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O'Kelly AC, Del Carmen MG, Wasfy JH. Learning How to Protect the Health System by Protecting the Caregivers. JAMA Netw Open 2024; 7:e244167. [PMID: 38687484 DOI: 10.1001/jamanetworkopen.2024.4167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Anna C O'Kelly
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcela G Del Carmen
- Massachusetts General Physicians Organization, Boston, Massachusetts
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Ludmir J, Suero-Abreu GA, Gonzalez de la Nuez A, Robles M, Wood MJ, Del Carmen MG, Wasfy JH. Building a post-myocardial infarction discharge intervention program for Hispanic patients. Healthc (Amst) 2024; 12:100730. [PMID: 38087744 DOI: 10.1016/j.hjdsi.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/08/2023] [Accepted: 12/03/2023] [Indexed: 03/12/2024]
Abstract
Hispanic patients disproportionally suffer from disparities in care delivery in the setting of acute myocardial infarction (AMI). More specifically, Hispanic patients have higher 30-day readmission rates post-AMI and are less likely to be referred to cardiac rehab. Because of the challenges Hispanic patients face with post-AMI care, the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI) was launched to provide a culturally sensitive discharge framework to improve readmission and mortality rates in this population. Patients enrolled in this study participate in a comprehensive post-discharge program involving follow-up with a Spanish-speaking cardiologist, a two-part educational virtual group visit program, and access to support throughout the study. During the initial year of the study, 35 patients enrolled and successfully participated in the program. This case study reviews the implementation process, initial outcomes, challenges, and future plans of the program.
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Affiliation(s)
- Jonathan Ludmir
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA.
| | - Giselle A Suero-Abreu
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
| | | | - Martin Robles
- Department of Internal Medicine, University of California, San Francisco, Fresno, USA
| | - Malissa J Wood
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
| | - Marcela G Del Carmen
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Jason H Wasfy
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
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Rotenstein LS, Del Carmen MG, Dudley J. Enhancing Lactation Accommodations for Physicians-An Opportunity for Tangible Investments in Our Workforce. JAMA Netw Open 2023; 6:e2327736. [PMID: 37552483 DOI: 10.1001/jamanetworkopen.2023.27736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Affiliation(s)
- Lisa S Rotenstein
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Marcela G Del Carmen
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, Massachusetts
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica Dudley
- Department of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Now with Press Ganey Associates, Boston, Massachusetts
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Silberman JN, Bercow AS, Gockley AA, Eisenhauer EL, Sisodia R, Randall T, Del Carmen MG, Goodman A, Castro CM, Melamed A, Bregar AJ. Trends in the use of neoadjuvant chemotherapy for low-grade serous ovarian cancer in the United States. Gynecol Oncol 2023; 175:60-65. [PMID: 37327540 DOI: 10.1016/j.ygyno.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To describe trends in neoadjuvant chemotherapy (NACT) use for low-grade serous ovarian carcinoma (LGSOC) and to quantify associations between NACT and extent of cytoreductive surgery. METHODS We identified women treated for stage III or IV serous ovarian cancer in a Commission on Cancer accredited program between January 2004-December 2020. Regression models were developed to evaluate trends in NACT use for LGSOC, to identify factors associated with receipt of NACT, and to quantify associations between NACT and bowel or urinary resection at the time of surgery. Demographic and clinical factors were used for confounder control. RESULTS We observed 3350 patients who received treatment for LGSOC during the study period. The proportion of patients who received NACT increased from 9.5% in 2004 to 25.9% in 2020, corresponding to an annual percent change of 7.2% (95% CI 5.6-8.9). Increasing age (rate ratio (RR) 1.15; 95% CI 1.07-1.24), and stage IV disease (RR 2.66; 95% CI 2.31-3.07) were associated with a higher likelihood of receiving NACT. For patients with high-grade disease, NACT was associated with a decrease in likelihood of bowel or urinary surgery (35.3% versus 23.9%; RR 0.68, 95% CI 0.65-0.71). For LGSOC, NACT was associated with a higher likelihood of these procedures (26.6% versus 32.2%; RR 1.24, 95% CI 1.08-1.42). CONCLUSION NACT use among patients with LGSOC has increased from 2004 to 2020. While NACT was associated with a lower rate of gastrointestinal and urinary surgery among patients with high-grade disease, patients with LGSOC receiving NACT were more likely to undergo these procedures.
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Affiliation(s)
- Jason N Silberman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Alexandra S Bercow
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Allison A Gockley
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Eric L Eisenhauer
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Sisodia
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Randall
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Marcela G Del Carmen
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Annekathryn Goodman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Cesar M Castro
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Alexander Melamed
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
| | - Amy J Bregar
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
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Daly DJ, Essien UR, Del Carmen MG, Scirica B, Berman AN, Searl Como J, Wasfy JH. Race, ethnicity, sex, and socioeconomic disparities in anticoagulation for atrial fibrillation: A narrative review of contemporary literature. J Natl Med Assoc 2023; 115:290-297. [PMID: 36882341 DOI: 10.1016/j.jnma.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/27/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the United States and is responsible for 1 in 7 ischemic strokes. While anticoagulation is effective at preventing strokes, prior work has highlighted significant disparities in anticoagulation prescribing. Furthermore, racial, ethnic, sex, and socioeconomic disparities in AF outcomes have been described. As such, we aimed to review recent data on disparities with respect to anticoagulation for AF published between January 2018 and February 2021. The search string consisted of 7 phrases that combined AF, anticoagulation, and disparities involving sex, race, ethnicity, income, socioeconomic status (SES), and access to care and identified 13 relevant articles. The aggregate data demonstrated that Black patients were less likely to be prescribed anticoagulation than patients of other racial/ethnic groups. Additionally, Black patients were more likely to be prescribed warfarin instead of direct oral anticoagulants (DOACs) despite evidence that DOACs are safer and better tolerated. Lower-income patients and patients with less education were also less likely to receive DOACs. Some studies found that women were less likely to be anticoagulated than men even when their estimated stroke risk was higher, although other studies did not show sex-based differences. Building upon prior work, our study demonstrates that racial and ethnic disparities have persisted in the management of AF. Additionally, we our work highlights that there are significant disparities in anticoagulation management for AF associated with sex, income, and education. More work is needed to identify mechanisms for these disparities and identify potential solutions to achieve pharmacoequity.
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Affiliation(s)
- Danielle J Daly
- Population Health Management, Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA.
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marcela G Del Carmen
- Harvard T.H. Chan School of Public Health, Boston, MA;; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA;; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA;; Massachusetts General Physicians Organization, Boston, MA; Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- Harvard Medical School, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jennifer Searl Como
- Population Health Management, Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Boston, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
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Bercow AS, Rauh-Hain JA, Melamed A, Mazina V, Growdon WB, Del Carmen MG, Goodman A, Bouberhan S, Randall T, Sisodia R, Bregar A, Eisenhauer EL, Minami C, Molina G. Association of hospital-level factors with utilization of sentinel lymph node biopsy in patients with early-stage vulvar cancer. Gynecol Oncol 2023; 169:47-54. [PMID: 36508758 DOI: 10.1016/j.ygyno.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate utilization of sentinel lymph node biopsy (SLNB) for early-stage vulvar cancer at minority-serving hospitals and low-volume facilities. METHODS Between 2012-2018, individuals with T1b vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients undergoing SLNB or inguinofemoral lymph node dissection (IFLD). Multivariable logistic regression, adjusted for patient, facility, and disease characteristics, was used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. RESULTS Of the 3,532 patients, 2,406 (68.1%) underwent lymph node evaluation, with 1,704 (48.2%) undergoing IFLD and 702 (19.8%) SLNB. In a multivariable analysis, treatment at minority-serving hospitals (OR 0.39, 95% CI 0.19-0.78) and low-volume hospitals (OR 0.44, 95% CI 0.28-0.70) were associated with significantly lower odds of undergoing SLNB compared to receiving care at non-minority-serving and high-volume hospitals, respectively. While SLNB utilization increased over time for the entire cohort and stratified subgroups, use of the procedure did not increase at minority-serving hospitals. After controlling for patient and tumor characteristics, SLNB was not associated with worse OS compared to IFLD in patients with positive (HR 1.02, 95% CI 0.63-1.66) or negative (HR 0.92, 95% CI 0.70-1.21) nodal pathology. CONCLUSIONS For patients with early-stage vulvar cancer, treatment at minority-serving or low-volume hospitals was associated with significantly decreased odds of undergoing SLNB. Future efforts should be concentrated toward ensuring that all patients have access to advanced surgical techniques regardless of where they receive their care.
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Affiliation(s)
- Alexandra S Bercow
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Varvara Mazina
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, New York University Langone Medical Center, New York, NY, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sara Bouberhan
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas Randall
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel Sisodia
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christina Minami
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Breast Surgery, Department of Surgery, Dana-Farber/Brigham and Women's Hospital, Boston, MA, United States of America
| | - George Molina
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
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Sisodia RC, Del Carmen MG. Lesions of the Ovary and Fallopian Tube. Reply. N Engl J Med 2022; 387:1723-1724. [PMID: 36322863 DOI: 10.1056/nejmc2212426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Escribe C, Eisenstat SA, Palamara K, O'Donnell WJ, Wasfy JH, Del Carmen MG, Lehrhoff SR, Bravard MA, Levi R. Understanding Physician Work and Well-being Through Social Network Modeling Using Electronic Health Record Data: a Cohort Study. J Gen Intern Med 2022; 37:3789-3796. [PMID: 35091916 PMCID: PMC9640486 DOI: 10.1007/s11606-021-07351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Understanding association between factors related to clinical work environment and well-being can inform strategies to improve physicians' work experience. OBJECTIVE To model and quantify what drivers of work composition, team structure, and dynamics are associated with well-being. DESIGN Utilizing social network modeling, this cohort study of physicians in an academic health center examined inbasket messaging data from 2018 to 2019 to identify work composition, team structure, and dynamics features. Indicators from a survey in 2019 were used as dependent variables to identify factors predictive of well-being. PARTICIPANTS EHR data available for 188 physicians and their care teams from 18 primary care practices; survey data available for 163/188 physicians. MAIN MEASURES Area under the receiver operating characteristic curve (AUC) of logistic regression models to predict well-being dependent variables was assessed out-of-sample. KEY RESULTS The mean AUC of the model for the dependent variables of emotional exhaustion, vigor, and professional fulfillment was, respectively, 0.665 (SD 0.085), 0.700 (SD 0.082), and 0.669 (SD 0.082). Predictors associated with decreased well-being included physician centrality within support team (OR 3.90, 95% CI 1.28-11.97, P=0.01) and share of messages related to scheduling (OR 1.10, 95% CI 1.03-1.17, P=0.003). Predictors associated with increased well-being included higher number of medical assistants within close support team (OR 0.91, 95% CI 0.83-0.99, P=0.05), nurse-centered message writing practices (OR 0.89, 95% CI 0.83-0.95, P=0.001), and share of messages related to ambiguous diagnosis (OR 0.92, 95% CI 0.87-0.98, P=0.01). CONCLUSIONS Through integration of EHR data with social network modeling, the analysis highlights new characteristics of care team structure and dynamics that are associated with physician well-being. This quantitative methodology can be utilized to assess in a refined data-driven way the impact of organizational changes to improve well-being through optimizing team dynamics and work composition.
