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Milman T, Maeda A, Swift BE, Bouchard-Fortier G. Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database. Int J Gynecol Cancer 2024; 34:602-609. [PMID: 38097349 DOI: 10.1136/ijgc-2023-004970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity. METHODS A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression. RESULTS Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity. CONCLUSION In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.
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Affiliation(s)
- Tal Milman
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Azusa Maeda
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health System, Toronto, Ontario, Canada
| | - Brenna E Swift
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health System, Toronto, Ontario, Canada
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Español P, Luzarraga A, Teixeira N, Soler C, Luna-Guibourg R, Rovira R. An institutional study: Does Body Mass Index influence surgical approach, surgical morbidities, and outcomes in endometrial cancer patients? Facts Views Vis Obgyn 2023; 15:259-268. [PMID: 37742203 PMCID: PMC10643010 DOI: 10.52054/fvvo.15.3.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Endometrial Cancer (EC), the most common genital tract malignancy in women, is recognised to be associated with a high Body Mass Index (BMI). Objective The aim of the study was to evaluate the impact of obesity on intra and post-operative morbidity for patients treated for EC. Materials and Methods This was a retrospective observational study including patients with EC that were surgically treated at Hospital de la Santa Creu i Sant Pau during nine consecutive years. The patients were divided in groups according to BMI: <30 Kg/m2, ≥30-<40 Kg/m2 and ≥40 Kg/m2. Demographic and pathological characteristics, surgical outcomes, perioperative complications and long-term outcomes were recorded. Results The study included 290 patients; 164 patients with BMI <30 Kg/m2(56.5%), 107 patients with ≥30-<40 Kg/m2 36.9%) and 19 patients with ≥40 Kg/m2(6.65%). Patients with BMI ≥40Kg/m2 were younger, presented a higher percentage of endometrioid histology (84.2%, p<0.01), well-differentiated tumours (73.7%, p<0.01) and were more frequently in the initial stages at diagnosis (94.7%) compared to the other groups. A significant percentage of the patients were operated on laparoscopically (88.7%, 88.8%, 94.7% respectively). No significant differences were found in the evaluation of the surgical outcomes. The results relative to complications showed an overall tendency toward increase in the ≥40 Kg/m2 BMI group but no statistical differences were identified among the groups in terms of complications or long-term outcomes. Conclusions There was a rising trend towards increased complications with increasing BMI in the study population, however, this was found not to be statistically significant. Therefore, the optimisation of co-morbidities and the adaptation of surgical treatment is important for the management of obese patients with endometrial cancer. What is new? The study allows the comparison between groups with different BMI in patients with endometrial cancer. Different surgical outcomes, intra operative, early, and late complications are clearly identified, and survival outcomes are also investigated in our study.
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Amirthanayagam A, Wood M, Teece L, Ismail A, Leighton R, Jacob A, Chattopadhyay S, Davies Q, Moss EL. Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy. Cancers (Basel) 2023; 15:4335. [PMID: 37686610 PMCID: PMC10487232 DOI: 10.3390/cancers15174335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/03/2023] [Accepted: 08/12/2023] [Indexed: 09/10/2023] Open
Abstract
A longitudinal, descriptive, prospective, and prolective study of individuals with endometrial or cervical cancer/pre-cancer diagnoses and high BMI (over 35 kg/m2) undergoing RH was conducted. Of the 53 participants recruited, 3 (6%) were converted to open surgery. The 50 RH participants had median BMI 42 kg/m2 (range 35 to 60): the range 35-39.9 kg/m2 had 17 cases; the range 40-44.9 kg/m2 had 15 cases; 45-49.9 kg/m2 8 cases; and those ≥50 kg/m2 comprised 10 cases. The mean RH operating time was 128.1 min (SD 25.3) and the median length of hospital stay was 2 days (range 1-14 days). Increased BMI was associated with small, but statistically significant, increases in operating time and anaesthetic time, 65 additional seconds and 37 seconds, respectively, for each unit increase in BMI. The median self-reported time for individuals who underwent RH to return to their pre-operative activity levels was 4 weeks (range 2 to >12 weeks). There was a significant improvement in pain and physical independence scores over time (p = 0.001 and p < 0.001, respectively) and no significant difference in scores for overall QOL, pain, or physical independence scores was found between the BMI groups. Patient-reported recovery and quality of life following RH is high in individuals with high BMI (over 35 kg/m2) and does not appear to be impacted by the severity of obesity.
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Affiliation(s)
- Anumithra Amirthanayagam
- Leicester Cancer Research Centre, College of Life Sciences, University of Leicester, University Road, Leicester LE1 7RH, UK
| | - Matthew Wood
- Department of Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Lucy Teece
- Department of Population Health Sciences, College of Life Sciences, University of Leicester, University Road, Leicester LE1 7RH, UK
| | - Aemn Ismail
- Department of Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Ralph Leighton
- Department of Anaesthetics, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Annie Jacob
- Department of Anaesthetics, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Supratik Chattopadhyay
- Department of Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Quentin Davies
- Department of Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
| | - Esther L. Moss
- Leicester Cancer Research Centre, College of Life Sciences, University of Leicester, University Road, Leicester LE1 7RH, UK
- Department of Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 2023; 30:1508-1519. [PMID: 36310311 PMCID: PMC10466211 DOI: 10.1245/s10434-022-12663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA.
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Kohut A, Whitaker T, Walter L, Li SY, Han E, Lee S, Wakabayashi MT, Dellinger TH, Han ES, Rodriguez-Rodriguez L, Chung C. Feasibility of combining pelvic reconstruction with gynecologic oncology-related surgery. Int Urogynecol J 2023; 34:177-183. [PMID: 35501570 DOI: 10.1007/s00192-022-05212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/12/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS At our institution, every patient seen by the gynecologic oncology service is screened for pelvic floor dysfunction. This study was aimed at determining if a combined surgical approach by gynecologic oncology and urogynecology services at our institution was feasible and safe for this patient population. METHODS We performed a retrospective review of patients undergoing combined surgery by gynecologic oncology and urogynecology services at our institution from 2013 to 2021. Perioperative variables, postoperative adverse events, and long-term outcomes were assessed, and descriptive statistics were performed. RESULTS From 20 December 2013 to 29 January 2021, a total of 102 patients underwent concurrent surgical repair of pelvic organ prolapse and/or stress urinary incontinence. Seventy-three patients (71.6%) had normal/benign pathologic conditions, and 29 (28.4%) had premalignant/malignant pathologic conditions. Ten patients (9.8%) had a postoperative complication, including reoperation for exposed midurethral sling (4.9%), urinary retention requiring midurethral sling release (2.9%), reoperation for hemoperitoneum (1.0%), and anemia requiring blood transfusion (1.0%). Nine complications occurred in patients with benign/normal pathologic conditions (12.3%), and one complication occurred in patients with pre-malignant/malignant pathologic conditions (3.4%). CONCLUSIONS In our single-institution experience, concurrent gynecologic oncology and pelvic floor reconstructive surgery were safe and feasible in combination with no reported major morbidity events.
