Preoperative quality of life and surgical outcomes in gynecologic oncology patients: a new predictor of operative risk?

Factors associated with emergency room readmission after elective surgery for ovarian carcinoma

BACKGROUND

Hospital readmission is a quality metric of hospital care and has been studied in ovarian carcinoma, but its evaluation has several limitations. Also, emergency room (ER) readmission is considered an adverse effect because it represents patient costs. Therefore, our objective was to determine the rate of ER readmission, its causes, and associated factors.

METHODS

A retrospective study of 592 patients with ovarian carcinoma who underwent upfront surgery, neoadjuvant therapy, or surgery for recurrent disease. An analysis of factors associated with ER readmission, hospital readmission, and surgical complications was performed, including multivariate analysis to assess for case-mix factors.

RESULTS

Of 592 patients, the median age was 51 years, and the predominant type of treatment was the neoadjuvant approach (52.9%); 46% underwent upfront surgeries and six surgeries for recurrence. The ratio to ER readmission was 11.8% (70 patients), of whom 12 patients were admitted more than once. The factors associated with ER readmission were prolonged surgery, intraoperative bleeding, extended hospital stay, the time of the day when the surgery was performed, and post-surgical complications. The hospital readmissions were 4.2%, and the overall morbidity was 17.6%. In the multivariate analysis, the only factor associated with ER readmission was the presence of surgical complications (OR = 39.01). The factors independently associated with hospital readmission were the entrance to the intensive care unit (OR = 1.37), the presence of surgical complications (OR = 2.85), and ER readmission (OR = 1.45).

CONCLUSION

ER readmission is an adverse event representing the presence of symptoms/complications in patients. Evaluating the ER readmission independently of the readmission to the hospital is critical because it will allow modifying medical care behaviors to prevent patients from unnecessarily returning to the hospital after a hospital discharge to manage preventable medical problems.

TRIAL REGISTRATION

researchregistry7882.

Role of predictive markers for severe postoperative complications in gynecological cancer surgery: a prospective study (RISC-Gyn Trial)

BACKGROUND

Surgery for gynecological cancer involves highly invasive and complex procedures potentially associated with various complications, which can cause extended hospital stays and delay of subsequent therapy, with a detrimental effect on the prognosis. The aim of this study was to explore and define the predictors of severe postoperative complications in patients undergoing surgery for gynecologic cancer.

METHODS

Patients undergoing surgery for gynecologic cancers were analyzed prospectively from October 2015 through January 2017. Using validated assessment tools preoperatively, we assessed comorbidities, performance status, quality of life, nutritional and body composition by bioelectrical impedance analysis, and the surgical data of each patient. Surgical complications were graded using the Clavien-Dindo criteria. Using stepwise logistic regression models, we identified predictive markers for postoperative complications.

RESULTS

Of the 226 enrolled patients, 40 (17.7%) experienced a grade ≥IIIb complication according to the Clavien-Dindo criteria. In the regression analysis, overweight/obesity (body mass index >25) (OR 6.41, 95% CI 2.38 to 17.24; p<0.001) and impaired physical functioning defined by a quality of life questionnaire (OR 4.19, 95% CI 1.84 to 9.50; p=0.001) emerged as significant predictors of postoperative complications. Moreover, postoperative complications were predicted by phase angle of bioelectrical impedance analysis <4.75° (OR 3.11, 95% CI 1.35 to 7.16; p=0.008) and Eastern Cooperative Oncology Group (ECOG) performance status >1 (OR 2.51, 95% CI 1.06 to 5.92; p=0.04). Intraoperative factors associated with higher risk of postoperative complications were increased use of norepinephrine (>11 µg/kg/min) (OR 5.59, 95% CI 2.16 to 14.44; p<0.001) and performance of large bowel resection (OR 4.28, 95% CI 1.67 to 10.97; p=0.002).

CONCLUSION

In patients undergoing surgery for gynecological cancer, preoperative evaluation of performance status according to ECOG, domains of quality of life and nutritional status, as well as intraoperative monitoring of risk factors, might help to identify patients at high risk for severe postoperative complications, and thus reduce surgical morbidity and mortality.