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Affiliation(s)
- Célia Escribe
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Stephanie A Eisenstat
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kerri Palamara
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Walter J O'Donnell
- Harvard Medical School, Boston, MA, USA
- Pulmonary/Critical Care Division, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Marjory A Bravard
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Retsef Levi
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Affiliation(s)
- Rachel C Sisodia
- From Massachusetts General Hospital and Harvard Medical School - both in Boston
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10
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Ortega MV, Del Carmen MG, Wakamatsu M, Goldstein SA, Siegal-Botti E, Wasfy JH. Asynchronous telehealth visits for the treatment of overactive bladder. Menopause 2022; 29:723-727. [PMID: 35674652 DOI: 10.1097/gme.0000000000001957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Overactive bladder affects 17% of women, and adherence to treatment is notoriously low. The objective of this pilot study is to investigate the efficacy and feasibility of the use of asynchronous telehealth visits for the treatment of women with overactive bladder. METHODS This is a pilot study of women who participated in the asynchronous telehealth program with a new diagnosis of overactive bladder presenting to the Massachusetts General Hospital from January of 2020 to March of 2021. Pre-post differences in Urogenital Distress Inventory score-6, and Incontinence Severity Index Scores were compared with paired t tests as coprimary endpoints. To assess potential mechanisms of association between asynchronous visits and patient-reported outcomes, total fluid intake, caffeinated beverage consumption, urinary frequency, episodes of urinary leakage were also compared as secondary endpoints. RESULTS A total of 23 women participated, with 50 e-visits completed. The first asynchronous visit was completed after a median of 42days (IQR 36, 51.5) from the initial visit. There was a decrease in the Urogenital Distress Inventory-6 score between the first asynchronous visit and the last (29 points, IQR 16, 37 vs 12 points, IQR 12, 25), respectively (P = 0.014). Similar findings were seen with the Incontinence Severity Index questionnaire, from three (IQR 2, 4) to three (IQR 1, 3) after the asynchronous visit (P = 0.002). CONCLUSION We demonstrate the feasibility of asynchronous visits for the treatment of overactive bladder. Although our results suggest efficacy, given the prepost change in overactive bladder-related questionnaire scores following asynchronous visits, the comparative effectiveness of asynchronous visits versus regular care needs to be confirmed in a randomized trial.
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Affiliation(s)
- Marcus V Ortega
- Massachusetts General Physicians Organization, Boston, MA
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcela G Del Carmen
- Massachusetts General Physicians Organization, Boston, MA
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - May Wakamatsu
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Susan A Goldstein
- Performance Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA
| | - Eirian Siegal-Botti
- Performance Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston, MA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Boston, MA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Begin AS, Hidrue M, Lehrhoff S, Del Carmen MG, Armstrong K, Wasfy JH. Factors Associated with Physician Tolerance of Uncertainty: an Observational Study. J Gen Intern Med 2022; 37:1415-1421. [PMID: 33904030 PMCID: PMC8074695 DOI: 10.1007/s11606-021-06776-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area. OBJECTIVE To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout. DESIGN Online confidential survey. SETTING The Massachusetts General Physicians Organization (MGPO). PARTICIPANTS All 2172 clinically active faculty in the MGPO. MAIN MEASURES We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics. KEY RESULTS Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90). CONCLUSION At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.
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Affiliation(s)
- Arabella Simpkin Begin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Pharmacology, University of Oxford, Oxford, UK. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Michael Hidrue
- Massachusetts General Physicians Organization, Boston, USA
| | - Sara Lehrhoff
- Massachusetts General Physicians Organization, Boston, USA
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Physicians Organization, Boston, USA.,Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Ellis DB, Sisodia R, Paul M, Qiu K, Hidrue MK, Berg S, Oliver J, Del Carmen MG. Impact of Gabapentin on PACU Length of Stay and Perioperative Intravenous Opioid Use for ERAS Hysterectomy Patients. J Med Syst 2022; 46:26. [PMID: 35396607 DOI: 10.1007/s10916-022-01815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
We investigated the impact of preoperative gabapentin on perioperative intravenous opioid requirements and post anesthesia care unit length of stay (PACU LOS) for patients undergoing laparoscopic and vaginal hysterectomies within an Enhanced Recovery After Surgery (ERAS) pathway. A multidisciplinary team retrospectively examined 2,015 patients who underwent laparoscopic or vaginal hysterectomies between October 2016 and January 2020 at a single academic institution. The average PACU LOS was 168 min among patients who did not receive gabapentin vs. 180 min both among patients who received ≤ 300 mg of gabapentin and patients who received > 300 mg of gabapentin. After adjusting for demographics and medical comorbidities, PACU LOS for patients given ≤ 300 mg gabapentin was 6% longer (rate ratio (RR) = 1.06, 95% CI = 1.01-1.11) than for patients who were not given gabapentin, and for patients who received > 300 mg of gabapentin was 7% longer (RR = 1.07, 95%CI = 1.01-1.13) than for those who did not receive gabapentin. Patients who received ≤ 300 mg gabapentin received 9% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.91, 95% CI = 0.86 - 0.97); patients who received > 300 mg of gabapentin received 12% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.88, 95% CI = 0.82 - 0.95). These findings represent an absolute difference of 0.09 mg intravenous hydromorphone. There were no statistically significant differences in total intravenous fentanyl received. Preoperative gabapentin given as part of an ERAS pathway is associated with statistically but not clinically significant increases in PACU LOS and decreases in total perioperative intravenous opioid use.
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Affiliation(s)
- Dan B Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Rachel Sisodia
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Meryl Paul
- Department of Anesthesiology, Salem Hospital, 81 Highland Avenue, Salem, MA, 01970, USA
| | - Kai Qiu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sheri Berg
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jevon Oliver
- Director, Pharmacy Services, Integrated Care, Mass General Brigham, 399 Revolution Drive, Suite 950, Somerville, MA, 02145, USA
| | - Marcela G Del Carmen
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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13
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Dorken Gallastegi A, Mikdad S, Kapoen C, Breen KA, Naar L, Gaitanidis A, El Hechi M, Pian-Smith M, Cooper JB, Antonelli DM, MacKenzie O, Del Carmen MG, Lillemoe KD, Kaafarani HMA. Intraoperative Deaths: Who, Why, and Can We Prevent Them? J Surg Res 2022; 274:185-195. [PMID: 35180495 DOI: 10.1016/j.jss.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/26/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns. METHODS IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype. RESULTS Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup. CONCLUSIONS We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.
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Affiliation(s)
- Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah Mikdad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carolijn Kapoen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kerry A Breen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Leon Naar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts
| | - May Pian-Smith
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey B Cooper
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donna M Antonelli
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Olivia MacKenzie
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcela G Del Carmen
- Department of Obstetrics, Gynecology & Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Massachusetts General Physicians Organization, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, Massachusetts.
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14
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Safavi KC, Frendl D, Ellis D, Sisodia RC, Ricciardi R, McGovern FJ, Ferris TG, Thompson RW, Del Carmen MG. Hospital at Home for Surgical Patients: A Case Series From a Pioneer Program at a Large Academic Medical Center. Ann Surg 2022; 275:e275-e277. [PMID: 34914664 DOI: 10.1097/sla.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kyan C Safavi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Massachusetts General Physicians Organization, Boston, MA
| | - Daniel Frendl
- Massachusetts General Physicians Organization, Boston, MA
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Dan Ellis
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Massachusetts General Physicians Organization, Boston, MA
| | - Rachel Clark Sisodia
- Massachusetts General Physicians Organization, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Timothy G Ferris
- Massachusetts General Physicians Organization, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ryan W Thompson
- Massachusetts General Physicians Organization, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Marcela G Del Carmen
- Massachusetts General Physicians Organization, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
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15
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Foley OW, Ferris TG, Thompson RW, Heng M, Ricciardi R, Del Carmen MG, Safavi KC. Potential impact of hospital at home on postoperative readmissions. Am J Manag Care 2021; 27:e420-e425. [PMID: 34889584 DOI: 10.37765/ajmc.2021.88797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Hospital at home (HAH) is a health care delivery model that substitutes hospital-level services in the home for inpatient hospitalizations. HAH has been shown to be safe and effective for medical patients but has not been investigated in surgical readmissions. We estimated the potential impact of an HAH program for patients readmitted within 60 days postoperatively and described the characteristics of eligible patients to aid in the design of future programs. STUDY DESIGN This was a cross-sectional study of 60-day postoperative readmissions at a tertiary care center in 2018. METHODS We identified the number of readmissions that may have been eligible for HAH, collected descriptive information, and estimated the financial margin that could have been generated had eligible readmissions been diverted to HAH. RESULTS There were 2366 readmissions within 60 days of surgery in 2018. A total of 731 readmissions met inclusion criteria for HAH (30.1%), accounting for 4152 bed days. Of these readmissions, the most common diagnoses were infection, gastrointestinal complications, and cardiac complications. Patients' home addresses were within 16 miles of the hospital in 447 cases (61.1%). Avoidance of these readmissions and use of the beds for new admissions represented a potential backfill margin of $8.8 million, not incorporating the cost of HAH. CONCLUSIONS Many 60-day postoperative readmissions may be amenable to HAH enrollment, representing a significant opportunity to improve patient experience and generate hospital revenue. This is of particular interest in the post-COVID-19 era. To maximize their impact, HAH programs should tailor clinical and operational services to this population.
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Affiliation(s)
- Olivia W Foley
- Division of Gynecologic Oncology, Massachusetts General Hospital, 55 Fruit St, GRB 4-444, Boston, MA 02114.