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Affiliation(s)
- Adrian Kohut
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Taylor Whitaker
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Logan Walter
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Susan Y Li
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Elinor Han
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Stephen Lee
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Mark T Wakabayashi
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Thanh H Dellinger
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Ernest S Han
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Lorna Rodriguez-Rodriguez
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Christopher Chung
- Department of Surgery, Division of Gynecologic Oncology, City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
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Simon O, Dion L, Nyangoh Timoh K, Dupré PF, Azaïs H, Bendifallah S, Touboul C, Dabi Y, Graesslin O, Raimond E, Costaz H, Kerbage Y, Huchon C, Mimoun C, Koskas M, Akladios C, Lecointre L, Canlorbe G, Chauvet P, Ouldamer L, Levêque J, Lavoué V. Impact of severe obesity in the management of patients with high-risk endometrial cancer: A FRANCOGYN study. J Gynecol Obstet Hum Reprod 2022; 51:102429. [DOI: 10.1016/j.jogoh.2022.102429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/29/2022] [Accepted: 06/09/2022] [Indexed: 10/18/2022]
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Ross RC, Akinde YM, Schauer PR, le Roux CW, Brennan D, Jernigan AM, Bueter M, Albaugh VL. The role of bariatric and metabolic surgery in the development, diagnosis, and treatment of endometrial cancer. Front Surg 2022; 9:943544. [PMID: 36117808 PMCID: PMC9470773 DOI: 10.3389/fsurg.2022.943544] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/25/2022] [Indexed: 12/13/2022] Open
Abstract
The obesity pandemic continues to contribute to a worsening burden of disease worldwide. The link between obesity and diseases such as diabetes, cardiovascular disease, and cancer has been well established, yet most patients living with obesity remain untreated or undertreated. Metabolic and bariatric surgery is the most effective and durable treatment for obesity, is safe, and may have a protective benefit with respect to cancer incidence. In this review, an overview of the link between obesity, metabolic surgery, and cancer is discussed with emphasis on indications for endometrial cancer, the malignancy most strongly associated with obesity. Considerable evidence from retrospective and prospective cohort studies supports a decreased risk of endometrial cancer in patients with obesity who undergo bariatric surgery compared with nonsurgical controls. Survivors of endometrial cancer are at increased risk of poor health outcomes associated with obesity, and women with endometrial cancer are more likely to die of cardiovascular disease and other obesity-related illnesses than of the malignancy itself. Recent advances in anticancer drug therapies have targeted pathways that may also be therapeutically altered with metabolic surgery. Metabolic surgery has significant potential to enter the treatment paradigm for endometrial cancer, and gynecologic oncologist visits present an opportunity to identify patients who may benefit the most.
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Affiliation(s)
- Robert C. Ross
- Translational and Integrative Gastrointestinal and Endocrine Research Laboratory, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
| | - Yetunde M. Akinde
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Philip R. Schauer
- Metamor Institute, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
| | - Carel W. le Roux
- School of Medicine, St. Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Donal Brennan
- UCD Gynecological Oncology Group, UCD School of Medicine, Catherine McAuley Research Centre, Mater Misericordiae University Hospital, Belfield, Dublin, Ireland
| | - Amelia M. Jernigan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Marco Bueter
- Department of Visceral and Transplantation Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Vance L. Albaugh
- Translational and Integrative Gastrointestinal and Endocrine Research Laboratory, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
- Metamor Institute, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, United States
- Correspondence: Vance L. Albaugh
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Chaiken SR, Bohn JA, Bruegl AS, Caughey AB, Munro EG. Hysterectomy with a General Gynecologist vs. Gynecologic Oncologist in the Setting of Endometrial Intraepithelial Neoplasia: A Cost-Effectiveness Analysis. Am J Obstet Gynecol 2022; 227:609.e1-609.e8. [PMID: 35662547 DOI: 10.1016/j.ajog.2022.05.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/10/2022] [Accepted: 05/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic oncologist to complete staging. There is current ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic oncologist. OBJECTIVE To better understand if patients with EIN should be initially referred to a gynecologic oncologist for treatment, we examined the cost-effectiveness of hysterectomy by general gynecologists versus gynecologic oncologists for patients with EIN. STUDY DESIGN We created a decision-analytic model using TreeAge Pro software to compare outcomes between patients with EIN undergoing hysterectomy by a general gynecologist versus a gynecologic oncologist. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years (QALYs), primary lymph node dissection (LND), secondary LND, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic oncologist. We performed univariable sensitivity analyses as well as multivariable probabilistic sensitivity analysis to assess the model's robustness given the uncertainty of model inputs. RESULTS In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic oncologist was associated with a decrease in 10,811 second surgeries for LND, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a LND due to perioperative mortalities that occurred prior to LND with a gynecologic oncologist. Hysterectomy with a gynecologic oncologist was the dominant, cost-effective strategy as it saved $116 million and increased QALYs by 180. In our univariable analyses, hysterectomy with a gynecologic oncologist was cost-saving and increased QALYs over a wide range of probabilities and costs for LND, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic oncologist is only a cost-effective and cost-saving saving strategy in just over 50% of multivariable simulations, demonstrating that that there is significant uncertainty in the model's cost-effectiveness. CONCLUSIONS In our model, hysterectomy with a gynecologic oncologist for patients with EIN was associated with cost savings and increased QALYs. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.
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Bohn JA, Hernandez-Zepeda ML, Hersh AR, Munro EG, Kahn JM, Caughey AB, Bruegl A. Does obesity influence the preferred treatment approach for early-stage cervical cancer? A cost-effectiveness analysis. Int J Gynecol Cancer 2021; 32:133-140. [PMID: 34887286 DOI: 10.1136/ijgc-2021-003004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/22/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Abdominal radical hysterectomy in early-stage cervical cancer has higher rates of disease-free and overall survival compared with minimally invasive radical hysterectomy. Abdominal radical hysterectomy may be technically challenging at higher body mass index levels resulting in poorer surgical outcomes. This study sought to examine the influence of body mass index on outcomes and cost effectiveness between different treatments for early-stage cervical cancer. METHODS A Markov decision-analytic model was designed using TreeAge Pro software to compare the outcomes and costs of primary chemoradiation versus surgery in women with early-stage cervical cancer. The study used a theoretical cohort of 6000 women who were treated with abdominal radical hysterectomy, minimally invasive radical hysterectomy, or primary chemoradiation therapy. We compared the results for three body mass index groups: less than 30 kg/m2, 30-39.9 kg/m2, and 40 kg/m2 or higher. Model inputs were derived from the literature. Outcomes included complications, recurrence, death, costs, and quality-adjusted life years. An incremental cost-effectiveness ratio of less than $100 000 per quality-adjusted life year was used as our willingness-to-pay threshold. Sensitivity analyses were performed broadly to determine the robustness of the results. RESULTS Comparing abdominal radical hysterectomy with minimally invasive radical hysterectomy, abdominal radical hysterectomy was associated with 526 fewer recurrences and 382 fewer deaths compared with minimally invasive radical hysterectomy; however, abdominal radical hysterectomy resulted in more complications for each body mass index category. When the body mass index was 40 kg/m2 or higher, abdominal radical hysterectomy became the dominant strategy because it led to better outcomes with lower costs than minimally invasive radical hysterectomy. Comparing abdominal radical hysterectomy with primary chemoradiation therapy, recurrence rates were similar, with more deaths associated with surgery across each body mass index category. Chemoradiation therapy became cost effective when the body mass index was 40 kg/m2 or higher. CONCLUSION When the body mass index is 40 kg/m2 or higher, abdominal radical hysterectomy is cost saving compared with minimally invasive radical hysterectomy and primary chemoradiation is cost effective compared with abdominal radical hysterectomy. Primary chemoradiation may be the optimal management strategy at higher body mass indexes.
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Affiliation(s)
- Jacqueline A Bohn
- Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, Oregon, USA
| | | | - Alyssa R Hersh
- Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Elizabeth G Munro
- Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenna M Kahn
- Department of Radiation Oncology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Amanda Bruegl
- Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, Oregon, USA
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O'Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS 2021; 25:JSLS.2020.00087. [PMID: 34248330 PMCID: PMC8241283 DOI: 10.4293/jsls.2020.00087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. Methods This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. Results Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. Conclusion TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.