Preoperative quality of life as prediction for severe postoperative complications in gynecological cancer surgery: results of a prospective study

Purpose

The aim of this study was to investigate preoperative quality of life (QoL) as a predictive tool for severe postoperative complications (POC) in gynecological cancer surgery.

Methods

This is a prospective study of patients undergoing gynecologic cancer surgery at an academic center in Germany. QoL was assessed by the EORTC Quality of Life Questionnaire (QLQ-C30) and the NCCN Distress Thermometer (DT). Several geriatric assessment tools have been applied. POC were graded using Clavien–Dindo criteria. Using multivariable logistic regression models, we identified predictive clinical characteristics for postoperative complications.

Results

Within 30 days of surgery, 40 patients (18%) experienced grade ≥ 3b complications including 9 patients (4%) who died. The dominant complication was anastomosis insufficiency with 13 patients (5.8%). In the multivariable stepwise logistic regression through all univariate significant variables, we found that impaired physical functioning was predictive of POC, defined by an EORTC score < 70 (OR 5.08, 95% CI 2.23–11.59, p < 0.001). Regarding symptoms nausea/vomiting assessed as an EORTC score > 20 (OR 3.08, 95% CI 1.15–8.26, p = 0.025) indicated a significant predictive value. Being overweight or obese (BMI > 25) were also identified as predictive factors (OR 5.44, 95% CI 2.04–14.49, p = 0.001) as were reduced Mini Mental State Examination (MMSE) results < 27 (OR 7.94, 95% CI 1.36–45.46, p = 0.02).

Conclusion

Preoperative QoL measurements could help to predict postoperative complications in patients with gynecological cancer. Patients with limitations of mobility, debilitating symptoms and cognitive impairment have an increased risk for developing severe POC.

Women's Experiences After Ovarian Cancer Surgery: Distress, Uncertainty, and the Need for Occupational Therapy

IMPORTANCE

Despite the growing literature on the association of functional, physical, and quality-of-life (QOL) deficits with poor postoperative outcomes, there is a gap in the literature identifying women's occupational performance needs after ovarian cancer surgery.

OBJECTIVE

To describe the experiences of women hospitalized after ovarian cancer surgery to identify potential areas for intervention. Goals were to (1) identify functional needs and limitations at time of discharge as measured by the typical acute care occupational therapy evaluation and semistructured interview and (2) understand the women's perspectives of their needs for occupational therapy and a safe return to home.

DESIGN

Single-arm, cross-sectional descriptive study. Mixed-methods data collection and analysis.

SETTING

Academic cancer center.

PARTICIPANTS

Women with ovarian cancer (N = 11) who had completed surgery.

INTERVENTION

Semistructured interviews and patient-reported outcome measures (PROMs) completed postsurgery.

OUTCOMES AND MEASURES

PROMs included the National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problem List, the PROMIS® Global Physical Health (GPH) and Global Mental Health (GMH) scales, and the Possibilities for Activity Scale-Women (PActS-W).

RESULTS

The mean NCCN Distress score was 6.0 (standard deviation [SD] = 3.1, with the top three concerns being pain (80%), worry (80%), and fatigue (78%). Mean GPH and GMH T scores were 38.0 (SD = 8.8) and 48.2 (SD = 8.4), respectively. Women scored a mean of 39.2 (SD = 11.2, range = 26-58) on the PActS-W. Thematic analyses found that the women were uncertain about potential functional limitations and significantly distressed.

CONCLUSION AND RELEVANCE

Women with ovarian cancer experienced high levels of uncertainty and distress after surgery. Integrating in-home or community-based occupational therapy into routine care could decrease functional distress and uncertainty and help women manage concerns related to pain, worry, and fatigue.

WHAT THIS ARTICLE ADDS

This study suggests that occupational therapy evaluation and intervention are needed to decrease distress and improve QOL of women upon discharge after ovarian cancer surgery.

Adherence to postoperative thromboprophylactic medication among gynecologic oncology patients: A subanalysis

INTRODUCTION

Venous thromboembolism (VTE) is a major cause of morbidity and mortality among gynecologic cancer patients, especially in the immediate postoperative period. We sought to identify patterns related with patient non-adherence to postoperative prophylactic anticoagulation.