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16
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Begin AS, Del Carmen MG, Wasfy JH. In Response: Physician Tolerance of Uncertainty. J Gen Intern Med 2021; 36:3237. [PMID: 34357578 PMCID: PMC8481399 DOI: 10.1007/s11606-021-06992-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Arabella Simpkin Begin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Pharmacology, University of Oxford, Oxford, UK.
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Marcela G Del Carmen
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Physicians Organization, Boston, MA, USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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17
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Affiliation(s)
- Xiaowen Wang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School (X.W.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston (M.K.H., M.G.d.C., J.H.W.)
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology (M.G.d.C.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (M.K.H., M.G.d.C., J.H.W.)
| | - Rory B Weiner
- Cardiology Division (R.B.W., J.H.W.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jason H Wasfy
- Cardiology Division (R.B.W., J.H.W.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (M.K.H., M.G.d.C., J.H.W.)
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18
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Sullivan MW, Philp L, Kanbergs AN, Safdar N, Oliva E, Bregar A, Del Carmen MG, Eisenhauer EL, Goodman A, Muto M, Sisodia RC, Growdon WB. Lymph node assessment at the time of hysterectomy has limited clinical utility for patients with pre-cancerous endometrial lesions. Gynecol Oncol 2021; 162:613-618. [PMID: 34247769 DOI: 10.1016/j.ygyno.2021.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the proportion of patients with a pre-invasive endometrial lesion who meet Mayo criteria for lymph node dissection on final pathology to determine if the use of sentinel lymph node biopsy in patients with pre-invasive lesions would be warranted. METHODS All women who underwent hysterectomy for a pre-invasive endometrial lesion (atypical hyperplasia or endometrial intra-epithelial neoplasia) between 2009 and 2019 were included for analysis. Relevant statistical tests were utilized to test the associations between patient, operative, and pathologic characteristics. RESULTS 141 patients met inclusion criteria. 51 patients (36%) had a final diagnosis of cancer, the majority (96%) of which were Stage IA grade 1 endometrioid carcinomas. Seven patients (5%) met Mayo criteria on final pathology (one grade 3, seven size >2 cm, one >50% myoinvasive). Three of these seven patients had lymph nodes assessed of which 0% had metastases. Six of these patients had frozen section performed, and 2 met (33%) Mayo criteria intraoperatively. Of the seven patients in the overall cohort that had lymph node sampling, six had a final diagnosis of cancer and none had positive lymph nodes. Of the 51 patients with cancer, only 10 had cancer diagnosed using frozen section, and only two met intra-operative Mayo criteria. Age > 55 was predictive of meeting Mayo criteria on final pathology (p = 0.007). No patients experienced a cancer recurrence across a median follow up of 24.3 months. CONCLUSIONS Atypical hyperplasia and endometrial intra-epithelial neoplasia portend low risk disease and universal nodal assessment is of limited value.
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Affiliation(s)
- Mackenzie W Sullivan
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Lauren Philp
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexa N Kanbergs
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nida Safdar
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Esther Oliva
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Muto
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel C Sisodia
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Vanderpuye VD, Clemenceau JRV, Temin S, Aziz Z, Burke WM, Cevallos NL, Chuang LT, Colgan TJ, Del Carmen MG, Fujiwara K, Kohn EC, Gonzáles Nogales JE, Konney TO, Mukhopadhyay A, Paudel BD, Tóth I, Wilailak S, Ghebre RG. Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline. JCO Glob Oncol 2021; 7:1032-1066. [PMID: 34185571 PMCID: PMC8457806 DOI: 10.1200/go.21.00085] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To provide expert guidance to clinicians and policymakers in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer. METHODS A multidisciplinary, multinational ASCO Expert Panel reviewed existing guidelines, conducted a modified ADAPTE process, and conducted a formal consensus process with additional experts. RESULTS Existing sets of guidelines from eight guideline developers were found and reviewed for resource-constrained settings; adapted recommendations from nine guidelines form the evidence base, informing two rounds of formal consensus; and all recommendations received ≥ 75% agreement. RECOMMENDATIONS Evaluation of adult symptomatic women in all settings includes symptom assessment, family history, and ultrasound and cancer antigen 125 serum tumor marker levels where feasible. In limited and enhanced settings, additional imaging may be requested. Diagnosis, staging, and/or treatment involves surgery. Presurgical workup of every suspected ovarian cancer requires a metastatic workup. Only trained clinicians with logistical support should perform surgical staging; treatment requires histologic confirmation; surgical goal is staging disease and performing complete cytoreduction to no gross residual disease. In first-line therapy, platinum-based chemotherapy is recommended; in advanced stages, patients may receive neoadjuvant chemotherapy. After neoadjuvant chemotherapy, all patients should be evaluated for interval debulking surgery. Targeted therapy is not recommended in basic or limited settings. Specialized interventions are resource-dependent, for example, laparoscopy, fertility-sparing surgery, genetic testing, and targeted therapy. Multidisciplinary cancer care and palliative care should be offered.Additional information can be found at www.asco.org/resource-stratified-guidelines. It is ASCO's view that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.
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Affiliation(s)
| | | | - Sarah Temin
- American Society of Clinical Oncology, Alexandria, VA
| | - Zeba Aziz
- Hameed Latif Hospital, Lahore, Pakistan
| | | | | | | | | | | | | | - Elise C Kohn
- Saitama Medical University International Medical Center, Saitama, Japan
| | | | | | - Asima Mukhopadhyay
- Chittaranjan National Cancer Institute, Kolkata, India
- Northern Gynaecological Oncology Centre, Gateshead, Newcastle, United Kingdom
| | | | - Icó Tóth
- Mallow Flower Foundation, Dunaharaszti, Hungary
| | | | - Rahel G Ghebre
- University of Minnesota Medical School, Minneapolis, MN
- St Paul's Hospital Millennium Medical School, Addis Ababa, Ethiopia
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20
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Manning-Geist BL, Sullivan MW, Sarda V, Gockley AA, Del Carmen MG, Matulonis U, Growdon WB, Horowitz NS, Berkowitz RS, Clark RM, Worley MJ. Disease Distribution at Presentation Impacts Benefit of IP Chemotherapy Among Patients with Advanced-Stage Ovarian Cancer. Ann Surg Oncol 2021; 28:6705-6713. [PMID: 33683525 DOI: 10.1245/s10434-021-09746-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 02/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ovarian cancer with miliary disease spread is an aggressive phenotype lacking targeted management strategies. We sought to determine whether adjuvant intravenous/intraperitoneal (IV/IP) chemotherapy is beneficial in this disease setting. METHODS Patient/tumor characteristics and survival data of patients with stage IIIC epithelial ovarian cancer who underwent optimal primary debulking surgery from 01/2010 to 11/2014 were abstracted from records. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous variables. The Kaplan-Meier method was used to estimate survival curves, and outcomes were compared using log-rank tests. Factors significant on univariate analysis were combined into multivariate logistic regression survival models. RESULTS Among 90 patients with miliary disease spread, 41 (46%) received IV/IP chemotherapy and 49 (54%) received IV chemotherapy. IV/IP chemotherapy, compared with IV chemotherapy, resulted in improved progression-free survival (PFS; 23.0 versus 12.0 months; p = 0.0002) and overall survival (OS; 52 versus 36 months; p = 0.002) in patients with miliary disease. Among 78 patients with nonmiliary disease spread, 23 (29%) underwent IV/IP chemotherapy and 55 (71%) underwent IV chemotherapy. There was no PFS or OS benefit associated with IV/IP chemotherapy over IV chemotherapy in these patients. On multivariate analysis, IV/IP chemotherapy was associated with improved PFS (HR, 0.28; 95% CI 0.15-0.53) and OS (HR, 0.33; 95% CI 0.18-0.61) in patients with miliary disease compared with those with nonmiliary disease (PFS [HR, 1.53; 95% CI 0.74-3.19]; OS [HR, 1.47; 95% CI 0.70-3.09]). CONCLUSIONS Adjuvant IV/IP chemotherapy was associated with oncologic benefit in miliary disease spread. This survival benefit was not observed in nonmiliary disease.
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Affiliation(s)
- Beryl L Manning-Geist
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA. .,Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mackenzie W Sullivan
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vishnudas Sarda
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA
| | - Allison A Gockley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Worley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
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21
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Ellis DB, Agarwala A, Cavallo E, Linov P, Hidrue MK, Del Carmen MG, Sisodia R. Implementing ERAS: how we achieved success within an anesthesia department. BMC Anesthesiol 2021; 21:36. [PMID: 33546602 PMCID: PMC7863438 DOI: 10.1186/s12871-021-01260-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. Methods We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. Conclusions Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.
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Affiliation(s)
- Dan B Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Aalok Agarwala
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Boston, USA.,Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Elena Cavallo
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Pam Linov
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Marcela G Del Carmen
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rachel Sisodia
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Alimena S, Sullivan MW, Philp L, Dorney K, Hubbell H, Del Carmen MG, Goodman A, Bregar A, Growdon WB, Eisenhauer EL, Sisodia RC. Patient reported outcome measures among patients with vulvar cancer at various stages of treatment, recurrence, and survivorship. Gynecol Oncol 2020; 160:252-259. [PMID: 33139040 DOI: 10.1016/j.ygyno.2020.10.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/16/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our goal was to pragmatically describe patient reported outcomes (PROs) in a typical clinic population of vulvar cancer patients, as prior studies of vulvar cancer PROs have examined clinical trial participants. METHODS A prospective PRO program was implemented in the Gynecologic Oncology clinic of a tertiary academic institution in January 2018. Vulvar cancer patients through September 2019 were administered the European Organization for the Research and Treatment of Cancer Quality of life Questionnaire, the Patient Reported Outcome Measurement Information System Instrumental and Emotional Support Scales, and the Functional Assessment of Cancer Therapy-Vulvar questionnaire. Binary logistic regressions were performed to determine adjusted odds ratios for adverse responses to individual questions by insurance, stage, age, time since diagnosis, recurrence, radiation, and surgical radicality. RESULTS Seventy vulvar cancer patients responded to PROs (85.4% response rate). Seventy-one percent were > 1 year since diagnosis, 61.4% had stage I disease, and 28.6% recurred. Publicly insured women had less support and worse quality of life (QOL, aOR 4.15, 95% CI 1.00-17.32, p = 0.05). Women who recurred noted more interference with social activities (aOR 4.45, 95% CI 1.28-15.41, p = 0.019) and poorer QOL (aOR 5.22 95% CI 1.51-18.10, p = 0.009). There were no major differences by surgical radicality. Those >1 year since diagnosis experienced less worry (aOR 0.17, 95% CI 0.04-0.63, p = 0.008). CONCLUSIONS Surgical radicality does not affect symptoms or QOL in vulvar cancer patients, whereas insurance, recurrence, and time since diagnosis do. This data can improve counseling and awareness of patient characteristics that would benefit from social services referral.
