Complete Compared With Partial Salpingectomy for Postpartum Sterilization

In this narrative review, we describe evidence regarding the associated risks, benefits, and cost effectiveness of postpartum complete salpingectomy compared with partial salpingectomy. Permanent contraception can be performed via several methods, but complete salpingectomy is becoming more common secondary to its coincident benefit of ovarian cancer risk reduction. Small prospective studies and larger retrospective cohort studies have demonstrated the feasibility and safety of complete salpingectomy in the postpartum period. Additionally, multiple cost-effectiveness analyses have demonstrated the cost effectiveness of this method secondary to ovarian cancer reduction over the life span. Although future larger cohort studies will allow for more precise estimates of the effect of complete salpingectomy on ovarian cancer risk and incidence of rare complications, current data suggest that complete salpingectomy should be offered to patients as a method of permanent contraception in the postpartum period.

Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost-effectiveness analysis

Objective

To assess the potential cost-effectiveness of prehabilitation in medically frail patients undergoing surgery for epithelial ovarian cancer (EOC).

Methods

We created a cost-effectiveness model evaluating the impact of prehabilitation on a cohort of medically frail women undergoing primary surgical intervention for EOC. Cost was assessed from the healthcare system perspective via (1) inpatient charges from 2018–2019 institutional Diagnostic Related Grouping data for surgeries with and without major complications; (2) nursing facility costs from published market surveys. Major complication and non-home discharge rates were estimated from the literature. Based on published pilot studies, prehabilitation was determined to decrease these rates. Incremental cost-effectiveness ratio for cost per life year saved utilized a willingness-to-pay threshold of $100,000/life year. Modeling was performed with TreeAge software.

Results

In a cohort of 4,415 women, prehabilitation would cost $371.1 Million (M) versus $404.9 M for usual care, a cost saving of $33.8 M/year. Cost of care per patient with prehabilitation was $84,053; usual care was $91,713. When analyzed for cost-effectiveness, usual care was dominated by prehabilitation, indicating prehabilitation was associated with both increased effectiveness and decreased cost compared with usual care. Sensitivity analysis showed prehabilitation was more cost effective up to a cost of intervention of $9,418/patient.

Conclusion

Prehabilitation appears to be a cost-saving method to decrease healthcare system costs via two improved outcomes: lower complication rates and decreased care facility requirements. It represents a novel strategy to optimize healthcare efficiency. Prospective studies should be performed to better characterize these interventions in medically frail patients with EOC.

Prehabilitation cost-effectiveness analysis was performed for medically frail epithelial ovarian cancer patients undergoing surgery. It was cost-saving for the healthcare system via lower complication rates and discharge care requirements. Prehabilitation was cost effective up to a cost of $9,418/patient.

The challenge of HPV vaccination uptake and opportunities for solutions: Lessons learned from Alabama

The human papillomavirus (HPV) vaccine is an important tool for cancer prevention. However, vaccination rates in Alabama, a state with high rates of HPV-related cancers, remain below the national average. Our objective was to develop a comprehensive assessment of HPV vaccination in our state, with the goal to make recommendations for tailored multilevel interventions. A multimodal approach with quantitative and qualitative data was used to determine barriers and facilitators to HPV vaccination in Alabama. This included a survey of pediatric care providers and structured interviews with pediatricians, parents, nurses and community stakeholders. Two separate investigators evaluated the interview transcripts for major themes that occurred in 65% or more interviews. Major barriers included lack of knowledge, concerns about vaccine safety, and the link between the HPV vaccine and sexuality. Qualitative interviews further revealed barriers such as misinformation received from the internet and parental vaccine hesitancy. Opportunities for increasing vaccination include parental education, establishment of a reminder system, increasing access to HPV vaccine providers, and education for providers. Additional facilitators revealed through interviews included: trust in physicians, using the internet or social media to propagate positive messaging, physicians and clinical staff education, utilizing existing technology more effectively, highlighting nurses' roles as partners in HPV prevention, and the potential of schools as a venue for promotion of the vaccine. Our data are consistent with prior research showing major barriers to HPV vaccination. Several recommendations for optimizing HPV vaccination uptake in Alabama on the patient, provider and system level are given.