METHODS

Participant data (N = 400) were reviewed from a previously conducted randomized controlled trial comparing the safety and efficacy of prophylactic postoperative anticoagulation with enoxaparin versus apixaban among gynecologic oncology patients. Variables hypothesized to be related to medication adherence were pre-selected by the study authors, and adherence was defined as missing ≤2 days of medication (4 pills or 2 injections) in 28 days postoperatively. For univariate comparisons and multivariate modeling, the threshold for statistical significance was set at p < .05.

RESULTS

Non-adherence (N = 64) was associated with lower quality of life (QOL) score, history of anxiety disorder, decreased medication satisfaction, taking more medications at baseline, higher baseline heart rate, fewer total intraoperative procedures, not undergoing radical hysterectomy and/or lymph node dissection, not meeting 2-week postoperative milestones, and 28-day emergency department (ED) visit or readmission. African American race, lower mental QOL, difficulty remembering to take medication, and 28-day ED visit or readmission were predictive of non-adherence in a multivariate model. Patients taking enoxaparin versus apixaban more frequently attributed non-adherence to pain or bruising (25.0% vs. 3.1%, P = .01).

CONCLUSION

Our findings provide new insights into factors associated with medication adherence that are particularly relevant to gynecologic oncology patients after surgery. Preoperative interventions to identify patients with these risk factors for more intensive followup of postoperative anticoagulation regimen may help increase medication adherence.

Associations Among Sleep Latency, Subjective Pain, and Thermal Pain Sensitivity in Gynecologic Cancer

OBJECTIVE

Pain is common among women with gynecologic cancer and contributes to depressed mood, sleep disturbances, and likelihood of future chronic pain. Little is known about how psychosocial factors are associated with central sensitization of pain in gynecologic cancer. This study examined relations among depressive symptoms, sleep, subjective pain, and aftersensation pain (a proxy for central sensitization of pain) in gynecologic cancer.

METHODS

Participants were 42 women (mean age [SD] = 59.60 [10.11] years) enrolled in a randomized clinical trial examining psychological intervention effects on sleep, pain, mood, and stress hormones/cytokines in gynecologic cancer. Six to eight weeks after surgery, participants completed an assessment of depressive symptoms, sleep, and subjective pain and a temporal summation of pain protocol via quantitative sensory testing (QST).

RESULTS

Controlling for recent chemotherapy, history of chronic pain, and analgesic medication use, regression analyses revealed that longer sleep onset latency (SOL; B = 3.112, P = 0.039, bias-corrected and accelerated (BCa) 95% confidence interval [CI] = 0.371 to 6.014) and greater sensory pain (B = 0.695, P = 0.023, BCa 95% CI = 0.085 to 1.210) were associated with greater aftersensation pain at 15 seconds. Greater sensory pain scores were associated with greater aftersensation pain at 30 seconds (B = 0.286, P = 0.045, BCa 95% CI = 0.008 to 0.513). Depression was not associated with aftersensation pain. The overall models accounted for 44.5% and 40.4% of the variance in aftersensation pain at 15 and 30 seconds, respectively. Conclusions. Longer SOL and higher subjective sensory pain were related to greater aftersensation of experimentally induced pain in women postsurgery for gynecologic cancers. Interventions that improve sleep and subjective sensory pain during the perisurgical period may reduce risk for central sensitization of pain.

Patient-Reported Outcomes in Surgical Oncology: An Overview of Instruments and Scores

Traditional measures of quality and effectiveness in surgical oncology have focused on morbidity, mortality, and when available, recurrence rates. Measuring patient-reported outcomes (PROs) has become more widely accepted during the last decade. This article reviews instruments commonly used in the surgical treatment of cancer patients to evaluate PROs. In addition, it discusses the linkage of PROs and health-related quality of life measures with traditional surgical complications and highlights future directions related to the expanding use of PROs in the surgical care of cancer patients.