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Affiliation(s)
- Stephanie Alimena
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mackenzie W Sullivan
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren Philp
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Katelyn Dorney
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harrison Hubbell
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel Clark Sisodia
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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23
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Kanbergs AN, Manning-Geist BL, Pelletier A, Sullivan MW, Del Carmen MG, Horowitz NS, Growdon WB, Clark RM, Muto MG, Worley MJ. Neoadjuvant chemotherapy does not disproportionately influence post-operative complication rates or time to chemotherapy in obese patients with advanced-stage ovarian cancer. Gynecol Oncol 2020; 159:687-691. [PMID: 32951891 DOI: 10.1016/j.ygyno.2020.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To determine whether neoadjuvant chemotherapy (NACT) disproportionately benefits obese patients. METHODS Data were collected from stage IIIC-IV ovarian cancer patients treated between 01/2010-07/2015. We performed univariate/multivariate logistic regression analyses with post-operative infection, readmission, any postoperative complication, and time to chemotherapy as outcomes. An interaction term was included in models, to determine if the effect of NACT on post-operative complications was influenced by obesity status. RESULTS Of 507 patients, 115 (22.6%) were obese and 392 (77.3%) were non-obese (obese defined as BMI ≥30). Among obese patients undergoing primary debulking surgery (PDS) vs. NACT, rates of postoperative infection were 42.9% vs. 30.8% (p = 0.12), 30-day readmission 30.2% vs. 11.5% (p < 0.02), and any post-operative complication were 44.4% vs 30.8% (p = 0.133). Among non-obese patients undergoing PDS vs. NACT, rates of post-operative infection were 20.0% vs. 12.9% (p = 0.057), 30-day readmission 16.9% vs. 9.2% (p = 0.02), and any post-operative complication were 19.4% vs 28% (p = 0.044). Obesity was associated with post-operative infection (OR 2.3; 95%CI 1.22-4.33), 30-day readmission/reoperation (OR 2.27; 95%CI 1.08-3.21) and the development of any post-operative complication (OR 2.1; CI 1.13-3.74). However, there was not a significant interaction between obesity and NACT in any of the models predicting post-operative complications. CONCLUSIONS The decision to use NACT should not be predicated on obesity alone, as the reduction in post-operative complications in obese patients is similar to non-obese patients.
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Affiliation(s)
- Alexa N Kanbergs
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Beryl L Manning-Geist
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Andrea Pelletier
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Mackenzie W Sullivan
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael G Muto
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States
| | - Michael J Worley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States
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Wasfy JH, Hidrue MK, Natarajan P, Ngo J, Cafiero-Fonseca ET, McDermott ST, Ferris TG, Del Carmen MG. Response by Wasfy et al to Letter Regarding Article, "Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission". Circ Cardiovasc Qual Outcomes 2020; 13:e007184. [PMID: 32907388 DOI: 10.1161/circoutcomes.120.007184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine (J.H.W., P.N., S.T.M.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., T.G.F., M.G.d.C.)
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., T.G.F., M.G.d.C.)
| | - Pradeep Natarajan
- Cardiology Division, Department of Medicine (J.H.W., P.N., S.T.M.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jacqueline Ngo
- Performance Analysis and Improvement Unit (J.N., E.T.C.-F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Elizabeth T Cafiero-Fonseca
- Performance Analysis and Improvement Unit (J.N., E.T.C.-F.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Susan T McDermott
- Cardiology Division, Department of Medicine (J.H.W., P.N., S.T.M.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Timothy G Ferris
- Department of Medicine (T.G.F.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., T.G.F., M.G.d.C.)
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (M.G.d.C.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., T.G.F., M.G.d.C.)
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25
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Wasfy JH, Hidrue MK, Ngo J, Tanguturi VK, Cafiero-Fonseca ET, Thompson RW, Johnson N, McDermott ST, Singh JP, Del Carmen MG, Ferris TG. Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission. Circ Cardiovasc Qual Outcomes 2020; 13:e006043. [PMID: 32393130 DOI: 10.1161/circoutcomes.119.006043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Jacqueline Ngo
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.).,Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Varsha K Tanguturi
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Ryan W Thompson
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Natalie Johnson
- Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Susan T McDermott
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jagmeet P Singh
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (M.G.d.C.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Timothy G Ferris
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
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26
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Rao S, Ferris TG, Hidrue MK, Lehrhoff SR, Lenz S, Heffernan J, McKee KE, Del Carmen MG. Physician Burnout, Engagement and Career Satisfaction in a Large Academic Medical Practice. Clin Med Res 2020; 18:3-10. [PMID: 31959669 PMCID: PMC7153796 DOI: 10.3121/cmr.2019.1516] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/23/2019] [Accepted: 09/09/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine (1) if engagement among physicians impacted plans to stay in current role and job satisfaction, (2) what factors impact engagement and burnout, and (3) the relationship between engagement and burnout. Burnout has been described as a syndrome characterized by depersonalization, emotional exhaustion, and a sense of low personal accomplishment resulting in decreased effectiveness at work. Engagement may be regarded as the antonym to burnout and has been described as a connection to one's work characterized by dedication, vigor, and absorption. DESIGN We extracted data from an academic practice-wide survey conducted at two time-points and evaluated physician burnout and engagement. We used the Maslach Burnout Inventory and the Utrecht Work Engagement Scale to evaluate the association between burnout and engagement and the impact of engagement on mitigating the effect of burnout in a large physician academic faculty practice. SETTING Large academic practice PARTICIPANTS: Academic physicians METHODS: The authors conducted a hospital-wide physician practice survey in 2014 and 2017 assessing physician burnout and engagement. RESULTS Of eligible physicians (n=1882), 92.0% completed a survey. High levels of engagement and burnout were shown in 59.5% and 45.6%, respectively. Compared to physicians with high levels of engagement and low levels of burnout, physicians with low engagement and low burnout were less satisfied with their career (OR=0.20, 95% CI=0.11-0.35) and less likely to stay in their current role (OR=0.52, 95% CI= 0.37-0.73). Among physicians with high levels of burnout, highly engaged physicians were more satisfied (OR=0.21; 95% CI=0.12-0.36 vs OR=0.08; 95% CI=0.05-0.12) and more likely to stay in their career (OR=0.34; 95% CI=0.25-0.45 vs OR=0.27; 95% CI=0.21-0.34) than non-engaged physicians. CONCLUSION Engaged physicians have higher career satisfaction. There are many actionable ways to improve engagement.
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Affiliation(s)
- Sandhya Rao
- Senior Medical Director for Population Health Management, Partners Health; Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA
| | - Timothy G Ferris
- Chief Executive Officer, Massachusetts General Physicians Organization; Professor of Medicine, Harvard Medical School, Boston, MA
| | - Michael K Hidrue
- Senior Health Economist, Massachusetts General Physicians Organization, Boston, MA
| | - Sara R Lehrhoff
- Director of Physician Programs, Massachusetts General Hospital Physicians Organization, Boston, MA
| | - Sara Lenz
- Chief of Staff, Massachusetts General Physicians Organization, Boston, MA
| | - James Heffernan
- Chief Financial Officer, Massachusetts General Physicians Organization, Boston, MA
| | - Kathleen E McKee
- Massachusetts General Physicians Organization; Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Marcela G Del Carmen
- Chief Medical Officer, Massachusetts General Physicians Organization; Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA
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27
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Melamed A, Bercow AS, Bunnell K, Rauh-Hain JA, Wright JD, Rice LW, Del Carmen MG. Age-Associated Risk of 90-Day Postoperative Mortality After Cytoreductive Surgery for Advanced Ovarian Cancer. JAMA Surg 2020; 154:669-671. [PMID: 31066875 DOI: 10.1001/jamasurg.2019.0907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Alexandra S Bercow
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Katherine Bunnell
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia College of Physicians and Surgeons, New York, New York
| | - Laurel W Rice
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, Madison
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
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Abstract
Initiatives to mitigate physician burnout and improve patient experience occur largely in isolation. At the level of the department/division, we found lower physician burnout was associated with a more positive patient experience. Physician Maslach Burnout Inventory data and patient Consumer Assessment of Healthcare Providers and Systems Clinician and Group experience scores were significantly correlated with 5 of 12 patient experience questions: “Got Routine Care Appointment” (−0.632, P = .001), “Recommend Provider” (−0.561, P = .005), “Provider Knew Medical History” (−0.532, P = .009), “Got Urgent Care Appointment” (−0.518, P = .014), and “Overall Rating” (−0.419, P = .047). These correlations suggest burnout and experience might be better addressed in tandem. Principles to guide an integrated approach are suggested.
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Affiliation(s)
- Kathleen E McKee
- Massachusetts General Physicians Organization, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea Tull
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Marcela G Del Carmen
- Massachusetts General Physicians Organization, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Edgman-Levitan
- John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, MA, USA
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29
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Affiliation(s)
- Dana R Gossett
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Marcela G Del Carmen
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard University Medical School, Boston, Massachusetts
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30
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Manning-Geist BL, Hicks-Courant K, Gockley AA, Clark RM, Del Carmen MG, Growdon WB, Horowitz NS, Berkowitz RS, Muto MG, Worley MJ. A novel classification of residual disease after interval debulking surgery for advanced-stage ovarian cancer to better distinguish oncologic outcome. Am J Obstet Gynecol 2019; 221:326.e1-326.e7. [PMID: 31082382 DOI: 10.1016/j.ajog.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Complete surgical resection affords the best prognosis at the time of interval debulking surgery. When complete surgical resection is unachievable, optimal residual disease is considered the next best alternative. Despite contradicting evidence on the survival benefit of interval debulking surgery if macroscopic residual disease remains, the current definition of "optimal" in patients undergoing interval debulking surgery is defined as largest diameter of disease measuring ≤1.0 cm, independent of the total volume of disease. OBJECTIVE To examine the relationship between volume and anatomic distribution of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing neoadjuvant chemotherapy then interval debulking surgery. For patients who did not undergo a complete surgical resection, a surrogate for volume of residual disease was used to assess oncologic outcomes. STUDY DESIGN Patient demographics, operative characteristics, anatomic site of residual disease, and outcome data were collected from medical records of patients with International Federation of Gynecology and Obstetrics stage IIIC and IV epithelial ovarian cancer undergoing interval debulking surgery from January 2010 to July 2015. Among patients who did not undergo complete surgical resection but had ≤1 cm of residual disease, the number of anatomic sites (single location vs multiple locations) with residual disease was used as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival and overall survival was evaluated. RESULTS Of 270 patients undergoing interval debulking surgery, 173 (64.1%) had complete surgical resection, 34 (12.6%) had ≤1 cm of residual disease in a single anatomic location, 47 (17.4%) had ≤1 cm of residual disease in multiple anatomic locations, and 16 (5.9%) were suboptimally debulked. Median progression-free survival for each group was 14, 12, 10, and 6 months, respectively (P<.001). Median overall survival for each group was: 58, 37, 26, and 33 months, respectively (P<.001). CONCLUSION Following interval debulking surgery, patients with complete surgical resection have the best prognosis, followed by patients with ≤1 cm single-anatomic location disease. In contrast, despite being considered "optimally debulked," patients with ≤1 cm multiple-anatomic location disease have a survival similar to suboptimally debulked patients.