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Affiliation(s)
- Katherine A O'Hanlan
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Pamela L Emeney
- University of California in San Francisco-Fresno, Fresno, CA 93701
| | - Madelyn I Frank
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Leila C Milanfar
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Margaret S Sten
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Kathryn F Uthman
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
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Feigenberg T, Cormier B, Gotlieb WH, Jegatheeswaran K, Helpman L, Kim SR, Lau S, May T, Saab D, Plante M, Renaud MC, Samouelian V, Shamiya S, Vicus D, Wright K, Kwon JS. Factors associated with an increased risk of recurrence in patients diagnosed with high-grade endometrial cancer undergoing minimally invasive surgery: A study of the society of gynecologic oncology of Canada (GOC) community of practice (CoP). Gynecol Oncol 2021; 162:606-612. [PMID: 34183164 DOI: 10.1016/j.ygyno.2021.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is a standard surgical approach for comprehensive surgical staging in women with endometrial cancer. As rates and complexity of MIS are steadily increasing, it is important to identify potential risk factors which may be associated with this approach. This study evaluates the impact of local factors on the risk of disease recurrence. METHODS A retrospective cohort study was conducted of patients diagnosed with high grade endometrial cancer (HGEC) who underwent MIS between 2012 and 2016 at eight Canadian centers. Data was collected from medical records. The 75th percentile was calculated for estimated uterine volume and weight. All recurrences were categorized into two groups; intra-abdominal vs. extra-abdominal. To search for significant covariates associated with recurrence-free survival a Cox proportional hazard model was performed. RESULTS A total of 758 patients were included in the study. Intra-uterine manipulator was used in 497 (35.8%) of patients. Vaginal lacerations were documented in 9.1%. Median follow-up was 30.5 months (interquartile range 20-47). There were 157 who had disease recurrence (20.71%), including 92 (12.14%) intra-abdominal and 60 (7.92%) extra-abdominal only recurrences. In univariate analysis myometrial invasion, LVI, stage, uterine volume and weight > 75th percentile and chemotherapy were associated with increased risk of intra-abdominal recurrence. In multivariable analysis only stage, and specimen weight > 75th percentile (OR 2.207, CI 1.123-4.337) remained significant. Uterine volume, and weight were not associated with increased risk of extra-abdominal recurrences. CONCLUSION For patients diagnosed with HGEC undergoing MIS, extracting a large uterus is associated with a significantly increased risk for intra-abdominal recurrence.
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Affiliation(s)
- Tomer Feigenberg
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Trillium Health Partners, Ontario, Canada.
| | - Beatrice Cormier
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Université de Montreal, Québec, Canada
| | - Walter Henri Gotlieb
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
| | - Kizanee Jegatheeswaran
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Limor Helpman
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, McMaster University, Ontario, Canada
| | - Soyoun Rachel Kim
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of British Columbia, British Columbia, Canada
| | - Susie Lau
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
| | - Taymaa May
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Center, Ontario, Canada
| | - Dima Saab
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Marie Plante
- Gynecologic Oncology Division, CHU de Québec-Hôtel-Dieu de Québec-Université Laval, Québec, Canada
| | - Marie Claude Renaud
- Gynecologic Oncology Division, CHU de Québec-Hôtel-Dieu de Québec-Université Laval, Québec, Canada
| | - Vanessa Samouelian
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Université de Montreal, Québec, Canada
| | - Sarah Shamiya
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada
| | - Danielle Vicus
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Kristin Wright
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, McMaster University, Ontario, Canada
| | - Janice S Kwon
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of British Columbia, British Columbia, Canada
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12
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Sehouli J, Mueller K, Richter R, Anker M, Woopen H, Rasch J, Grabowski JP, Prinz‐Theissing E, Inci MG. Effects of sarcopenia and malnutrition on morbidity and mortality in gynecologic cancer surgery: results of a prospective study. J Cachexia Sarcopenia Muscle 2021; 12:393-402. [PMID: 33543597 PMCID: PMC8061344 DOI: 10.1002/jcsm.12676] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/10/2020] [Accepted: 12/23/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Malnutrition and sarcopenia often occur simultaneously in cancer patients and are thought to have harmful effects on both surgical and oncological outcomes. Therefore, we want to evaluate the effects of sarcopenia and malnutrition on severe postoperative complications and overall survival in gynecologic cancer patients. METHODS We assessed nutritional parameters and run a bioelectrical impedance analysis in 226 women. Extracellular mass to body cell mass index, phase angle alpha, muscle mass, and fat mass were evaluated. To determine if patients suffer from sarcopenia, we ran the Timed 'Up and Go' test, performed hand grip strength, and calculated a skeletal muscle index. Postoperative complications were categorized using Clavien-Dindo Classification. Utilizing ROC analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. Kaplan-Meier method and log-rank test were used for overall survival analysis. RESULTS Of the 226 female patients, 120 (53%) had a BMI ≥ 25 kg/m2 , 56 (26%) had a phase angle < 4.75°, and 68 (32%) were sarcopenic according to skeletal muscle index < 27%. Within 30 days after surgery, 40 (18%) patients developed severe postoperative complications, and 4% had died. According to multivariable regression analysis, ECOG status > 1 (OR 4.56, 95% CI: 1.46-14.28, P = 0.009), BMI ≥ 25 kg/m2 (OR 8.22, 95% CI: 3.01-22.48, P < 0.001), phase angle < 4.75° (OR 3.95, 95% CI: 1.71-9.10, P = 0.001), and tumour stage ≥ III A (OR 3.65, 95% CI: 1.36-9.76, P = 0.01) were predictors of severe postoperative complications. During 59 months of follow-up, 108 (48%) patients had died. According to multivariable Cox regression ECOG status > 1 (HR 2.51, 95% CI: 1.25-5.03, P = 0.01), hypoalbuminemia (HR 2.15, 95% CI: 1.28-3.59, P = 0.004), phase angle < 4.5° (HR 1.76, 95% CI 1.07-2.90, P = 0.03), tumour stage ≥ III A (HR 2.61, 95% CI: 1.53-4.45, P < 0.001), and severe postoperative complications (HR 2.82, 95% CI: 1.80-4.41, P < 0.001) were predictors of overall mortality. CONCLUSIONS We observed that preoperatively assessed ECOG status > 1, BMI > 25 kg, as well as phase angle alpha < 4.75° and FIGO stage ≥ III A are significantly associated with severe postoperative complications within the first month. Whereas ECOG status > 1, hypoalbuminemia, phase angle < 4.5° as well as FIGO stage ≥ III A and severe postoperative complications within 30 days correlate significantly with poor overall survival.