Preoperative Health-Related Quality of Life Predicts Minimal Clinically Important Difference and Survival after Surgical Resection of Hepatocellular Carcinoma

Despite the growing use of minimal clinically important difference (MCID) as a cancer outcome measure, no study has reported clinically significant outcomes in cancer patients. We defined MCID and evaluated the use of preoperative HRQoL for predicting MCID and survival after surgical resection of hepatocellular carcinoma (HCC). In total, 369 patients completed the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) and the SF-36 at baseline and at two years post-operative at three tertiary academic hospitals. The corresponding MCID values were 3.6 (SF-36 physical component summary), 4.2 (SF-36 mental component summary), 5.4 (FACT-General total score), and 6.7 (FACT-Hep total score). The predictors of achieving postoperative MCID were significantly higher in patients who had low preoperative HRQoL score, advanced age, high education level, and high BMI (p < 0.05). However, patients with a high preoperative HRQoL score, high education level, high BMI, and low Charlson comorbidity index score were significantly associated with survival (p < 0.05). Preoperative HRQoL scores were predictive of MCID and overall survival after surgical resection of HCC. The findings of this study may be useful for managing the preoperative expectations of candidates for HCC resection and for developing shared decision-making procedures for patients undergoing surgical resection of HCC.

Health-related quality of life predicted subsequent health care resource utilization in patients with active cancer

Purpose

The objective of this study was to estimate the association between SF-12v2® Health Survey (SF-12v2) scores and subsequent health care resource utilization (HCRU) among patients with cancer.

Methods

We analyzed 18+ year participants in the Medical Expenditure Panel Survey, diagnosed with active cancer or malignancy (n = 647). HCRU was measured by total medical expenditures (MEs) and number of medical events (EVs) in the 6 months following the SF-12v2 assessment. The effect of SF-12v2 scores (physical (PCS) and mental (MCS) component summary scores and the SF-6D health-utility score) on HCRU was estimated using generalized linear models. Estimates were obtained for the entire sample and for the four cancer groups present in the sample: breast, prostate, skin, and lung.

Results

For PCS and MCS, a one-point better score was associated with 2% lower MEs (P < 0.001) and 2.5% lower MEs (P = 0.015), respectively. A 0.05-point better SF-6D score was associated with 7% lower MEs (P = 0.003). PCS and SF-6D were more strongly associated with MEs for prostate cancer patients (P = 0.009 and P = 0.003) and PCS was more strongly associated with MEs for skin cancer patients (P = 0.019), compared to other cancer groups. A 1-point better PCS predicted 1% lower EVs, while a 0.05 better SF-6D score predicted 4% lower EVs.

Conclusions

The significant associations between SF-12v2 scores from oncology patients and subsequent HCRU can guide interpretations of SF-12v2 scores in evaluation of therapies and in health policy decisions.

Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy

INTRODUCTION AND HYPOTHESIS

This study's objectives were to compare the incidence of adverse events after concurrent urogynecologic and gynecologic oncology surgery to gynecologic oncology surgery alone and to describe the frequency of modification in planned urogynecologic procedures. The authors hypothesized there would be no difference in major complications.

METHODS

This was a retrospective matched cohort study of women who underwent concurrent surgery at a large tertiary care center between January 2004 and June 2017. Cohorts were matched by surgeon, surgery route, date, and final pathologic diagnosis. Perioperative data and postoperative adverse events classified by Clavien-Dindo grade were compared.

RESULTS

One hundred and eight patients underwent concurrent surgeries, with 216 matched cohorts. Concurrent-case patients were more likely to be older, postmenopausal, have greater vaginal parity, have had preoperative chemotherapy, and have preoperative cardiac or pulmonary disease. There were no differences in intraoperative complications or Dindo grade ≥ 3 adverse events between groups, but there were more grade 2 adverse events in the concurrent cohort (44 vs 19%, p < 0.0001) including postoperative urinary tract infection (UTI) (26 vs 7%, p < 0.0001). Concurrent surgery remained associated with a higher incidence of grade ≥ 2 events on multivariate analysis [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2, p = 0.0004). Discharge with a urinary catheter was more frequent after concurrent cases (35 vs 2%, p < 0.0001). Planned urogynecologic procedures were modified in 10% (n = 11) of cases.

CONCLUSIONS

Concurrent surgeries have an increased incidence of minor but not serious perioperative adverse events. One in ten planned urogynecologic procedures is either modified or abandoned during combined surgeries.