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Del Carmen GA, Stapleton S, Qadan M, Del Carmen MG, Chang D. Does the Day of the Week Predict a Cesarean Section? A Statewide Analysis. J Surg Res 2019; 245:288-294. [PMID: 31421375 DOI: 10.1016/j.jss.2019.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/29/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although guidelines for clinical indications of cesarean sections (CS) exist, nonclinical factors may affect CS practices. We hypothesize that CS rates vary by day of the week. METHODS An analysis of the Office of Statewide Health Planning and Development database for California from 2006 to 2010 was performed. All patients admitted to a teaching or nonteaching hospital for attempted vaginal delivery were included. Patients who died within 24 h of admission were excluded. Weekend days were defined as Saturday and Sunday, and weekdays were defined as Monday to Friday. The primary outcome was CS versus vaginal delivery. Multivariable analysis was performed, adjusting for patient demographics, clinical factors, and system variables. RESULTS A total of 1,855,675 women were included. The overall CS rate was 9.02%. On unadjusted analysis, CS rates were significantly lower on weekends versus weekdays (6.65% versus 9.58%, P < 0.001). On adjusted analysis, women were 27% less likely to have a CS on weekends than on weekdays (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.71-0.75, P < 0.001). In addition, Hispanic ethnicity and delivery in teaching hospitals were associated with a decreased likelihood of CS (OR 0.91, 95% CI 0.86-0.96, P = 0.01; OR 0.80, 95% CI 0.69-0.93, P < 0.001, respectively). CONCLUSIONS CS rates are significantly decreased on weekends relative to weekdays, even when controlling for patient, hospital, and system factors.
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Affiliation(s)
| | - Sahael Stapleton
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - David Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Ceppi L, Bardhan NM, Na Y, Siegel A, Rajan N, Fruscio R, Del Carmen MG, Belcher AM, Birrer MJ. Real-Time Single-Walled Carbon Nanotube-Based Fluorescence Imaging Improves Survival after Debulking Surgery in an Ovarian Cancer Model. ACS Nano 2019; 13:5356-5365. [PMID: 31009198 DOI: 10.1021/acsnano.8b09829] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Improved cytoreductive surgery for advanced stage ovarian cancer (OC) represents a critical challenge in the treatment of the disease. Optimal debulking reaching no evidence of macroscopic disease is the primary surgical end point with a demonstrated survival advantage. Targeted molecule-based fluorescence imaging offers complete tumor resection down to the microscopic scale. We used a custom-built reflectance/fluorescence imaging system with an orthotopic OC mouse model to both quantify tumor detectability and evaluate the effect of fluorescence image-guided surgery on post-operative survival. The contrast agent is an intraperitoneal injectable nanomolecular probe, composed of single-walled carbon nanotubes, coupled to an M13 bacteriophage carrying a modified peptide binding to the SPARC protein, an extracellular protein overexpressed in OC. The imaging system is capable of detecting a second near-infrared window fluorescence (1000-1700 nm) and can display real-time video imagery to guide intraoperative tumor debulking. We observed high microscopic tumor detection with a pixel-limited resolution of 200 μm. Moreover, in a survival-surgery orthotopic OC mouse model, we demonstrated an increased survival benefit for animals treated with fluorescence image-guided surgical resection compared to standard surgery.
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Affiliation(s)
- Lorenzo Ceppi
- Center for Cancer Research, The Gillette Center for Gynecologic Oncology , Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts 02114 , United States
- Department of Medicine and Surgery , University of Milan-Bicocca , 20126 Milan , Italy
| | - Neelkanth M Bardhan
- Department of Materials Science and Engineering , Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
- The David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , Massachusetts 02142 , United States
- Department of Biological Engineering , Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
| | - YoungJeong Na
- Center for Cancer Research, The Gillette Center for Gynecologic Oncology , Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts 02114 , United States
| | - Andrew Siegel
- Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
| | - Nandini Rajan
- Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
| | - Robert Fruscio
- Department of Medicine and Surgery , University of Milan-Bicocca , 20126 Milan , Italy
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology , Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts 02114 , United States
| | - Angela M Belcher
- Department of Materials Science and Engineering , Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
- The David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , Massachusetts 02142 , United States
- Department of Biological Engineering , Massachusetts Institute of Technology , Cambridge , Massachusetts 02139 , United States
| | - Michael J Birrer
- Center for Cancer Research, The Gillette Center for Gynecologic Oncology , Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts 02114 , United States
- O'Neal Comprehensive Cancer Center, Division of Hematology-Oncology , University of Alabama at Birmingham , Birmingham , Alabama 35294 , United States
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Manning-Geist BL, Alimena S, Del Carmen MG, Goodman A, Clark RM, Growdon WB, Horowitz NS, Berkowitz RS, Muto MG, Worley MJ. Infection, thrombosis, and oncologic outcome after interval debulking surgery: Does perioperative blood transfusion matter? Gynecol Oncol 2019; 153:63-67. [PMID: 30635213 DOI: 10.1016/j.ygyno.2019.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine whether perioperative red blood cell transfusion (PRBCT) affects infection, thrombosis, or survival rates in epithelial ovarian cancer (EOC) patients undergoing neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS). METHODS Demographics, operative characteristics, and outcome data were abstracted from records of stage IIIC-IV EOC patients managed with NACT-IDS from 01/2010-07/2015. Associations of PRBCT with morbidity and oncologic outcomes were evaluated. RESULTS Of 270 patients, 136 (50.4%) received PRBCT. Patients with preoperative anemia and higher estimated blood loss (EBL) were more likely to undergo PRBCT (OR,95%CI 1.80, 1.02-3.17) and (OR,95%CI 1.00, 1.002-1.004), respectively. There were no significant differences in PRBCT based on patient age, Charlson Comorbidity Index, or stage. When compared to low complexity operations, patients with moderate and high complexity surgeries were more likely to receive PRBCT (OR,95%CI 1.81, 1.05-3.09) and (OR,95%CI 2.25, 1.13-4.50), respectively. On univariate analysis, PRBCT was associated with intraabdominal infection (OR,95%CI 8.31, 1.03-67.41), but not wound complications (OR,95%CI 1.57, 0.76-3.23) or venous thromboembolism/pulmonary embolism (VTE/PE) (OR,95%CI 2.02, 0.49-8.23). After adjusting for surgical complexity and preoperative anemia, PRBCT was not independently associated with intraabdominal infection (OR,95%CI 7.66, 0.92-63.66), wound complications (OR,95%CI 1.70, 0.80-3.64), or VTE/PE (OR,95%CI 2.15, 0.51-9.09). When comparing patients undergoing PRBCT versus those who did not, there were no significant differences in median progression-free survival (PFS) or median overall survival (OS) on univariate analysis after adjusting for age, stage and residual disease. CONCLUSIONS Among patients undergoing NACT-IDS, intraabdominal infection, wound complication and VTE/PE rates are similar, regardless of PRBCT. PRBCT does not impact PFS or OS.
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Affiliation(s)
- Beryl L Manning-Geist
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Stephanie Alimena
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Michael G Muto
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Michael J Worley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
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Melamed A, Margul DJ, Chen L, Keating NL, Del Carmen MG, Yang J, Seagle BLL, Alexander A, Barber EL, Rice LW, Wright JD, Kocherginsky M, Shahabi S, Rauh-Hain JA. Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer. N Engl J Med 2018; 379:1905-1914. [PMID: 30379613 PMCID: PMC6464372 DOI: 10.1056/nejmoa1804923] [Citation(s) in RCA: 445] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Minimally invasive surgery was adopted as an alternative to laparotomy (open surgery) for radical hysterectomy in patients with early-stage cervical cancer before high-quality evidence regarding its effect on survival was available. We sought to determine the effect of minimally invasive surgery on all-cause mortality among women undergoing radical hysterectomy for cervical cancer. METHODS We performed a cohort study involving women who underwent radical hysterectomy for stage IA2 or IB1 cervical cancer during the 2010-2013 period at Commission on Cancer-accredited hospitals in the United States. The study used inverse probability of treatment propensity-score weighting. We also conducted an interrupted time-series analysis involving women who underwent radical hysterectomy for cervical cancer during the 2000-2010 period, using the Surveillance, Epidemiology, and End Results program database. RESULTS In the primary analysis, 1225 of 2461 women (49.8%) underwent minimally invasive surgery. Women treated with minimally invasive surgery were more often white, privately insured, and from ZIP Codes with higher socioeconomic status, had smaller, lower-grade tumors, and were more likely to have received a diagnosis later in the study period than women who underwent open surgery. Over a median follow-up of 45 months, the 4-year mortality was 9.1% among women who underwent minimally invasive surgery and 5.3% among those who underwent open surgery (hazard ratio, 1.65; 95% confidence interval [CI], 1.22 to 2.22; P=0.002 by the log-rank test). Before the adoption of minimally invasive radical hysterectomy (i.e., in the 2000-2006 period), the 4-year relative survival rate among women who underwent radical hysterectomy for cervical cancer remained stable (annual percentage change, 0.3%; 95% CI, -0.1 to 0.6). The adoption of minimally invasive surgery coincided with a decline in the 4-year relative survival rate of 0.8% (95% CI, 0.3 to 1.4) per year after 2006 (P=0.01 for change of trend). CONCLUSIONS In an epidemiologic study, minimally invasive radical hysterectomy was associated with shorter overall survival than open surgery among women with stage IA2 or IB1 cervical carcinoma. (Funded by the National Cancer Institute and others.).