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Affiliation(s)
- Jalid Sehouli
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Kristina Mueller
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Rolf Richter
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Markus Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK)Charité Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT)BerlinGermany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
- Department of Cardiology (CBF)Charité Universitätsmedizin BerlinBerlinGermany
| | - Hannah Woopen
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Julia Rasch
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Jacek P. Grabowski
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Eva Prinz‐Theissing
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Melisa Guelhan Inci
- Department of Gynecology, European Competence Center for Ovarian Cancer, Berlin, GermanyCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
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Januszek SM, Wita-Popow B, Kluz M, Janowska M, Januszek R, Wróbel A, Rogowski A, Malinowski KP, Zuzak T, Kluz T. Risk Factors for Surgical Treatment of Endometrial Cancer Using Traditional and Laparoscopic Methods. J Clin Med 2021; 10:429. [PMID: 33499336 PMCID: PMC7865410 DOI: 10.3390/jcm10030429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 11/22/2022] Open
Abstract
Surgical treatment is the most important part of therapy for endometrial cancer. The aim of the study was to define factors having the most significant impact on surgical treatment of endometrial cancer when using traditional and laparoscopic methods. In the study, we evaluated 75 females who were treated for endometrial cancer via laparoscopic surgery in 2019 and used a historical control of 70 patients treated by laparotomy in 2011. The evaluated risk factors included the method of surgery, type of lymphadenectomy, patient's age, various obesity parameters, histological grading, cancer clinical staging, pelvic dimensions, previous abdominal surgeries, comorbidities, and number of deliveries. The duration of hospitalization, operation time, loss of hemoglobin, and procedure-related complications were used as parameters of perioperative outcomes. Multivariable linear regression analysis confirmed the following factors as being predictors of worse perioperative outcomes: laparotomy, abdominal obesity (waist circumstance and waist-to-hip ratio), range of lymphadenectomy, prior abdominal surgeries, and larger pelvic dimensions. Abdominal obesity is a significant risk factor in the treatment of endometrial cancer. Laparotomy continues to be utilized frequently in the management of endometrial cancer in Poland as well as elsewhere, and adopting a minimally invasive approach is likely to be beneficial for patient outcome.
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Affiliation(s)
- Sławomir M. Januszek
- Department of Gynecology and Obstetrics, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland; (B.W.-P.); (M.J.); (T.Z.); (T.K.)
| | - Barbara Wita-Popow
- Department of Gynecology and Obstetrics, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland; (B.W.-P.); (M.J.); (T.Z.); (T.K.)
| | - Marta Kluz
- Department of Pathology, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland;
| | - Magdalena Janowska
- Department of Gynecology and Obstetrics, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland; (B.W.-P.); (M.J.); (T.Z.); (T.K.)
| | - Rafał Januszek
- Department of Clinical Rehabilitation, University of Physical Education, 31-571 Kraków, Poland;
| | - Andrzej Wróbel
- Second Department of Gynecology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland;
| | - Artur Rogowski
- Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszyński University in Warsaw, 01-938 Warsaw, Poland;
- Department of Obstetrics and Gynecology, Mother and Child Institute, 01-211 Warsaw, Poland
| | - Krzysztof P. Malinowski
- Faculty of Health Sciences, A Institute of Public Health, Jagiellonian University Medical College, 31126 Kraków, Poland;
| | - Tomasz Zuzak
- Department of Gynecology and Obstetrics, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland; (B.W.-P.); (M.J.); (T.Z.); (T.K.)
| | - Tomasz Kluz
- Department of Gynecology and Obstetrics, Fryderyk Chopin University Hospital No. 1, 35-055 Rzeszów, Poland; (B.W.-P.); (M.J.); (T.Z.); (T.K.)
- Department of Gynecology and Obstetrics, Institute of Medical Sciences, Medical College of Rzeszow University, 35-310 Rzeszów, Poland
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14
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Gracia Segovia M, Coronado Martín P, Herraiz M. Cirugía ginecológica en la paciente obesa. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Kiesel L, Eichbaum C, Baumeier A, Eichbaum M. Obesity Epidemic-The Underestimated Risk of Endometrial Cancer. Cancers (Basel) 2020; 12:E3860. [PMID: 33371216 PMCID: PMC7767192 DOI: 10.3390/cancers12123860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer (EC) is the most frequently observed malignant gynecologic disease in developed countries. There is a strong association between the established risk factor obesity and the incidence of EC. Furthermore, the rate of women with a body mass index (BMI) > 30 kg/m2 is increasing worldwide, correspondingly leading to a higher prevalence of EC. Understanding the adipose tissue as an endocrine organ, elementary pathophysiological pathways of tumorigenesis have been revealed. This includes the fundamental role of hyperglycemia, insulin resistance, and hyperestrogenemia, as well as interactions with a chronic proinflammatory microenvironment. Therapeutic options potentially include metformin or bariatric surgery. Moreover, changes in individual lifestyle such as weight reduction, physical activity, and an awareness of healthy nutrition are effective in preventing the disease.
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Affiliation(s)
- Ludwig Kiesel
- Department of Gynecology and Obstetrics, University of Münster Medical School, Albert-Schweitzer-Campus 1, 48149 Münster, Germany;
| | - Christine Eichbaum
- Department of Gynecology and Obstetrics, University of Frankfurt Medical School, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany;
| | - Ariane Baumeier
- Department of Gynecology and Obstetrics, University of Münster Medical School, Albert-Schweitzer-Campus 1, 48149 Münster, Germany;
| | - Michael Eichbaum
- Department of Gynecology and Obstetrics, Helios Dr. Horst-Schmidt-Kliniken Wiesbaden, Ludwig-Erhard-Str. 100, 65199 Wiesbaden, Germany
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Kakkos A, Ver Eecke C, Ongaro S, Traen K, Peeters F, Van Trappen P, Laenen A, Despierre E, Van Nieuwenhuysen E, Vergote I, Goffin F. Robot-assisted surgery for women with endometrial cancer: Surgical and oncologic outcomes within a Belgium gynaecological oncology group cohort. Eur J Surg Oncol 2020; 47:1117-1123. [PMID: 33268212 DOI: 10.1016/j.ejso.2020.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate surgical and oncologic outcomes of patients treated by robot-assisted surgery for endometrial cancer within the Belgium Gynaecological Oncology Group (BGOG). STUDY DESIGN We performed a retrospective analysis of women with clinically Stage I endometrial cancer who underwent surgical treatment from 2007 to 2018 in five institutions of the BGOG group. RESULTS A total of 598 consecutive women were identified. The rate of conversion to laparotomy was low (0.8%). The mean postoperative Complication Common Comprehensive Index (CCI) score was 3.4. The rate of perioperative complications did not differ between age groups, however the disease-free survival was significantly lower in patients over 75 years compared to patients under 65 years of age (p=0.008). Per-operative complications, conversion to laparotomy rate, post-operative hospital stay, CCI score and disease-free survival were not impacted by increasing BMI. CONCLUSION Robot-assisted surgery for the surgical treatment of patients suffering from early-stage endometrial cancer is associated with favourable surgical and oncologic outcomes, particularly for unfavourable groups such as elderly and obese women, thus permitting a low morbidity minimally-invasive surgical approach for the majority of patients in expert centres.
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Affiliation(s)
- A Kakkos
- Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Liège, Site Notre Dame des Bruyères et Centre Hospitalier Régional, Liège, Belgium.
