancer Database of women undergoing cytoreductive surgery for high-grade serous carcinoma between 2004 and 2012. The primary outcome of the study was mortality rate by hospital volume. The secondary outcome was to evaluate the performance of hospital rankings based on 30- and 90-day mortality rates. Hospitals were categorized by cases per year as low volume (10 or fewer), intermediate (11-20), high (21-30), and ultra-high (31 or more).

RESULTS

A total of 24,827 women from 602 hospitals were included. Overall 30-day mortality was 2.1% (95% CI 1.95-2.3) compared with 90-day mortality of 5.1% (95% CI 4.8-5.4%, P<.001). For each hospital volume category, the 90-day mortality was approximately double that of the 30-day mortality. Substituting 90-day in place of 30-day mortality for hospital ranking, 57 hospitals (9.5%) changed ranks (26 worsened and 31 improved). Based on the logistic regression model (after controlling for age, race-ethnicity, income, Charlson comorbidity index, insurance status, hospital volume, distance from place of residence to the hospital, receipt of neoadjuvant chemotherapy, and year of diagnosis), care at the ultra-high-volume centers was an independent predictor of lower odds of death at 90 days [adjusted odds ratios (OR) 0.60, 95% CI 0.38-0.96, P=.034] but not at 30 days (adjusted OR 0.64, 95% CI 0.35-1.18).

CONCLUSION

Compared with low-volume centers, ultra-high-volume centers are associated with significantly lower 30- and 90-day risk-adjusted mortality. The 90-day mortality rate is double that of the 30-day rate and may be a better metric for assessing the initial quality of care for patients with ovarian cancer.

Primary Surgery or Neoadjuvant Chemotherapy in Advanced Ovarian Cancer: The Debate Continues…

Primary debulking surgery (PDS) followed by platinum-based chemotherapy has been the cornerstone of treatment for advanced ovarian cancer for decades. Primary debulking surgery has been repeatedly identified as one of the key factors in improving survival in patients with advanced ovarian cancer, especially when minimal or no residual disease is left behind. Achieving these results sometimes requires extensive abdominal and pelvic surgical procedures and consultation with other surgical teams. Some clinicians who propose a primary chemotherapy approach reported an increased likelihood of leaving no macroscopic disease after surgery and improved patient-reported outcomes and quality-of-life (QOL) measures. Given the ongoing debate regarding the relative benefit of PDS versus neoadjuvant chemotherapy (NACT), tumor biology may aid in patient selection for each approach. Neoadjuvant chemotherapy offers the opportunity for in vivo chemosensitivity testing. Studies are needed to determine the best way to evaluate the impact of NACT in each individual patient with advanced ovarian cancer. Indeed, the biggest utility of NACT may be in research, where this approach provides the opportunity for the investigation of predictive markers, mechanisms of resistance, and a forum to test novel therapies.