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Affiliation(s)
- Alexander Melamed
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Daniel J Margul
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Ling Chen
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Nancy L Keating
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Marcela G Del Carmen
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Junhua Yang
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Brandon-Luke L Seagle
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Amy Alexander
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Emma L Barber
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Laurel W Rice
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Jason D Wright
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Masha Kocherginsky
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - Shohreh Shahabi
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
| | - J Alejandro Rauh-Hain
- From the Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School (A.M., M.G.C.), and the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - all in Boston; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Prentice Women's Hospital (D.J.M., J.Y., B.-L.L.S., A.A., E.L.B., M.K., S.S.), and the Division of Biostatistics, Department of Preventive Medicine (M.K.), Northwestern University, Feinberg School of Medicine, Chicago; the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University, and New York Presbyterian Hospital, New York (L.C., J.D.W.); the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison (L.W.R.); and the Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston (J.A.R.-H.)
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Clark RM, Rice LW, Del Carmen MG. Thirty-day unplanned hospital readmission in ovarian cancer patients undergoing primary or interval cytoreductive surgery: systematic literature review. Gynecol Oncol 2018; 150:370-377. [PMID: 29929923 DOI: 10.1016/j.ygyno.2018.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Thirty-day readmission rate has been proposed as metric of quality and remains an ongoing clinical concern in the primary treatment of patients with advanced-stage ovarian epithelial ovarian cancer. We conducted a review of the literature to identify rates, risk factors, and predictors for 30-day readmission in this population. METHODS A 10-year period MEDLINE (PubMed) search of English literature studies published between January 01, 2008-January 01, 2018 was performed to identify appropriate studies for review. RESULTS Thirty -day readmission rates for ovarian cancer patients undergoing primary treatment ranged from 2.5-19.3%. Neoadjuvant chemotherapy and interval cytoreductive surgery (NACT-ICS) surgery was associated with lower readmission rates, when compared to primary debulking surgery (PDS). The most frequently reported adverse events resulting in readmission include inpatient management of ileus/small bowel obstruction, wound-related complications, and thromboembolic events. Readmission predictors included the presence of other medical comorbidities, re-operation, and major complications occurring after initial hospital discharge. Some studies reported lower rates of readmission and survival in patients treated by NACT-ICS. CONCLUSIONS Policies and programs should be designed to measure short- and long-term outcomes in this patient population to avoid bias in assigning patients to NACT-ICS to maintain low 30-day readmission rates.
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Affiliation(s)
- Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Laurel W Rice
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Del Carmen MG, Pareja R, Melamed A, Rodriguez J, Greer A, Clark RM, Rice LW. Isolated para-aortic lymph node metastasis in FIGO stage IA2-IB2 carcinoma of the cervix: Revisiting the role of surgical assessment. Gynecol Oncol 2018; 150:406-411. [PMID: 30017539 DOI: 10.1016/j.ygyno.2018.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/03/2018] [Accepted: 07/10/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the utility of para-aortic lymph node dissection among women undergoing radical hysterectomy and pelvic lymph adenectomy for FIGO Stage IA2-IB2 cervical cancer using the National Cancer Database (NCDB). METHODS We identified patients with stage IA2-IB2 squamous cell, adenosquamous, or adenocarcinoma of the cervix diagnosed 2011-2014 in the NCDB. The primary outcome was the negative predictive value of histologically assessed pelvic lymph node status for para-aortic lymph node status among women undergoing pelvic and para-aortic lymph node dissection. We calculated probability of para-aortic lymph node metastasis conditional on pelvic lymph node status. Finally, we compared overall survival between patients undergoing para-aortic lymph node dissection and those in whom this procedure was omitted. RESULTS A total of 3212 patients met study inclusion criteria, of whom 994 (30.9%) underwent para-aortic lymph node dissection. In this group, the risk of isolated para-aortic metastasis was 0.11%. The negative predictive value of surgically assessed pelvic lymph nodes to predict para-aortic lymph node status was 99.9% (95% CI 99.9-99.9). Among 93 patients with pelvic lymph node metastasis, 18 (19.4%) had concurrent para-aortic lymph node metastasis. There was no difference in overall survival between women undergoing pelvic and para-aortic lymph node dissection compared with those undergoing pelvic lymphadenectomy only (p = 0.69). CONCLUSIONS In patients undergoing radical hysterectomy and pelvic lymphadenectomy for stage IA2-IB2 cervical cancer, para-aortic lymph node dissection is not warranted based on the low risk of isolated metastatic disease, and lack of survival benefit associated with the procedure.
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Rene Pareja
- Gynecologic Oncology Department, National Cancer Institute, Bogota, Colombia
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Juliana Rodriguez
- Gynecologic Oncology Department, National Cancer Institute, Bogota, Colombia
| | - Anna Greer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Laurel W Rice
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9 E, Boston, MA 02114, United States of America.
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Manning-Geist BL, Hicks-Courant K, Gockley AA, Clark RM, Del Carmen MG, Growdon WB, Horowitz NS, Berkowitz RS, Muto MG, Worley MJ. Moving beyond "complete surgical resection" and "optimal": Is low-volume residual disease another option for primary debulking surgery? Gynecol Oncol 2018; 150:233-238. [PMID: 29933927 DOI: 10.1016/j.ygyno.2018.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/09/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To examine the relationship between volume of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing primary debulking surgery (PDS). For patients that did not undergo a complete surgical resection (CSR), a surrogate for volume of residual disease was used to assess oncologic outcomes. METHODS Medical records of patients with FIGO stage IIIC and IV epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing PDS between January 2010 and November 2014 were reviewed. Patient demographics, operative characteristics, residual disease, anatomic site of residual disease and outcome data were collected. Among patients who did not undergo CSR, but had ≤1 cm of residual disease, the number of anatomic sites (single location vs. multiple locations) with residual disease was utilized as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival (PFS) and overall survival (OS) was evaluated. RESULTS Of 240 patients undergoing PDS, 94 (39.2%) had CSR, 41 (17.1%) had ≤1 cm of residual disease confined to a single anatomic location (≤1 cm-SL), 67 (27.9%) had ≤1 cm of residual disease in multiple anatomic locations (≤1 cm-ML) and 38 (15.8%) were sub-optimally (SO) debulked. Median PFS for CSR, ≤1 cm-SL, ≤1 cm-ML and SO-debulked were: 23, 19, 13 and 10 months, respectively (p < 0.001). Median OS for CSR, ≤1 cm-SL, ≤1 cm-ML and SO-debulked were: Not yet reached, 64, 50 and 49 months, respectively (p = 0.001). CONCLUSIONS Following PDS, CSR and ≤ 1 cm-SL patients have the best prognosis. In contrast, despite being considered "optimally debulked", ≤1 cm-ML patients have survival similar to those SO-debulked.
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Affiliation(s)
- Beryl L Manning-Geist
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Katherine Hicks-Courant
- Department of Obstetrics and Gynecology, Tufts Medical Center, Tufts Medical School, Boston, MA, United States of America
| | - Allison A Gockley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Rachel M Clark
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Michael G Muto
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Michael J Worley
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Dana-Farber Cancer Institute, Boston, MA, United States of America
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Laurel W Rice
- Department of Obstetrics and Gynecology, University of Wisconsin Hospital and Clinics, Madison, WI, United States
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Melamed A, Fink G, Wright AA, Keating NL, Gockley AA, Del Carmen MG, Schorge JO, Rauh-Hain JA. Effect of adoption of neoadjuvant chemotherapy for advanced ovarian cancer on all cause mortality: quasi-experimental study. BMJ 2018; 360:j5463. [PMID: 29298771 PMCID: PMC5751831 DOI: 10.1136/bmj.j5463] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To estimate the causal effect of increased use of neoadjuvant chemotherapy (NACT) on all cause mortality in advanced epithelial ovarian cancer. DESIGN Quasi-experimental fuzzy regression discontinuity design and cross sectional analysis. SETTING Cancer programs throughout the United States accredited by the Commission on Cancer. PARTICIPANTS 6034 women with a diagnosis of stage 3C or 4 epithelial ovarian cancer from regions that rapidly adopted use of NACT from 2011 to 2012 (27% increase in the New England and east south central regions) or remained unchanged (control regions, south Atlantic, west north central, and east north central regions). MAIN OUTCOME MEASURE All cause mortality within three years of diagnosis. Kaplan-Meier curves and proportional hazard models were estimated to compare mortality differences between rapidly adopting regions and controls. RESULTS 1156 women were treated for advanced epithelial ovarian cancer during 2011 and 2012 in the two rapidly adopting regions and 4878 women in the three control regions. In the rapidly adopting regions, patients treated in 2012 compared with 2011 had a mortality hazard ratio of 0.81 (95% confidence interval 0.71 to 0.94) after adjusting for mortality time trends, whereas no difference was observed in control regions (1.02, 0.93 to 1.12). Compared with control regions, larger declines in 90 day surgical mortality (7.0% to 4.0% v 5.0% to 4.3%, P=0.01) and in the proportion of women not receiving surgery and chemotherapy (20.0% to 17.4% v 19.0 to 19.5%, P=0.04) were observed in rapidly adopting regions. Cross sectional analysis confirmed that treatment in regions with greater use of NACT was associated was lower mortality (P=0.001). CONCLUSIONS Adoption of NACT for advanced epithelial ovarian cancer in New England and east south central regions led to a sizable reduction in mortality within three years after diagnosis.
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Affiliation(s)
- Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Günther Fink
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Alexi A Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Allison A Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Pepin K, Bregar A, Davis M, Melamed A, Hinchcliff E, Gockley A, Horowitz N, Del Carmen MG. Intensive care admissions among ovarian cancer patients treated with primary debulking surgery and neoadjuvant chemotherapy-interval debulking surgery. Gynecol Oncol 2017; 147:612-616. [PMID: 28988028 DOI: 10.1016/j.ygyno.2017.09.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Admissions to intensive care units (ICU) are costly, but are necessary for some patients undergoing radical cancer surgery. When compared to primary debulking surgery (PDS), neoadjuvant chemotherapy (NACT) with interval debulking surgery, is associated with less peri-operative morbidity. In this study, we compare rates, indications and lengths of ICU stays among ovarian cancer patients admitted to the ICU within 30days of cytoreduction, either primary or interval. METHODS A retrospective chart review was performed of patients with stage III-IV ovarian cancer who underwent surgical cytoreduction at two large academic medical centers between 2010 and 2014. Chi square tests, Student t-tests, and Mann-U Whitney tests were used. RESULTS A total of 635 patients were included in the study. There were 43 ICU admissions, 7% of patients. Compared to NACT, a higher percentage of PDS patients required ICU admission, 9.4% vs 3.9% of patients (P=0.004). ICU admission indications did not vary between PDS and NACT patients. NACT patients admitted to the ICU had comparable mean surgical complexity scores to those PDS patients admitted to the ICU, 6.2 (95%CI 5.3-7.1) vs 4.5 (95%CI 3.1-6.0) (P=0.006). Length of ICU admission did not vary between groups, PDS 2.7days (95%CI 2.3-3.2) vs 3.5days (95%CI 1.5-5.6) for NACT (P=0.936). CONCLUSIONS The rate of ICU admissions among patients undergoing PDS is higher than for NACT. Among patients admitted to the ICU, indications for admission, length of stay and surgical complexity were similar between patients treated with NACT and PDS.