| | - C Ver Eecke
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Leuven Cancer Institute, Catholic University of Leuven, Leuven, Belgium
| | - S Ongaro
- Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Liège, Site Notre Dame des Bruyères et Centre Hospitalier Régional, Liège, Belgium
| | - K Traen
- Department of Obstetrics and Gynaecology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - F Peeters
- Department of Obstetrics and Gynaecology, General Hospital Klina, Brasschaat, Belgium
| | - Ph Van Trappen
- Department of Obstetrics and Gynaecology, General Hospital Sint-Jan, Bruges, Belgium
| | - A Laenen
- Department of Biostatistics and Methodology, Catholic University of Leuven, Leuven, Belgium
| | - E Despierre
- Department of Obstetrics and Gynaecology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - E Van Nieuwenhuysen
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Leuven Cancer Institute, Catholic University of Leuven, Leuven, Belgium
| | - I Vergote
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Leuven Cancer Institute, Catholic University of Leuven, Leuven, Belgium
| | - F Goffin
- Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire de Liège, Site Notre Dame des Bruyères et Centre Hospitalier Régional, Liège, Belgium
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Harrison R, Iniesta MD, Pitcher B, Ramirez PT, Cain K, Siverand AM, Mena G, Lasala J, Meyer LA. Enhanced recovery for obese patients undergoing gynecologic cancer surgery. Int J Gynecol Cancer 2020; 30:1595-1602. [PMID: 32848023 DOI: 10.1136/ijgc-2020-001663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery. METHODS We performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance. RESULTS After matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48-66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, p<0.001) and greater median estimated blood loss (300 mL vs 200 mL, p<0.001). Median (IQR) post-operative length of stay was the same for obese and non-obese patients: 3 days (IQR 2-4). Obese and non-obese patients had similar rates of grade III-IV complications (10.9% and 6.6%, respectively, p=0.06), re-operation (2.3% and 1.4%, respectively, p=0.58), and re-admission (11.8% and 8.0%, respectively, p=0.13). Grade I-II complications were more common among obese patients (62.4% vs 48.3%, p<0.001) because they had more wound complications (17.8% vs 4.9%, p<0.001). Obese patients received more opioids both during surgery (morphine equivalent dose 57.25 mg (IQR 35-72.5) vs 50 mg (IQR 25-622.5), p=0.003) and after surgery (morphine equivalent daily dose 45 mg/day (IQR 10-96.2) vs 29.37 mg/day (IQR 7.5-70), p=0.01). Obese and non-obese patients had similar ERAS program compliance (70.1% and 69.8%, respectively, p=0.32). CONCLUSIONS Neither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.
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Affiliation(s)
- Ross Harrison
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandelyn Pitcher
- Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Clinical Pharmacy Services, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ashley M Siverand
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Simpson AN, Sutradhar R, Ferguson SE, Robertson D, Cheng SY, Li Q, Baxter NN. Perioperative outcomes of women with and without class III obesity undergoing hysterectomy for endometrioid endometrial cancer: A population-based study. Gynecol Oncol 2020; 158:681-688. [PMID: 32571681 DOI: 10.1016/j.ygyno.2020.06.480] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/04/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Population-based data on perioperative complications among women with endometrial cancer and severe obesity are lacking. We evaluated 30-day complication rates among women with and without class III obesity (body mass index ≥ 40 kg/m2) undergoing primary surgical management for endometrioid endometrial cancer (EEC), and how outcomes differed according to surgical approach (open vs. minimally invasive). METHODS We performed a retrospective population-based cohort study of women with EEC undergoing hysterectomy in Ontario, Canada, between 2006 and 2015. We evaluated perioperative complications in the whole cohort, and in a 1:1 matched analysis using hard and propensity score matching to ensure similar distributions of patient, tumour, provider and institution-level factors between women with and without class III obesity (identified using a surgical billing code). The primary outcome of interest was the 30-day perioperative complication rate. RESULTS 12,112 women met inclusion criteria; 2697 (22.3%) had class III obesity. We matched 2320 (86%) women with class III obesity to those without. The composite complication rate was significantly higher among women with class III obesity (23.2% vs. 18.4%, standardized mean difference [SMD] = 0.12), primarily due to wound infection/disruption (12.1% vs. 6.2%). There was no difference in outcomes for women with and without class III obesity when a minimally invasive approach was used. CONCLUSIONS Wound infection/disruption was increased for women with class III obesity compared to women without. Otherwise, perioperative complications were similar between the matched pairs. When minimally invasive approaches were used, women with class III obesity had a similar risk of complications as women without obesity.
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Affiliation(s)
- A N Simpson
- Department of Obstetrics and Gynecology, St. Michael's Hospital/Unity Health Toronto, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital/Unity Health Toronto, Toronto, ON, Canada.
| | - R Sutradhar
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - S E Ferguson
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, University Health Network/Mount Health Systems, Toronto, ON, Canada
| | - D Robertson
- Department of Obstetrics and Gynecology, St. Michael's Hospital/Unity Health Toronto, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Q Li
- ICES, Toronto, ON, Canada
| | - N N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Gambacorti-Passerini ZM, López-De la Manzanara Cano C, Pérez Parra C, Cespedes Casas MC, Sánchez Hipólito L, Martín Francisco C, Muñoz-Rodríguez JR. Obesity in Patients with Endometrial Cancer: May It Affect the Surgical Outcomes of Laparoscopic Approach? Obes Surg 2020; 29:3285-3290. [PMID: 31250386 DOI: 10.1007/s11695-019-03986-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the impact of obesity on surgical outcomes for women with endometrial cancer (EC) managed by laparoscopic surgery. Minimal invasive surgery has been incorporated in the surgical management of EC, improving perioperative outcomes. However, this approach may become more challenging in case of obesity. So it is important to accurately evaluate and establish the most appropriate surgical approach for these patients. MATERIALS AND METHODS From January 2008 through April 2016, we conducted a prospective observational study, including all consecutive patients with a histological diagnosis of EC undergoing surgical staging by laparoscopy at our institution. Patients were classified in two groups (obese vs non-obese) according to their body mass index. Information about short- and long-term outcomes were recorded and analyzed during an outpatient follow-up. RESULTS Between January 2008 and April 2016, 83 women underwent laparoscopic surgery for EC at our institution. Forty-six (56.6%) of them were classified as obese. Surgical outcomes were similar in both groups. No significant difference was reported in surgical time, number of lymph nodes removed, blood loss, length of hospital stay, and incidence of intra- or postoperative complications. Also, long-term outcomes did not show any statistical significant difference: recurrence rate was 6.4% (3/47) among obese patients and 13.9% (5/36) among non-obese (p = 0.251). No difference was reported even in time to recurrence (log-rank p = 0.280) and in survival time (log-tank p = 0.132) between the two groups. CONCLUSIONS Our results show that obesity did not impair the outcomes of laparoscopic surgery for EC. This surgical approach may be offered to obese patients with the same level of safety, radicality, and efficiency as for the normal-weight population.
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Affiliation(s)
- Z M Gambacorti-Passerini
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain.
| | - C López-De la Manzanara Cano
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain.,University of Castilla-La Mancha, Ciudad Real, Spain
| | - C Pérez Parra
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain.,Department of Obstetrics and Gynecology, Albacete University Hospital, Albacete, Spain
| | - M C Cespedes Casas
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain
| | - L Sánchez Hipólito
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain
| | - C Martín Francisco
- Department of Obstetrics and Gynecology, Ciudad Real University General Hospital, Calle del Obispo Rafael Torija, s/n, 13005, Ciudad Real, Spain
| | - J R Muñoz-Rodríguez
- Translational Research Unit, Ciudad Real University General Hospital, Ciudad Real, Spain
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Behbehani S, Suarez-Salvador E, Buras M, Magtibay P, Magrina J. Mortality Rates in Benign Laparoscopic and Robotic Gynecologic Surgery: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 27:603-612.e1. [DOI: 10.1016/j.jmig.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/27/2019] [Accepted: 10/08/2019] [Indexed: 11/17/2022]
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Mortality Rates in Laparoscopic and Robotic Gynecologic Oncology Surgery: A Systemic Review and Meta-analysis. J Minim Invasive Gynecol 2019; 26:1253-1267.e4. [DOI: 10.1016/j.jmig.2019.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/07/2019] [Accepted: 06/10/2019] [Indexed: 11/18/2022]
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Cusimano MC, Simpson AN, Dossa F, Liani V, Kaur Y, Acuna SA, Robertson D, Satkunaratnam A, Bernardini MQ, Ferguson SE, Baxter NN. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications. Am J Obstet Gynecol 2019; 221:410-428.e19. [PMID: 31082383 DOI: 10.1016/j.ajog.2019.05.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE DATA Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2). STUDY We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2) who underwent primary hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies. RESULTS We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m2). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m2, and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m2. Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms. CONCLUSION Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.