Surgical Apgar Score predicts 30-day morbidity in elderly patients who undergo non-laparoscopic gynecologic surgery: A retrospective analysis

INTRODUCTION

The aim of this study was to determine whether a preoperative health status index and intraoperative data could predict perioperative morbidity and mortality in women over the age of 65 years undergoing surgery for gynecologic disorders.

METHODS

The medical records of 68 female patients who were ≥65 years of age and who underwent surgery under general anesthesia in our institute from January 2014 to December 2015 were retrospectively reviewed. Preoperative data were extracted from a database and included comorbidities, American Society of Anesthesiologists physiological status classification, the Charlson Comorbidity Index, the Subjective Global Assessment 2011 revision, the subjects' risk of falling, body mass index, and age. The intraoperative factors investigated included the type of surgery and the Surgical Apgar Score (SAS). Major postoperative complications were defined as > Grade 3 based on the Clavien-Dindo classification version 2.0.

RESULTS

Of the 68 elderly gynecological patients, 6 (8.8%) developed serious Grade 3 or worse complications within 30 days of surgery. The only factor that significantly affected postoperative complications was the SAS, an index of the patient's intraoperative condition. The optimum cut-off SAS for the occurrence of complications was determined by the receiver operating characteristic curve to be ≤ 6 points; a score ≤6 points predicted the development of postoperative complications with 66.7% sensitivity and 79.0% specificity.

CONCLUSION

In this study, the SAS predicted the development of serious complications in elderly gynecological patients within 30 days of surgery more accurately than did other comorbidities, preoperative assessments, and type of surgery.

A Systematic Review of Emergency Department Use Among Cancer Patients

BACKGROUND

Recent reports call for reductions in costly and potentially avoidable services such as emergency department (ED) visits. Providing high-quality and safe care for oncology patients remains challenging for ED providers given the diversity of patients seeking care and the unpredictable clinical environment. While ED use by oncology patients is appropriate for acute health concerns, some ED visits may be preventable with well-coordinated care and adequate symptom management.

OBJECTIVE

The aim of this study was to summarize available evidence regarding the incidence, predictors of, and reasons for ED visits among oncology patients.

METHODS

Keyword/MeSH term searches were conducted using 4 online databases. Inclusion criteria were publication date between April 1, 2003, and December 5, 2014; sample size of 50 or more; and report of the incidence or predictors of ED use among oncology patients.

RESULTS

The 15 studies that met criteria varied in study aim, design, and time frames for calculating ED utilization rates. The incidence of ED visits among oncology patients ranged from 1% to 83%. The 30-day standardized visit rate incidence ranged from 1% to 12%. Collectively, the studies lack population-based estimates for all cancers combined.

CONCLUSIONS

The studies included in this review suggest that rates of ED use among cancer patients exceed those of the general population. However, the extent of ED use by oncology patients and the reasons for ED visits remain understudied.

IMPLICATIONS FOR PRACTICE

Nurses are involved in the treatment of cancer, patient education, and symptom management. Nurses are well positioned to develop patient-centered treatment and care coordination plans to improve quality of care and reduce ED visits.

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery

STUDY OBJECTIVE

To evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS).

DESIGN

A retrospective chart review (Canadian Task Force classification II-1).

SETTING

A university hospital.

PATIENTS

All patients undergoing MIS on the gynecologic oncology service from January 1, 2009, to December 30, 2013.

INTERVENTIONS

Surgical procedures were reviewed, and appropriate Common Procedural Terminology codes were assigned. Twenty-one preoperative risk factors were abstracted from the chart and entered into the ACS NSQIP surgical risk calculator. The predicted risk of discharge to postacute care and 8 additional postoperative complications were calculated and recorded. Actual postoperative complications were abstracted from the medical record. The association between the calculated risk and the actual outcome was determined using logistic regression. The ability of the calculator to accurately predict a particular event was assessed using the c-statistic and Brier score.

MEASUREMENTS AND MAIN RESULTS

Of the 876 patients reviewed, a majority underwent hysterectomy (71.6%), with almost half of those patients undergoing additional cancer staging procedures (34.8%). Although the calculator was a poor predictor of postoperative complications, it was a strong predictor for discharge to postacute care (c-statistic = 0.91, Brier score = 0.02) with an odds ratio of 2.31 (95% confidence interval, 1.65-3.25; p < .0001).