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Affiliation(s)
- Kristen Pepin
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States; Brigham and Women's Hospital, 75 Francis St, Boston, MA 20115, United States.
| | - Amy Bregar
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Michelle Davis
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 20115, United States
| | - Alexander Melamed
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Emily Hinchcliff
- MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, United States
| | - Allison Gockley
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 20115, United States
| | - Neil Horowitz
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 20115, United States
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Melamed A, Manning-Geist B, Bregar AJ, Diver EJ, Goodman A, Del Carmen MG, Schorge JO, Rauh-Hain JA. Associations between residual disease and survival in epithelial ovarian cancer by histologic type. Gynecol Oncol 2017; 147:250-256. [PMID: 28822556 DOI: 10.1016/j.ygyno.2017.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/02/2017] [Accepted: 08/03/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Surgical cytoreduction has been postulated to affect survival by increasing the efficacy of chemotherapy in ovarian cancer. We hypothesized that women with high-grade serous ovarian cancer, which usually responds to chemotherapy, would derive greater benefit from complete cytoreduction than those with histologic subtypes that are less responsive to chemotherapy, such as mucinous and clear cell carcinoma. METHODS We conducted a retrospective cohort study of patients who underwent primary cytoreductive surgery and adjuvant chemotherapy for stage IIIC or IV epithelial ovarian cancer from 2011 to 2013 using data from the National Cancer Database. We constructed multivariable models to quantify the magnitude of associations between residual disease status (no residual disease, ≤1cm, or >1cm) and all-cause mortality by histologic type among women with clear cell, mucinous, and high-grade serous ovarian cancer. Because 26% of the sample had unknown residual disease status, we used multiple imputations in the primary analysis. RESULTS We identified 6,013 women with stage IIIC and IV high-grade serous, 307 with clear cell, and 140 with mucinous histology. The association between residual disease status and mortality hazard did not differ significantly among histologic subtypes of ovarian cancer (p for interaction=0.32). In covariate adjusted models, compared to suboptimal cytoreduction, cytoreduction to no gross disease was associated with a hazard reduction of 42% in high-grade serous carcinoma (hazard ratio [HR]=0.58, 95% confidence interval [CI]=0.49-0.68), 61% in clear cell carcinoma (HR=0.39, 95% CI=0.22-0.69), and 54% in mucinous carcinoma (HR=0.46, 95% CI=0.22-0.99). CONCLUSIONS We found no evidence that surgical cytoreduction was of greater prognostic importance in high-grade serous carcinomas than in histologies that are less responsive to chemotherapy.
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Affiliation(s)
- Alexander Melamed
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Beryl Manning-Geist
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Amy J Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Elisabeth J Diver
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Abstract
OBJECTIVE Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients. METHODS MEDLINE was searched for studies on menopause management published in English through December of 2016. RESULTS Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking. CONCLUSIONS Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.
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Affiliation(s)
- Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Laurel W Rice
- Department of Obstetrics and Gynecology, University of Wisconsin Hospital and Clinics, Madison, WI, United States
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Gockley A, Melamed A, Bregar AJ, Clemmer JT, Birrer M, Schorge JO, Del Carmen MG, Rauh-Hain JA. Outcomes of Women With High-Grade and Low-Grade Advanced-Stage Serous Epithelial Ovarian Cancer. Obstet Gynecol 2017; 129:439-447. [PMID: 28178043 PMCID: PMC5328143 DOI: 10.1097/aog.0000000000001867] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare outcomes of women with advanced-stage low-grade serous ovarian cancer and high-grade serous ovarian cancer and identify factors associated with survival among patients with advanced-stage low-grade serous ovarian cancer. METHODS A retrospective study of patients diagnosed with grade 1 or 3, advanced-stage (stage IIIC and IV) serous ovarian cancer between 2003 and 2011 was undertaken using the National Cancer Database, a large administrative database. The effect of grade on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. Among women with low-grade serous ovarian cancer, propensity score matching was used to compare all-cause mortality among similar women who underwent chemotherapy and lymph node dissection and those who did not. RESULTS A total of 16,854 (95.7%) patients with high-grade serous ovarian cancer and 755 (4.3%) patients with low-grade serous ovarian cancer were identified. Median overall survival was 40.7 months among high-grade patients and 90.8 months among women with low-grade tumors (P<.001). Among patients with low-grade serous ovarian cancer in the propensity score-matched cohort, the median overall survival was 88.2 months among the 140 patients who received chemotherapy and 95.9 months among the 140 who did not receive chemotherapy (P=.7). Conversely, in the lymph node dissection propensity-matched cohort, median overall survival was 106.5 months among the 202 patients who underwent lymph node dissection and 58 months among the 202 who did not (P<.001). CONCLUSION When compared with high-grade serous ovarian cancer, low-grade serous ovarian cancer is associated with improved survival. In patients with advanced-stage low-grade serous ovarian cancer, lymphadenectomy but not adjuvant chemotherapy was associated with improved survival.
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Affiliation(s)
- Allison Gockley
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, and the Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, and the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Rauh-Hain JA, Melamed A, Wright A, Gockley A, Clemmer JT, Schorge JO, Del Carmen MG, Keating NL. Overall Survival Following Neoadjuvant Chemotherapy vs Primary Cytoreductive Surgery in Women With Epithelial Ovarian Cancer: Analysis of the National Cancer Database. JAMA Oncol 2017; 3:76-82. [PMID: 27892998 DOI: 10.1001/jamaoncol.2016.4411] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Uncertainty remains about the relative benefits of primary cytoreductive surgery (PCS) vs neoadjuvant chemotherapy (NACT) for advanced-stage epithelial ovarian cancer (EOC). Objective To compare overall survival of PCS vs NACT in a large national population of women with advanced-stage EOC. Design, Setting, and Participants Retrospective cohort study of women with stage IIIC and IV EOC diagnosed between 2003 and 2011 treated at hospitals across the United States reporting to the National Cancer Data Base. We focused on patients 70 years or younger with a Charlson comorbidity index of 0 who were likely candidates for either treatment. Exposures Initial treatment approach of PCS vs NACT, examined using an intent-to-treat analysis. Main Outcomes and Measures Overall survival, defined as months from cancer diagnosis to death or date of the last contact. We used propensity score matching to compare similar women who underwent PCS and NACT. The association of treatment approach with overall survival was assessed using the Kaplan-Meier method and the log-rank test. We assessed whether the findings were influenced by differences in the prevalence of an unobserved confounder, such as limited performance status (Eastern Cooperative Oncology Group 1-2), preoperative disease burden, and BRCA status. Results Among 22 962 patients (mean [SD] age, 56.12 [9.38] years), 19 836 (86.4%) received PCS and 3126 (13.6%) underwent NACT. We matched 2935 patients treated with NACT with similar patients who received PCS. The median follow-up was 56.5 (95% CI, 54.5-59.2) months in the PCS group and 56.3 (95% CI, 54.5-59.8) months in the NACT group in the propensity-matched cohort. Among propensity score-matched groups, the median overall survival was 37.3 (95% CI, 35.2-38.7) months in the PCS group and 32.1 (95% CI, 30.8-34.1) months in the NACT group (P < .001). However, if the NACT group had a higher proportion of women with performance statuses of 1 to 2 compared with those who underwent PCS (60% vs 50%), the association of PCS and improved survival would not be statistically significant. Conclusions and Relevance Primary cytoreductive surgery was associated with improved survival compared with NACT in otherwise healthy women with advanced-stage epithelial ovarian cancer aged 70 years or younger. The lower survival in women who received NACT could be explained by a higher prevalence of limited performance status in women undergoing NACT.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexi Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts3Division of Population Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Allison Gockley
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joel T Clemmer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 5Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Bregar AJ, Alejandro Rauh-Hain J, Spencer R, Clemmer JT, Schorge JO, Rice LW, Del Carmen MG. Disparities in receipt of care for high-grade endometrial cancer: A National Cancer Data Base analysis. Gynecol Oncol 2017; 145:114-121. [PMID: 28159409 DOI: 10.1016/j.ygyno.2017.01.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine patterns of care and survival for Hispanic women compared to white and African American women with high-grade endometrial cancer. METHODS We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with uterine grade 3 endometrioid adenocarcinoma, carcinosarcoma, clear cell carcinoma and papillary serous carcinoma between 2003 and 2011. The effect of treatment on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS 43,950 women were eligible. African American and Hispanic women had higher rates of stage III and IV disease compared to white women (36.5% vs. 36% vs. 33.5%, p<0.001). African American women were less likely to undergo surgical treatment for their cancer (85.2% vs. 89.8% vs. 87.5%, p<0.001) and were more likely to receive chemotherapy (36.8% vs. 32.4% vs. 32%, p<0.001) compared to white and Hispanic women. Over the entire study period, after adjusting for age, time period of diagnosis, region of the country, urban or rural setting, treating facility type, socioeconomic status, education, insurance, comorbidity index, pathologic stage, histology, lymphadenectomy and adjuvant treatment, African American women had lower overall survival compared to white women (Hazard Ratio 1.21, 95% CI 1.16-1.26). Conversely, Hispanic women had improved overall survival compared to white women after controlling for the aforementioned factors (HR 0.87, 95% CI 0.80-0.93). CONCLUSIONS Among women with high-grade endometrial cancer, African American women have lower all-cause survival while Hispanic women have higher all-cause survival compared to white women after controlling for treatment, sociodemographic, comorbidity and histopathologic variables.