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Affiliation(s)
- Maria C Cusimano
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea N Simpson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics & Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Valentina Liani
- Faculty of Medicine and Surgery, University of Trieste, Trieste TS Italy
| | - Yuvreet Kaur
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Deborah Robertson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics & Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Abheha Satkunaratnam
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics & Gynecology, North York General Hospital, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Department of Surgery, Toronto, Ontario, Canada; Division of General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.
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Armfield NR, Janda M, Obermair A. Obesity in total laparoscopic hysterectomy for early stage endometrial cancer: health gain and inpatient resource use. Int J Qual Health Care 2019; 31:283-288. [PMID: 30060080 DOI: 10.1093/intqhc/mzy162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/22/2018] [Accepted: 07/20/2018] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To explore relationships between BMI (morbid/severe obesity; BMI ≥ 35 kg/m2 vs. non morbid/severe obesity; BMI < 35 kg/m2), postoperative health gain and hospital resource use for women who receive a Total Laparoscopic Hysterectomy (TLH) for early stage endometrial cancer. DESIGN Secondary analysis of RCT data (LACE Study; Total Abdominal Hysterectomy vs. TLH). SETTING 20 tertiary gynaecological cancer centres in Australia, New Zealand and Hong Kong. POPULATION About 404 women who received TLH to treat early stage endometrial cancer. METHODS For women with BMI < 35 vs. BMI ≥ 35 kg/m2, we compared (i) postoperative health gain, using utility scores derived from responses to the EQ-5D-3L health-related quality of life instrument, and (ii) inpatient hospital resource use, using adverse events, surgery duration and postoperative length of stay as indicators, to 6 months post-surgery. MAIN OUTCOME MEASURES Health gain, resource use. RESULTS Mean postoperative health gain was 0.07 units, and did not vary by BMI. Women with a BMI ≥ 35 had an increased rate of severe postoperative AEs (BMI ≥ 35 RR = 1.95, P = 0.02), and the surgery took on average 9.6 min longer (BMI < 35 kg/m2 122.5 min 95% CI 117.4-127.8; BMI ≥ 35 kg/m2 132.1 min 95% CI 126.3-138.2; P = 0.02). CONCLUSION While postoperative health gain for women with BMI ≥ 35 was similar to that of women with lower BMI, the gain was achieved at the expense of greater resource use. Further work could definitively quantify the excess cost of TLH for obese patients with endometrial cancer, and investigate the potential for non-surgical treatment options, at least for those women at high risk of postoperative AEs.
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Affiliation(s)
- N R Armfield
- Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - M Janda
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - A Obermair
- Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Centre for Gynaecological Cancer, Brisbane, Queensland, Australia
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Cusimano MC, Simpson AN, Han A, Hayeems R, Bernardini MQ, Robertson D, Kives SL, Satkunaratnam A, Baxter NN, Ferguson SE. Barriers to care for women with low-grade endometrial cancer and morbid obesity: a qualitative study. BMJ Open 2019; 9:e026872. [PMID: 31248922 PMCID: PMC6597640 DOI: 10.1136/bmjopen-2018-026872] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Obesity is a major risk factor for low-grade endometrial cancer. The surgical management of patients with obesity is challenging, and they may face unique barriers to accessing care. We completed a qualitative study to understand the experiences of low-grade endometrial cancer patients with morbid obesity, from symptom onset to diagnosis to surgery. DESIGN Semi-structured interviews were performed with endometrial cancer patients with morbid obesity (body mass index (BMI) >40 kg/m2) referred for primary surgery. Transcribed interviews were coded line-by-line and analysed using an interpretive descriptive approach that drew on labelling theory to understand patients' experiences. Thematic sufficiency was confirmed after 15 interviews. SETTING Two tertiary care centres in Toronto, Ontario, Canada. PARTICIPANTS Fifteen endometrial cancer patients with a median age of 61 years (range: 50-74) and a median BMI of 50 kg/m2 (range: 44-70) were interviewed. RESULTS Thematic analysis identified that (1) both patients and providers lack knowledge on endometrial cancer and its presenting symptoms and risk factors; (2) patients with morbid obesity are subject to stigma and poor communication in the healthcare system and (3, 4) although clinical, administrative, financial, geographic and facility-related barriers exist, quality care for patients with morbid obesity is an achievable goal. CONCLUSIONS Improved education on the prevention and identification of endometrial cancer is needed for both patients and providers. Delivery of cancer care to patients with morbid obesity may be improved through provider awareness of the impact of weight stigma and establishing streamlined care pathways at centres equipped to manage surgical complexity.
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Affiliation(s)
- Maria C Cusimano
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Andrea N Simpson
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Angela Han
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Robin Hayeems
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Gynaecology Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Deborah Robertson
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sari L Kives
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sarah E Ferguson
- Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Gynaecology Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Harrison RF, Mcnamara JE, Beaumont CB, Sadowski EA, Chappell RJ, Shahzad MM, Spencer RJ, Al-Niaimi AN, Barroilhet LM, Rose SL, Kushner DM. Using simple radiologic measurements to anticipate surgical challenge in endometrial cancer: a prospective study. Int J Gynecol Cancer 2019; 29:102-107. [DOI: 10.1136/ijgc-2018-000037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/27/2018] [Accepted: 09/13/2018] [Indexed: 11/04/2022] Open
Abstract
ObjectivesTo determine if linear measurements of adiposity from pre-operative imaging can improve anticipation of surgical difficulty among endometrial cancer patients.MethodsEighty patients with newly diagnosed endometrial cancer were enrolled. Routine pre-operative imaging (MRI or CT) was performed. Radiologic linear measurements of the following were obtained: anterior-to-posterior skin distance; anterior skin to anterior edge of L5 distance (total anterior); anterior peritoneum to anterior edge of L5 distance (visceral obesity); and posterior edge of L5 to posterior skin distance (total posterior). Surgeons completed questionnaires quantifying preoperative anticipated operative difficulty and postoperative reported operative difficulty. The primary objective was to assess for a correlation between linear measurements of visceral fat and reported operative difficulty.ResultsSeventy-nine patients had questionnaires completed, preoperative imaging obtained, and surgery performed. Univariate analysis showed all four linear measurements, body mass index, weight, and anticipated operative difficulty were associated with increased reported operative difficulty (P< 0.05). Multivariate analysis demonstrated that body mass index and linear measurements visceral obesity and total posterior were independently associated with increased reported operative difficulty (P< 0.05). Compared with body mass index, the visceral obesity measurement was more sensitive and specific for predicting increased reported operative difficulty (visceral obesity; sensitivity 54%, specificity 91 %; body mass index; sensitivity 38%, specificity 89%). A difficulty risk model combining body mass index, visceral obesity, and total posterior demonstrated better predictive performance than any individual preoperative variable.ConclusionsSimple linear measurements of visceral fat obtained from preoperative imaging are more predictive than body mass index alone in anticipating surgeon-reported operative difficulty. These easily obtained measurements may assist in preoperative decision making in this challenging patient population.