CONCLUSION

The ACS NSQIP surgical risk calculator does not accurately predict postoperative complications or length of stay in gynecologic oncology patients undergoing MIS. Although it was a strong predictor of need for discharge to postacute care, it vastly overestimated the number of patients requiring this service. Therefore, the calculator's risk score for discharge to postacute care may be considered during preoperative counseling but should not be a predictor of whether or not the patient should proceed with surgery.

Patient, treatment and discharge factors associated with hospital readmission within 30days after surgery for vulvar cancer

OBJECTIVES

The majority of hospital readmissions are unexpected and considered adverse events. The goal of this study was to examine the factors associated with unplanned readmission after surgery for vulvar cancer.

METHODS

Patient demographic, treatment, and discharge factors were collected on 363 patients with squamous cell carcinoma in situ or invasive cancer who underwent vulvectomy at our institution between January 2001 and June 2014. Clinical variables were correlated using χ² test and Student's t-test as appropriate for univariate analysis. Multivariate analysis was then performed.

RESULTS

Of 363 eligible patients, 35.6% had in situ disease and 64.5% had invasive disease. Radical vulvectomy was performed in 39.1% and 23.4% underwent lymph node assessment. Seventeen patients (4.7%) were readmitted within 30days, with length of stay ranging 2 to 37days and 35% of these patients required a re-operation. On univariate analyses comorbidities, radical vulvectomy, nodal assessment, initial length of stay, and discharge to a post acute care facility (PACF) were associated with hospital readmission. On multivariate analysis, only discharge to a PACF was significantly associated with readmission (OR 6.30, CI 1.12-35.53, P=0.04). Of those who were readmitted within 30days, 29.4% had been at a PACF whereas only 6.6% of the no readmission group had been discharged to PACF (P=0.003).

CONCLUSIONS

Readmission affected 4.7% of our population, and was associated with lengthy hospitalization and reoperation. After controlling for patient comorbidities and surgical radicality, multivariate analysis suggested that discharge to a PACF was significantly associated with risk of readmission.

A comparison of propensity score-based approaches to health service evaluation: a case study of a preoperative physician-led clinic for high-risk surgical patients

RATIONALE, AIMS AND OBJECTIVES

A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design.

METHOD

Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding.

RESULTS

Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts.

CONCLUSIONS

The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations.

The impact of surgical complications on health-related quality of life in women undergoing gynecologic and gynecologic oncology procedures: a prospective longitudinal cohort study

BACKGROUND

There are currently no assessments of the impact of surgical complications on health-related quality of life in gynecology and gynecologic oncology. This is despite complications being a central focus of surgical outcome measurement, and an increasing awareness of the need for patient-reported data when measuring surgical quality.

OBJECTIVE

We sought to measure the impact of surgical complications on health-related quality of life at 1 month postoperatively, in women undergoing gynecologic and gynecologic oncology procedures.

STUDY DESIGN

This is a prospective cohort study of women undergoing surgery by gynecologic oncologists at a tertiary care academic center from October 2013 through October 2014. Patients were enrolled preoperatively and interviewed at baseline and 1, 3, and 6 months postoperatively. Health-related quality of life measures included validated general and disease-specific instruments, measuring multiple aspects of health-related quality of life, including anxiety and depression. The medical record was abstracted for clinical data and surgical complications were graded using validated Clavien-Dindo criteria, and women grouped into those with and without postoperative complications. Bivariate statistics, analysis of covariance, responder analysis, and multivariate modeling was used to analyze the relationship of postoperative complications to change health-related quality of life from baseline to 1 month. Plots of mean scores and change over time were constructed.

