Race-related disparities in patterns of uterine cancer recurrence

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Background: Racial disparities in uterine cancer outcomes are present, as Black patients with uterine cancer have markedly higher mortality when compared with White patients. Potential etiologies of this discrepancy have been investigated, including implicit bias, histopathologic factors and stage at presentation, molecular and genetic factors, and socioeconomic factors. The purpose of this study is to explore if non-White patients with uterine cancer are more likely to experience distant cancer recurrence compared to White patients. Methods: A single-institution retrospective cohort study was performed examining all patients diagnosed with uterine cancer from 2006-2016. Data regarding patient demographics, medical co-morbidities, histology, stage, treatment course, and disease recurrence were abstracted from the medical record. Race was categorized based on how a patient was registered in the medical record. The primary outcome was location of recurrence, with local recurrence defined as vaginal/cuff recurrence and distant recurrence representing nodal, intraperitoneal, or distant recurrence. A multivariable regression model was built in a backwards stepwise fashion to examine the association of individual covariates with distant recurrence as opposed to vaginal recurrence. Results: A total of 1205 patients with uterine cancer were included for analysis. Three hundred eighteen (26.5%) patients were White, 472 (39.2%) Black, 319 (26.5%) Hispanic, 91 (7.6%) Asian, and 4 (0.3%) other. A total of 223 (18.5%) patients experienced disease recurrence. Black women experienced a statistically significant increased risk of recurrence compared with non-Black women [OR 1.99 (95% CI 1.37-2.88), p < 0.01]. Additionally, Black patients were significantly more likely to experience nodal, intra-peritoneal and distant recurrences relative to White patients (p < 0.01). When adjusting for covariates including race, histology, grade, stage and adjuvant treatment, non-White race [OR 3.87 (95% CI (1.42-10.54), p < 0.01] was associated with significant increase in risk of distal recurrence. Conclusions: The findings of this study suggest that non-White race is potentially contributory to distant recurrence of uterine cancer, even when accounting for histopathologic differences, stage at presentation, and other traditional covariates. These findings suggest that the disparate outcomes experienced by non-White patients are likely multi-factorial in nature and highlight the need for efforts focused on optimizing treatment and improving outcomes of non-White women with uterine cancer.[Table: see text]

Necessity of routine cardiac evaluation in patients receiving pegylated liposomal doxorubicin for gynecologic cancer

OBJECTIVE

Pegylated liposomal doxorubicin (PLD) has similar reported clinical efficacy compared with conventional doxorubicin with less cardiotoxicity. The manufacturer of PLD advises that cardiac function should be evaluated with endomyocardial biopsy, echocardiography or multigated radionucleotide scan (MUGA) pre-treatment and during therapy. This study was designed to assess the necessity of pre-treatment cardiac evaluation in patients receiving PLD.

METHODS

After IRB approval, a retrospective study of all women with gynecologic cancer who received PLD from 2006 to 2018 was performed. Demographic information, treatment records, cardiac risk factors, and cardiac surveillance testing were examined. Wilcoxon signed rank sum test and logistic regression were used to evaluate the association of cumulative PLD exposure with cardiotoxicity.

RESULTS

A total of 235 patients received PLD for gynecologic cancer. Patients received a median of 3 cycles of PLD with a cumulative dosage of 237 mg over a median follow-up time of 24 months. Sixteen patients in the cohort (7%) had no cardiac surveillance at all. Of the remaining patients who underwent cardiac testing, 183 (84%) received MUGA scans and 36 (16%) had echocardiography. Of the 56 patients who had both pre- and post-treatment cardiac testing, there was no significant difference in median ejection fraction (p = 0.17). Three patients developed PLD-associated cardiac toxicity but only one patient had severe manifestations requiring discontinuation of PLD therapy.

CONCLUSIONS

Routine cardiac testing before, during or after treatment with PLD may be unnecessary. Cardiac testing may be more appropriate for individual patients for whom the clinical suspicion of PLD-related cardiac toxicity is high.