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Sarcopenia and Skeletal Muscle Quality as Predictors of Postoperative Complication and Early Mortality in Gynecologic Cancer. Int J Gynecol Cancer 2018; 28:412-420. [DOI: 10.1097/igc.0000000000001157] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Beck TL, Schiff MA, Goff BA, Urban RR. Robotic, Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer. J Minim Invasive Gynecol 2018; 25:986-993. [PMID: 29360514 DOI: 10.1016/j.jmig.2018.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVES To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013. DESIGN Population-based retrospective cohort study (Canadian Task Force classification II-2). SETTING Washington State. PATIENTS EC patients treated with robotic-assisted surgery (RAS), laparoscopy (LS), or laparotomy (XLAP). INTERVENTIONS Comprehensive Hospital Abstract Reporting System to identify patients and assess the association of surgical approach with length of stay, readmissions, and perioperative complications. MEASUREMENTS AND RESULTS We identified 3712 cases of EC managed with either RAS, LS, or XLAP. Mean length of stay was not clinically different for RAS (1.5 days) and LS (1.6 days) but was 2.31 days longer for XLAP compared with LS (p < .001). Odds of any readmission did not differ for either RAS or XLAP compared with LS; however, early readmissions were half as likely for RAS compared with LS (p = .014). Complications were more than 2.5 times as likely for XLAP versus LS (p < .001), whereas complications did not differ for RAS versus LS (p = .931). CONCLUSIONS RAS is as an alternative to LS in the treatment of EC and is preferable to XLAP. The use of RAS resulted in fewer early readmissions compared with LS and resulted in an increased proportion of cases via minimally invasive surgery.
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Affiliation(s)
- Tiffany L Beck
- Department of Obstetrics and Gynecology, Gynecologic Oncology Division, University of Washington, Seattle, Washington.
| | - Melissa A Schiff
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Barbara A Goff
- Department of Obstetrics and Gynecology, Gynecologic Oncology Division, University of Washington, Seattle, Washington
| | - Renata R Urban
- Department of Obstetrics and Gynecology, Gynecologic Oncology Division, University of Washington, Seattle, Washington
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Gali B, Bakkum-Gamez JN, Plevak DJ, Schroeder D, Wilson TO, Jankowski CJ. Perioperative Outcomes of Robotic-Assisted Hysterectomy Compared With Open Hysterectomy. Anesth Analg 2018; 126:127-133. [PMID: 28430689 DOI: 10.1213/ane.0000000000001935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increasing numbers of robotic hysterectomies (RH) are being performed. To provide ventilation (with pneumoperitoneum and steep Trendelenburg position) for these procedures, utilization of lung protective strategies with limiting airway pressures and tidal volumes is difficult. Little is known about the effects of intraoperative mechanical ventilation and high peak airway pressures on perioperative complications. We performed a retrospective review to determine whether patients undergoing RH had increased pulmonary complications compared to total abdominal hysterectomy (TAH). METHODS We performed a single center retrospective review comparing the intraoperative, anesthetic, and immediate and 30-day postoperative course of patients undergoing RH to TAH, including intraoperative ventilatory parameters and respiratory complications. Patients undergoing TAH (201) from 2004 to 2006 were compared to RH (251) from 2009 to 2012. It was our hypothesis that patients undergoing RH would have increased incidence of postoperative pulmonary complications. A secondary hypothesis was that morbid obesity predicts pulmonary complications in patients undergoing RH. Complications were compared between groups using Fisher's exact test. To account for potential confounders, the primary analysis was performed for a subgroup of patients matched on the propensity for RH. RESULTS A total of 351 RH and 201 TAH procedures are included. Higher inspiratory pressures were required in ventilation of the RH group (median [25th, 75th] 31 [26, 36] cm H2O) than the TAH group (23 [19, 27] cm H2O) (P < .001) at 30 minutes after incision. Peak inspiratory pressures at 30 minutes after incision for RH increased according to increasing body mass index group (P < .001). There were 163 RH and 163 TAH procedures included in the propensity matched analysis. From this analysis, there were no significant differences in cardiopulmonary complications between RH and TAH (0.6% vs 1.2%; odds ratio = 2.0, 95% confidence interval = 0.2-2.4; P = 1.00). Surgical site infection was significantly lower in the RH compared to TAH group (0.6% vs 8.6%; P < .001). Hospital length of stay was longer for those who underwent TAH versus RH (median [25th, 75th] 2 [2, 3] vs 1 [0, 2] days; P < .001). CONCLUSIONS There was no significant difference in perioperative complications in obese and morbidly obese women compared to nonobese undergoing RH. Patients undergoing RH had shorter hospital stays, fewer infectious complications, and no increase in overall complications compared to TAH. Higher ventilatory airway pressures (RH versus TAH and obese versus nonobese) did not result in an increase in cardiopulmonary or overall complications. We believe that peritoneal insufflation attenuates the effect of high airway pressures by raising intrapleural pressure and reducing the gradient across terminal bronchioles and alveoli. Thus, we propose that lung protective strategies for patients undergoing RH account for the markedly elevated intraperitoneal and intrapleural pressures, whereas transpulmonary airway pressures remain static. This reduced transpulmonary gradient attenuates the strain on lung tissue that would otherwise be imposed by ventilation at high pressures.
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Affiliation(s)
| | | | | | - Darrell Schroeder
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
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Lee YC, Lheureux S, Oza AM. Treatment strategies for endometrial cancer: current practice and perspective. Curr Opin Obstet Gynecol 2017; 29:47-58. [PMID: 27941361 DOI: 10.1097/gco.0000000000000338] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Endometrial cancer incidence is increasing in North America and is a major cause of morbidity and mortality in women. We review recent literature published on treatment of endometrial cancer and highlight areas of active interest. RECENT FINDINGS There has been movement toward minimal invasive surgery at diagnosis; lymph node staging remains controversial and continues to be investigated. Progress has been made to establish consensus on endometrial cancer risk classification to promote consistency for future trial design. Molecular characterization of endometrial cancer and its integration into clinicopathological profiling to develop predictive biomarkers for treatment selection are active areas of research. Optimal adjuvant treatment strategy in high-risk endometrial cancer remains to be defined with recognition of treatment-related toxicity. Despite encouraging results in drug development for treatment of advanced/recurrent endometrial cancer, no targeted therapies beyond hormonal therapy are approved. There is an urgent need for scientifically validated therapy with predictive biomarkers. SUMMARY Our understanding of endometrial cancer has evolved through improvements in molecular biology, allowing improved definition of target-specific therapies. The precise role and sequence of conventional and targeted therapies, including immunotherapy, will require careful attention to the design of clinical trials with translational emphasis to allow the discovery, validation, and implementation of predictive biomarkers into clinical care.