Abstract C92: A diagnostic review of barriers to and opportunities for improving HPV vaccination in Alabama

Background: The human papillomavirus (HPV) vaccine is an important tool for cancer prevention. Vaccination rates in Alabama, a state with high rates of HPV-related cancers, remain below the national average. Our objective was to develop a comprehensive assessment of HPV vaccination in our state, with the goal to make recommendations for tailored multilevel interventions.

Methods: With the PRECEDE-PROCEED model as a theoretical framework, a multimodal approach with quantitative and qualitative data was used to determine barriers and facilitators to HPV vaccination in Alabama. This included a survey of pediatricians and family medicine providers as well as structured qualitative interviews with pediatricians, parents, nurses, and community stakeholders. Two separate investigators evaluated the interview transcripts for major themes that occurred in 65% or more interviews.

Results: Major barriers that overlapped between all groups in both qualitative and quantitative data included lack of parental knowledge, concerns about vaccine safety, and the link between the HPV vaccine and sexuality. Opportunities for increasing HPV vaccination identified include parental education, establishment of a reminder system, increasing access to HPV vaccine providers, and education for providers. Qualitative interviews further expanded on these themes and revealed barriers such as misinformation received from the Internet and parental vaccine hesitancy. Additional opportunities and facilitators revealed through interviews included the trust patients have in physicians, using the Internet or social media to propagate positive messaging about the HPV vaccine, provider education for both physicians and clinical staff, utilizing existing technology more effectively, highlighting nurses' roles as partners in HPV prevention, and the potential of schools as a venue for patient education and promotion of the vaccine.

Conclusion: Our data are consistent with prior research showing major barriers to HPV vaccination. There is an especially high resistance to vaccination due to the link between the vaccine and sexual activity, often attributed to religious beliefs. Several recommendations for optimizing HPV vaccination uptake in Alabama on the patient, provider, and system level are given.

Citation Format: Sarah E. Dilley, Sylvia Peral, J. Michael Straughn, Jr., Isabel Scarinci. A diagnostic review of barriers to and opportunities for improving HPV vaccination in Alabama [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C92.

Treatment of low-grade endometrial stromal sarcoma in a nulligravid woman

A 32 year-old nulligravid woman with a uterine mass underwent exploratory laparotomy with myomectomy. Final pathology revealed a low-grade endometrial stromal sarcoma (ESS) with positive margins. She subsequently underwent definitive robotic hysterectomy and bilateral salpingectomy with ovarian preservation. She was diagnosed with a stage IB low-grade ESS. She is currently undergoing observation. Discussion of classification, surgical options, and adjuvant therapy is presented.

Lessons learned from domestic and international human papillomavirus vaccination programs: a review

Since the development of the human papillomavirus vaccine, many countries have created implementation programs to bolster vaccination rates and protect their populations. Despite demonstrated efficacy with decreased human papillomavirus-related disease abroad, the vaccine's potential to prevent morbidity and mortality in the United States is not being met. The purpose of this review is to discuss strategies of both international and domestic vaccination programs, their impact on human papillomavirus-related diseases, the unique obstacles faced by the United States, and future directions for success.

Malignant Brenner tumor associated with a germline BRCA2 mutation

•The first woman with a Malignant Brenner tumor and a BRCA2 mutation is described.•Not all women with epithelial ovarian cancers are referred for genetic counseling.•Women should be referred for genetics regardless of how rare the histology.

The impact of physician burnout on clinical and academic productivity of gynecologic oncologists: A decision analysis

OBJECTIVE

Physician burnout is associated with mental illness, alcohol abuse, and job dissatisfaction. Our objective was to estimate the impact of burnout on productivity of gynecologic oncologists during the first half of their career.

METHODS

A decision model evaluated the impact of burnout on total relative value (RVU) production during the first 15years of practice for gynecologic oncologists entering the workforce from 2011 to 2015. The SGO practice survey provided physician demographics and mean annual RVUs. Published data were used to estimate probability of burnout for male and female gynecologic oncologists, and the impact of depression, alcohol abuse, and early retirement. Academic productivity was defined as annual PubMed publications since finishing fellowship.