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Affiliation(s)
- Amy J Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ryan Spencer
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Joel T Clemmer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Laurel W Rice
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Bregar AJ, Melamed A, Diver E, Clemmer JT, Uppal S, Schorge JO, Rice LW, Del Carmen MG, Rauh-Hain JA. Minimally Invasive Staging Surgery in Women with Early-Stage Endometrial Cancer: Analysis of the National Cancer Data Base. Ann Surg Oncol 2017; 24:1677-1687. [PMID: 28074326 DOI: 10.1245/s10434-016-5752-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to determine factors associated with the adoption of minimally invasive surgery (MIS) compared with laparotomy in the treatment of endometrial cancer and to compare surgical outcomes and survival between these two surgical modalities. METHODS We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with presumed early-stage endometrial cancer between 2010 and 2012. We also identified factors associated with the performance of MIS and utilized propensity score matching to create a matched cohort of women who underwent minimally invasive staging surgery or laparotomy for surgical staging. RESULTS Overall, 20,346 women were eligible for inclusion in the study; 12,604 (61.9%) had MIS, while 7742 (38.1%) had a laparotomy. African American race (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.49-0.60], Hispanic ethnicity (OR 0.70, 95% CI 0.61-0.80), Charlson score >2 (OR 0.79, 95% CI 0.69-0.91), high-grade histology (OR 0.63, 95% CI 0.59-0.68), presumed clinical stage II disease (OR 0.53, 95% CI 0.46-0.60), and surgery at a community cancer program (OR 0.46, 95% CI 0.39-0.55) or in the Midwest region (OR 0.70, 95% CI 0.64-0.76) were associated with a decreased likelihood of having MIS, while private insurance (OR 1.69, 95% CI 1.45-1.97) and highest quartile median household income (OR 1.13, 95% CI 1.03-1.24) were associated with an increased likelihood of having MIS. After propensity score matching, there was no association between minimally invasive staging surgery and 3-year overall survival (hazard ratio 1.03, 95% CI 0.92-1.16). CONCLUSION There are notable racial, ethnic, socioeconomic, and geographic variations in the utilization of MIS for endometrial cancer staging in the US. After controlling for the aforementioned factors, MIS had a similar 3-year survival compared with laparotomy in women undergoing staging surgery for endometrial cancer.
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Affiliation(s)
- Amy J Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisabeth Diver
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joel T Clemmer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shitanshu Uppal
- Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Laurel W Rice
- Division of Gynecologic Oncology, University of Wisconsin, Madison, WI, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Melamed A, Hinchcliff EM, Clemmer JT, Bregar AJ, Uppal S, Bostock I, Schorge JO, Del Carmen MG, Rauh-Hain JA. Trends in the use of neoadjuvant chemotherapy for advanced ovarian cancer in the United States. Gynecol Oncol 2016; 143:236-240. [PMID: 27612977 DOI: 10.1016/j.ygyno.2016.09.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/28/2016] [Accepted: 09/01/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Neoadjuvant chemotherapy and interval debulking surgery for the treatment of advanced ovarian cancer has remained controversial, despite the publication of two randomized trials comparing this modality with primary cytoreductive surgery. This study describes temporal trends in the utilization of neoadjuvant chemotherapy and interval debulking surgery in clinical practice in the United States. METHODS We completed a time trend analysis of the National Cancer Data Base. We identified women with stage IIIC and IV epithelial ovarian cancer diagnosed between 2004 and 2013. We categorized subjects as having undergone one of four treatment modalities: primary cytoreductive surgery followed by adjuvant chemotherapy, neoadjuvant chemotherapy followed by interval debulking surgery, surgery only, and chemotherapy only. Temporal trends in the frequency of treatment modalities were evaluated using Joinpoint regression, and χ2 tests. RESULTS We identified 40,694 women meeting inclusion criteria, of whom 27,032 (66.4%) underwent primary cytoreductive surgery and adjuvant chemotherapy, 5429 (13.3%) received neoadjuvant chemotherapy and interval surgery, 5844 (15.4%) had surgery only, and 2389 (5.9%) received chemotherapy only. The proportion of women receiving neoadjuvant chemotherapy and surgery increased from 8.6% to 22.6% between 2004 and 2013 (p<0.001), and adoption of this treatment modality occurred primarily after 2007 (95%CI 2006-2009; p=0.001). During this period, the proportion of women who received primary cytoreductive surgery and chemotherapy declined from 68.1% to 60.8% (p<0.001), and the proportion who underwent surgery only declined from 17.8% to 9.9% (p<0.001). CONCLUSION Between 2004 and 2013 the frequency of neoadjuvant chemotherapy and interval surgery increased significantly in the United States.
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Affiliation(s)
- Alexander Melamed
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| | - Emily M Hinchcliff
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joel T Clemmer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Amy J Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Shitanshu Uppal
- Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Ian Bostock
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Rauh-Hain JA, Birrer M, Del Carmen MG. "Carcinosarcoma of the ovary, fallopian tube, and peritoneum: Prognostic factors and treatment modalities". Gynecol Oncol 2016; 142:248-54. [PMID: 27321238 DOI: 10.1016/j.ygyno.2016.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 05/31/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Ovarian carcinosarcoma (OCS) is a rare malignancy accounting for only 1-4% of all ovarian cancers. The treatment of OCS is largely based on data from small case series and management of other histologic subtypes of epithelial ovarian cancer. We reviewed the literature pertinent to the pathology, pathogenesis, diagnosis, and management of women with OCS. METHODS MEDLINE was searched in English for literature on OCS, focusing on the past 30years. Given the rarity of this tumor, studies were not limited by design or number of reported patients. RESULTS Molecular, epidemiologic, genetic, and histologic data indicate that most OCS are monoclonal. Patients with OCS generally present with advanced stage disease. Most of the available retrospective studies support the role of cytoreductive surgery in the management of OCS, with optimal debulking associated with improved survival. Platinum-based chemotherapy is the current accepted adjuvant treatment. Given the limited data regarding the management of recurrent OCS, patients are usually treated similarly to women diagnosed with other subtypes of epithelial ovarian cancer. CONCLUSION OCS represent a rare and aggressive histologic subtype of epithelial ovarian cancer. The goal of surgery is comprehensive staging in patients with early-stage disease and optimal cytoreduction patients with advanced-stage tumors. Platinum-based chemotherapy is the mainstay of adjuvant systemic treatment. Future studies are needed in order to elucidate the molecular basis for OCS and to evaluate the role of targeted therapy in its management.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Michael Birrer
- Division of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Strasser-Weippl K, Chavarri-Guerra Y, Villarreal-Garza C, Bychkovsky BL, Debiasi M, Liedke PER, Soto-Perez-de-Celis E, Dizon D, Cazap E, de Lima Lopes G, Touya D, Nunes JS, St Louis J, Vail C, Bukowski A, Ramos-Elias P, Unger-Saldaña K, Brandao DF, Ferreyra ME, Luciani S, Nogueira-Rodrigues A, de Carvalho Calabrich AF, Del Carmen MG, Rauh-Hain JA, Schmeler K, Sala R, Goss PE. Progress and remaining challenges for cancer control in Latin America and the Caribbean. Lancet Oncol 2016; 16:1405-38. [PMID: 26522157 DOI: 10.1016/s1470-2045(15)00218-1] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 12/22/2022]
Abstract
Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low-income and middle-income countries. Our findings in the 2013 Commission in The Lancet Oncology showed several discrepancies between the cancer landscape in Latin America and more developed countries. We reported that funding for health care was a small percentage of national gross domestic product and the percentage of health-care funds diverted to cancer care was even lower. Funds, insurance coverage, doctors, health-care workers, resources, and equipment were also very inequitably distributed between and within countries. We reported that a scarcity of cancer registries hampered the design of credible cancer plans, including initiatives for primary prevention. When we were commissioned by The Lancet Oncology to write an update to our report, we were sceptical that we would uncover much change. To our surprise and gratification much progress has been made in this short time. We are pleased to highlight structural reforms in health-care systems, new programmes for disenfranchised populations, expansion of cancer registries and cancer plans, and implementation of policies to improve primary cancer prevention.
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Affiliation(s)
- Kathrin Strasser-Weippl
- Centre for Oncology and Hematology, Wilhelminen Hospital, Vienna, Austria; The Global Cancer Institute, Boston, MA, USA
| | - Yanin Chavarri-Guerra
- The Global Cancer Institute, Boston, MA, USA; Hemato-Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico; Avon International Breast Cancer Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Cynthia Villarreal-Garza
- Instituto de Cancerología, Centro de Cáncer de Mama, Tecnologico de Monterrey, Monterrey, Nuevo León, Mexico; Departmento de Investigación y de Tumores Mamarios, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Brittany L Bychkovsky
- Dana Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Marcio Debiasi
- Hospital Mae de Deus, Porto Alegre, Rio Grande do Sul, Brazil; Hospital Sao Lucas da PUCRS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Pedro E R Liedke
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Instituto do Câncer Mãe de Deus, Porto Alegre, Rio Grande do Sul, Brazil
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Cancer Care in the Elderly Clinic, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico
| | - Don Dizon
- Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Eduardo Cazap
- Sociedad Latinoamericana y del Caribe de Oncología Médica, Buenos Aires, Argentina
| | - Gilberto de Lima Lopes
- Medical Oncology, Centro Paulista de Oncologia and Oncoclinicas do Brasil Group, São Paulo, Brazil; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diego Touya
- Department of Oncology, University of the Republic, Montevideo, Uruguay
| | | | - Jessica St Louis
- The Global Cancer Institute, Boston, MA, USA; Avon International Breast Cancer Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Caroline Vail
- The Global Cancer Institute, Boston, MA, USA; Avon International Breast Cancer Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Alexandra Bukowski
- The Global Cancer Institute, Boston, MA, USA; Avon International Breast Cancer Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Pier Ramos-Elias
- Instituto de Cancerología, Centro de Cáncer de Mama, Tecnologico de Monterrey, Monterrey, Nuevo León, Mexico
| | - Karla Unger-Saldaña
- Cátedra CONACYT, Unidad de Epidemiología, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | | | - Mayra E Ferreyra
- Oncology Department, Maria Curie Hospital, Buenos Aires, Argentina
| | - Silvana Luciani
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Angelica Nogueira-Rodrigues
- Federal University, Minas Gerais, Brazil; EVA-Group Brasileiro de Tumores Ginecológicos, Brazilian Gynecologic Oncology Group, Bahia, Brazil
| | | | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jose Alejandro Rauh-Hain
- Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Raúl Sala
- Grupo Argentino de Investigación Clínica en Oncología-GAICO, Rosario, Santa Fe, Argentina
| | - Paul E Goss
- The Global Cancer Institute, Boston, MA, USA; Avon International Breast Cancer Research Program, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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