RESULTS

Of 281 women enrolled, response rates were 80% (n = 231/281) at baseline, and from that cohort, 81% (n = 187/231), 74% (n = 170/231), and 75% (n = 174/231) at 1, 3, and 6 months, respectively. The primary analytic cohort comprised 185 women with completed baseline and 1-month interviews, and abstracted clinical data. Uterine (n = 84, 45%), ovarian (n = 23, 12%), cervical (n = 17, 9%), vulvar (n = 3, 2%), and other (n = 4, 2%) cancers were represented, along with 53 (30%) cases of benign disease. There were 42 (24%) racial/ethnic minority women. Minimally invasive (n = 115, 63%) and laparotomy (n = 60, 32%) procedures were performed. Postoperative complications occurred in 47 (26%) of patients who experienced grade 1 (n = 12), grade 2 (n = 29), and grade 3 (n = 6) complications. At 1 month, physical (20.6 vs 22.5, P = .04) and functional (15.4 vs 18.3, P = .02) well-being, global physical health (43.1 vs 46.3, P = .02), and work ability (3 vs 7.2, P = .001) were lower in postoperative complication vs non-postoperative complication women. Relative change, however, in most health-related quality of life domains from baseline to 1 month did not differ between postoperative complication and nonpostoperative complication groups. Postoperative complication patients did have increased odds of sustained or worsened anxiety at 1 month vs baseline (odds ratio, 2.5; 95% confidence interval, 1.2-5.0) compared to nonpostoperative complication patients.

CONCLUSION

Collectively, women who experienced postoperative complications after gynecologic and gynecologic oncology procedures did not appear to have differences in most health-related quality of life trends over time compared to those who did not. An exception was anxiety, where postoperative complications were associated with sustained or worsened levels of high anxiety after surgery.

Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study

INTRODUCTION AND HYPOTHESIS

Understanding of pelvic floor disorders among women with gynecological cancer is limited. The objective of this study was to describe the prevalence of pelvic floor disorders in women with suspected gynecological malignancy before surgery.

METHODS

A cross-sectional study was performed of women aged ≥18 with a suspected gynecological malignancy who enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort (HR/CSC) from August 2012 to June 2013. Demographics were obtained from the HR/CSC self-reported data; clinical data were abstracted from the electronic medical record. Subjects completed validated questionnaires (Rotterdam Symptom Checklist and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms) to assess bladder and bowel function.

RESULTS

Among 186 women scheduled for surgery for gynecological malignancy, 152 (82 %) completed baseline assessments before surgery. Mean age was 58.1 ± 13.3 years, and mean BMI was 33.6 ± 8.8 kg/m(2). The majority of subjects had uterine cancer (61.8 %), followed by ovarian (17.1 %) and cervical (11.1 %). At baseline, the rate of urinary incontinence (UI) was 40.9 %. A third of subjects reported stress UI, and one quarter reported urge UI. The overall rate of fecal incontinence was 3.9 %, abdominal pain was 47.4 %, constipation was 37.7 %, and diarrhea was 20.1 %. When comparing cancer types, there were no differences in pelvic floor symptoms.

CONCLUSION

Pelvic floor disorders are common in women with suspected gynecological malignancy at baseline before surgery. Recognizing pelvic floor disorders in the preoperative setting will allow for more individualized, comprehensive care for these women.

Risk factors for readmission in patients with ovarian, fallopian tube, and primary peritoneal carcinoma who are receiving front-line chemotherapy on a clinical trial (GOG 218): an NRG oncology/gynecologic oncology group study (ADS-1236)

BACKGROUND

Readmission within 30days is a measure of care quality. Ovarian cancer patients are at high risk for readmission, but specific risk factors are not defined. This study was designed to determine risk factors in patients with ovarian cancer receiving upfront surgery and chemotherapy.

METHODS

The study population was enrolled to GOG 0218. Factors predictive of admission within 30days of a previous admission or 40days of cytoreductive surgery were investigated. Categorical variables were compared by Pearson chi-square test, continuous variables by Wilcoxon-Mann-Whitney test. A logistic regression model was used to evaluate independent prognostic factors and to estimate covariate-adjusted odds. All tests were two-tailed, α=0.05.

RESULTS

Of 1873 patients, 197 (10.5%) were readmitted, with 59 experiencing >1 readmission. One-hundred-forty-four (73%) readmissions were post-operative (readmission rate 7.7%). Significant risk factors include: disease stage (stage 3 vs 4, p=0.008), suboptimal cytoreduction (36% vs 64%, p=0.001), ascites, (p=0.018), BMI (25.4 vs 27.6, p<0.001), poor PS (p<0.001), and higher baseline CA 125 (p=0.017). Patients readmitted within 40days of surgery had a significantly shorter interval from surgery to chemotherapy initiation (22 versus 32days, p<0.0001). Patients treated with bevacizumab had higher readmission rates in the case of patients with >1 readmission. On multivariate analysis, the odds of re-hospitalization increased with doubling of BMI (OR=1.81, 95% CI: 1.07-3.07) and PS of 2 (OR=2.05, 95% CI 1.21-3.48).