RESULTS

Without burnout, RVU production for the cohort of 250 gynecologic oncologists was 26.2 million (M) RVUs over 15years. With burnout, RVU production decreased by 1.6 M (5.9% decrease). Disproportionate rates of burnout among females resulted in 1.1 M lost RVUs for females vs. 488 K for males. Academic production without burnout was estimated at 9277 publications for the cohort. Burnout resulted in 1383 estimated fewer publications over 15years (14.9%).

CONCLUSIONS

The impact of burnout on clinical and academic productivity is substantial across all specialties. As health care systems struggle with human resource shortages, this study highlights the need for effective burnout prevention and wellness programs for gynecologic oncologists. Unless significant resources are designated to wellness programs, burnout will increasingly affect the care of our patients and the advancement of our field.

Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention

OBJECTIVES

Data suggesting a link between the fallopian tube and ovarian cancer have led to an increase in rates of salpingectomy at the time of pelvic surgery, a practice known as opportunistic salpingectomy (OS). However, the potential benefits, risks and costs for this new practice are not well established. Our objective was to assess the cost-effectiveness of opportunistic salpingectomy at the time of laparoscopic permanent contraception or hysterectomy for benign indications.

METHODS

We created two models to compare the cost-effectiveness of salpingectomy versus usual care. The hypothetical study population is 50,000 women aged 45 undergoing laparoscopic hysterectomy with ovarian preservation for benign indications, and 300,000 women aged 35 undergoing laparoscopic permanent contraception. SEER data were used for probabilities of ovarian cancer cases and deaths. The ovarian cancer risk reduction, complication rates, utilities and associated costs were obtained from published literature. Sensitivity analyses and Monte Carlo simulation were performed, and incremental cost-effectiveness ratios (ICERs) were calculated to determine the cost per quality adjusted life year (QALY) gained.

RESULTS

In the laparoscopic hysterectomy cohort, OS is cost saving and would yield $23.9 million in health care dollars saved. In the laparoscopic permanent contraception cohort, OS is cost-effective with an ICER of $31,432/QALY compared to tubal ligation, and remains cost-effective as long as it reduces ovarian cancer risk by 54%. Monte Carlo simulation demonstrated cost-effectiveness with hysterectomy and permanent contraception in 62.3% and 55% of trials, respectively.

CONCLUSIONS

Opportunistic salpingectomy for low-risk women undergoing pelvic surgery may be a cost-effective strategy for decreasing ovarian cancer risk at time of hysterectomy or permanent contraception. In our model, salpingectomy was cost-effective with both procedures, but the advantage greater at time of hysterectomy.

Distance from a Comprehensive Cancer Center: A proxy for poor cervical cancer outcomes?

OBJECTIVE

To evaluate the potential relationship between outcomes in cervical cancer patients based on distance from our Comprehensive Cancer Center (CCC).

METHODS

A retrospective cohort study of cervical cancer patients was performed. Abstracted data included: demographics, clinicopathologic variables, treatment, and survival. Analyses both by quartiles and distance <100 and ≥100miles from our institution were performed. Data were analyzed using SAS version 9.2.

RESULTS

390 patients living a median distance of 58.1miles (range 1.2-571miles) from our CCC were identified. Patients were generally white (n=249), non-smokers (n=226), with Stage IB disease (n=222), squamous histology (n=295) and underwent primary surgical therapy (n=229). Patients were divided into both quartiles as well as two strata: <100 and ≥100miles for comparison. Progression-free survival (PFS) and overall survival (OS) favored patients living closer to our center with a lower median OS for patients living ≥100miles (65.4vs. 99.4months; p=0.040). Cox proportional hazard modeling noted that advanced stage was predictive of inferior PFS and OS, while other clinical covariates including age, BMI, race, smoking status and histology had a variable impact on outcomes and distance >100miles was associated with a higher risk of death (hazard ratio [HR]=1.68, 95% confidence interval [CI] 1.11-2.54).

CONCLUSION

Overall survival for patients living >100miles from our CCC was worse when compared to patients in closer proximity. Outreach efforts and utilization of navigators may help decrease the impact of geographic and racial disparities on outcomes.