Readability assessment of online gynecologic oncology patient education materials from major governmental, non-profit and pharmaceutical organizations

OBJECTIVE

Patients are increasingly using online materials to learn about gynecologic cancer. Providers can refer patients to online educational materials produced by a number of different major medical organizations and pharmacology companies. The National Institutes of Health (NIH) and the American Medical Association (AMA) recommend that patient educational materials (PEMs) are written between a sixth and eighth grade reading level. In this study, we assess the readability of online PEMs published by major medical organizations and industry partners.

METHODS

Websites from twelve websites providing educational materials for gynecologic oncology patients were surveyed. Online PEMs were identified and analyzed using seven validated readability indices. One-way ANOVA and Tukey's Honestly Significant Difference (HSD) post-hoc analysis were performed to detect differences in readability between publishers.

RESULTS

Two-hundred and sixty PEMs were included in this analysis. Overall, PEMs were written at a mean 11th±0.6 grade reading level. Only 6.5% of articles were written at the AMA/NIH recommended reading grade level of 6th to 8th grade or below. ANOVA demonstrated a significant difference in readability between publishing associations (p<0.01). PEMs from the Centers for Disease Control had a mean 9th±1.2 grade reading level and were significantly lower than all other organizations. PEMs from The Foundation for Women's Cancer had a mean 13th±1.8 grade reading level and were significantly higher than most other organizations. PEMs from pharmaceutical companies (mean readability=10.1±1.1, N=30) required the lowest reading grade level and were significantly more readable than those from governmental organizations (11.1±1.7, p<0.05) and nonprofit medical associations (12.4±1.7, p<0.01) in ANOVA and Tukey-Kramer post hoc analysis.

CONCLUSIONS

Gynecologic oncology PEMs available from twelve major organization websites are written well above the recommended sixth to eighth grade reading difficulty level.

The use of QuikClot combat gauze in cervical and vaginal hemorrhage

QuikClot combat gauze is a synthetic hemostatic dressing used for hemorrhage control. There is a paucity of data describing the clinical use and hemostatic results of combat gauze in the obstetric and gynecologic setting. This case series demonstrates the use of combat gauze as an effective hemostatic agent when used as vaginal packing in cervical and vaginal hemorrhage. Hemostasis was achieved rapidly in all cases and further interventions were avoided. The combat gauze remained in place for a mean time of 15 h with no adverse side effects observed. The use of combat gauze as vaginal packing may provide an alternative option in the treatment of cervical and vaginal hemorrhage when other traditional conservative and surgical interventions fail or are unavailable.

Pregnancy context and women's health-related quality of life

OBJECTIVE

The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL).

STUDY DESIGN

English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables.

RESULTS

We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL.

CONCLUSIONS

After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL.

IMPLICATIONS

The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.

Incidental injury and repair of obturator nerve during laparoscopic pelvic lymphadenectomy

OBJECTIVE

To demonstrate a surgical video wherein left obturator nerve was iatrogenically injured during pelvic lymphadenectomy and repaired immediately with laparoscopic epineural end-to-end tension free anastomosis.

METHODS

This is a step-by-step demonstration of an incidental injury and laparoscopic repair of left obturator nerve during pelvic lymphadenectomy. The patient was a 59year-old Hispanic female who was found to have endometrial adenocarcinoma. She was referred to our division for laparoscopic staging during which left obturator nerve was iatrogenically injured. After completion of left pelvic lymphadenectomy, proximal and distal cut ends of the obturator nerve were identified. Careful inspection revealed that the nerve was transected cleanly without any fraying of the edges. Tension-free reattachment of the edges seemed possible without further mobilization of the nerve since the resected part was approximately 5mm. The obturator nerve edges were oriented and stay sutures were placed in order to perform tension-free anastomosis. Epineural end-to-end coaptation was completed with 5-0 polypropylene sutures [1,2].

RESULTS

Postoperatively, the patient did not exhibit any clinically apparent loss of adductor function or any other neurologic deficiency and was discharged home on postoperative day one. Over 6months of follow-up, the patient experienced no residual neuropathy or deficit in the left thigh.

CONCLUSION

Laparoscopic repair of a transected obturator nerve during gynecologic surgery is feasible. In this case, immediate repair of the damaged nerve by an experienced laparoscopic gynecologic surgeon did not result in any neurologic deficit postoperatively.