CONCLUSION

Significant risk factors for readmission in ovarian cancer patients undergoing primary surgery and chemotherapy include stage, residual disease, ascites, high BMI and poor PS. Readmissions are most likely after the initial surgical procedure, a discrete period to target with a prospective intervention.

Perioperative trajectory of patient reported symptoms: a pilot study in gynecologic oncology patients

OBJECTIVE

With the growing focus on patient-centered care, patient reported outcomes (PROs) are becoming an important component to clinical trials and quality metrics. The objective of this study was to pilot the collection of patient reported symptom burden in women undergoing surgery in a gynecologic oncology practice.

METHODS

Perioperative patient reported symptom burden was measured for women undergoing laparotomy on the gynecologic oncology service at the University of Texas MD Anderson Cancer Center. Symptoms were assessed using the M.D. Anderson Symptom Inventory (MDASI-OC), a 27 item tool validated for use in patients with ovarian cancer. The MDASI-OC was administered as a preoperative baseline, daily while admitted to the hospital after surgery, twice a week on the first week after discharge and then weekly until 8 weeks postoperatively.

RESULTS

29 patients were evaluable. Seventy-five percent of patients had a diagnosis of ovarian cancer. Of those patients, half underwent a primary debulking surgery and the other half had neoadjuvant chemotherapy prior to interval cytoreductive surgery. In the postoperative inpatient setting, the five symptoms with the highest overall burden were fatigue, pain, abdominal pain, dry mouth and drowsiness. Longitudinal change of the top 5 symptoms during hospitalization did not show any significant difference between those who had neoadjuvant chemotherapy and those who did not.

CONCLUSION

The collection of longitudinal PROs to assess symptom burden is feasible in patients undergoing gynecologic oncology surgery. Patient reported outcomes are a crucial component of patient-centered research and the longitudinal collection and analysis of symptom burden can allow for more meaningful comparisons of surgical technique and perioperative care.

Obesity is associated with worse quality of life in women with gynecologic malignancies: an opportunity to improve patient-centered outcomes

BACKGROUND

The objective of the current study was to evaluate the effect of obesity on pretreatment quality of life (QoL) in gynecologic oncology patients.

METHODS

The authors analyzed collected data from an institution-wide cohort study of women with gynecologic cancers enrolled from August 2012 to June 2013. The Functional Assessment of Cancer Therapy-General, site-specific symptom scales, and the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) global mental and physical health tools were administered. Survey results were linked to clinical data abstracted from medical records (demographics and comorbid conditions). Bivariate tests and multivariate linear regression models were used to evaluate factors associated with QoL scores.

RESULTS

A total of 182 women with ovarian, uterine, cervical, and vulvar/vaginal cancers were identified; of these, 152 (84%) were assessed before surgery. Mean body mass index was 33.5 kg/m(2) and race included white (120 patients [79%]), black (22 patients [15%]), and other (10 patients [6.5%]). A total of 98 patients (64.5%) were obese (body mass index ≥30). On multivariate analysis, subscales for functional (17 vs 19; P = .04), emotional (16 vs 19; P = .008), and social (22 vs 24; P = .02) well-being as well as overall Functional Assessment of Cancer Therapy-General scores (77 vs 86; P = .002) and Patient-Reported Outcomes Measurement Information System global physical health scores (45 vs 49; P = .003) were found to be significantly lower in obese versus nonobese patients.

CONCLUSIONS

Before cancer treatment, obese patients with gynecologic malignancies appear to have worse baseline QoL than their normal-weight counterparts. Emerging models of QoL-based cancer outcome measures may disproportionately affect populations with a high obesity burden. The potential disparate impact of cancer therapy on longitudinal QoL in the obese versus nonobese patients needs to be evaluated.