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Affiliation(s)
- Yeh C Lee
- Drug Development Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Shim SH, Lee SJ, Dong M, Suh JH, Kim SY, Lee JH, Kim SN, Kang SB, Kim J. Prediction model for 30-day morbidity after gynecological malignancy surgery. PLoS One 2017; 12:e0178610. [PMID: 28570652 PMCID: PMC5453555 DOI: 10.1371/journal.pone.0178610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 05/16/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The potential risk of postoperative morbidity is important for gynecologic cancer patients because it leads to delays in adjunctive therapy and additional costs. We aimed to develop a preoperative nomogram to predict 30-day morbidity after gynecological cancer surgery. METHODS Between 2005 and 2015, 533 consecutive patients with elective gynecological cancer surgery in our center were reviewed. Of those patients, 373 and 160 patients were assigned to the model development or validation cohort, respectively. To investigate independent predictors of 30-day morbidity, a multivariate Cox regression model with backward stepwise elimination was utilized. A nomogram based on this Cox model was developed and externally validated. Its performance was assessed using the concordance index and a calibration curve. RESULTS Ninety-seven (18.2%) patients had at least one postoperative complication within 30 days after surgery. After bootstrap resampling, the final model indicated age, operating time, and serum albumin level as statistically significant predictors of postoperative morbidity. The bootstrap-corrected concordance index of the nomogram incorporating these three predictors was 0.656 (95% CI, 0.608-0.723). In the validation cohort, the nomogram showed fair discrimination [concordance index: 0.674 (95% CI = 0.619-0.732] and good calibration (P = 0.614; Hosmer-Lemeshow test). CONCLUSION The 30-day morbidity after gynecologic cancer surgery could be predicted according to age, operation time, and serum albumin level. After further validation using an independent dataset, the constructed nomogram could be valuable for predicting operative risk in individual patients.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
- * E-mail:
| | - Meari Dong
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Jung Hwa Suh
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Seo Yeon Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Ji Hye Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Soo-Nyung Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Jayoun Kim
- Research Coordinating Center, Konkuk University Medical Center, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
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Machado KK, Fader AN. Approaches to Morbidly Obese Women with Gynecologic Cancer. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0181-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dong JQ, Zhang H, Jiang XF, Wang SZ, Du ZQ, Wang ZP, Leng L, Cao ZP, Li YM, Luan P, Li H. Comparison of serum biochemical parameters between two broiler chicken lines divergently selected for abdominal fat content. J Anim Sci 2016; 93:3278-86. [PMID: 26439996 DOI: 10.2527/jas.2015-8871] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In humans, obesity is associated with increased or decreased levels of serum biochemical indicators. However, the relationship is not as well understood in chickens. Due to long-term intense selection for fast growth rate, modern broilers have the problem of excessive fat deposition, exhibiting biochemical or metabolic changes. In the current study, the Northeast Agricultural University broiler lines divergently selected for abdominal fat content (NEAUHLF) were used to identify differences in serum biochemical parameters between the 2 lines. A total of 18 serum biochemical indicators were investigated in the 16th, 17th, and 18th generation populations of NEAUHLF, and the genetic parameters of these serum biochemical indicators were estimated. After analyzing the data from these 3 generations together, the results showed that the levels of 16 of the tested serum biochemical parameters were significantly different between the lean and fat birds. In the fat birds, serum concentrations of high-density lipoprotein cholesterol (HDL-C), HDL-C:low-density lipoprotein cholesterol (LDL-C), total bile acid, total protein, albumin, globulin, aspartate transaminase (AST):alanine transaminase (ALT), γ-glutamyl transpeptidase (GGT), uric acid, and creatinine were very significantly higher (P < 0.01), whereas LDL-C, albumin:globulin, glucose, AST, ALT, and free fatty acids concentrations in serum were very significantly lower than those in the lean birds (P < 0.01). Of these 16 serum biochemical parameters, 5 (LDL-C, HDL-C:LDL-C, total bile acid, albumin, and albumin:globulin) had high heritabilities (0.58 ≤ h2 ≤ 0.89), 6 (HDL-C, total protein, globulin, AST:ALT, GGT, and creatinine) had moderate heritabilities (0.29 ≤ h2 ≤ 0.48), and the remaining 5 had low heritabilities (h2 < 0.20). Serum HDL-C, HDL-C:LDL-C, and glucose had higher positive genetic correlation coefficients (rg) with abdominal fat traits (0.30 ≤ rg ≤ 0.80), whereas serum globulin, AST, and uric acid showed higher negative genetic correlations with abdominal fat traits (–0.62 ≤ rg ≤ –0.30). The remaining 10 serum biochemical parameters had lower genetic correlations with abdominal fat traits (–0.30 < rg < 0.30). In conclusion, we identified serum HDL-C and HDL-C:LDL-C levels as potential biomarkers for selection of lean birds. These findings will also be useful in future studies for investigating obesity and lipid metabolism in humans as well as in other animal species.
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Shimada YJ, Tsugawa Y, Brown DFM, Hasegawa K. Bariatric Surgery and Emergency Department Visits and Hospitalizations for Heart Failure Exacerbation: Population-Based, Self-Controlled Series. J Am Coll Cardiol 2016; 67:895-903. [PMID: 26916477 DOI: 10.1016/j.jacc.2015.12.016] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/01/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The United States is battling obesity and heart failure (HF) epidemics. Although studies have suggested relationships between obesity and HF morbidity, little is known regarding the effects of substantial weight reduction in obese patients with HF. OBJECTIVES This study investigated whether bariatric surgery is associated with a decreased rate of HF exacerbation. METHODS We performed a self-controlled case series study of obese patients with HF who underwent bariatric surgery, using the population-based emergency department (ED) and inpatient sample in California, Florida, and Nebraska. Primary outcome was ED visit or hospitalization for HF exacerbation from 2005 to 2011. We used conditional logistic regression to compare the outcome event rate during sequential 12-month periods, using pre-surgery months 13 to 24 as the reference period. RESULTS We identified 524 patients with HF who underwent bariatric surgery. During the reference period, 16.2% of patients had an ED visit or hospitalization for HF exacerbation. The rate remained unchanged in the subsequent 12-month pre-surgery period (15.3%; p = 0.67). In the first 12-month period after bariatric surgery, we observed a nonsignificantly reduced rate (12.0%; p = 0.052). However, the rate was significantly lower in the subsequent 13 to 24 months after bariatric surgery (9.9%; adjusted odds ratio: 0.57; p = 0.003). By contrast, there was no significant reduction in the rate of HF exacerbation among obese patients who underwent nonbariatric surgery (i.e., cholecystectomy, hysterectomy). CONCLUSIONS Our findings indicate that bariatric surgery is associated with a decline in the rate of HF exacerbation requiring ED evaluation or hospitalization among obese patients with HF.
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Affiliation(s)
- Yuichi J Shimada
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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McAlpine JN, Temkin SM, Mackay HJ. Endometrial cancer: Not your grandmother's cancer. Cancer 2016; 122:2787-98. [DOI: 10.1002/cncr.30094] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Jessica N. McAlpine
- Department of Gynecology and Obstetrics, Division Gynecologic Oncology; University of British Columbia and British Columbia Cancer Agency; Vancouver British Columbia Canada
| | - Sarah M. Temkin
- Kelly Gynecologic Oncology Service, Johns Hopkins School of Medicine; Baltimore Maryland
| | - Helen J. Mackay
- Division of Medical Oncology and Hematology, Faculty of Medicine; University of Toronto, Sunnybrook Odette Cancer Center; Toronto Ontario Canada
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Smits A, Lopes A, Das N, Kumar A, Cliby W, Smits E, Bekkers R, Massuger L, Galaal K. Surgical morbidity and clinical outcomes in ovarian cancer - the role of obesity. BJOG 2016; 123:300-8. [PMID: 26331299 DOI: 10.1111/1471-0528.13585] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the effect of body mass index on the surgical outcomes in ovarian cancer patients. In addition, we performed a systematic review to compare our outcomes with the current literature. DESIGN Retrospective cohort study and a systematic review of the literature. SETTING Gynaecology department at the Royal Cornwall Hospital Trust. POPULATION Surgically managed stage I-IV ovarian cancer patients between September 2006 and September 2014. METHODS Primary and secondary outcome measures were evaluated across BMI categories; BMI <25 kg/m², BMI 25–29.9 kg/m², BMI ≥30 kg/m² and BMI ≥40 kg/m². A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. MAIN OUTCOME MEASURES The primary outcome measure was surgical complications. Secondary outcome measures were other intra- and postoperative outcomes. RESULTS Two hundred twenty-eight women were included in the study, of which 84 had a BMI <25 kg/m², 84 women had a BMI 25–29.9 kg/m², and 60 women were obese (BMI ≥30 kg/m²), 13 of whom were morbidly obese. Morbid obesity was associated with increased rates of wound complications. However, BMI did not show an association with other outcomes. In the review, an increasing BMI was associated with increased rates of wound complications and prolonged hospital stay, but did not impact other surgical outcomes. CONCLUSION Obesity is associated with increased rates of wound complications and a prolonged hospital stay, but does not appear to affect other operative outcomes including cytoreduction status and 30-day mortality. Therefore, operative management and postoperative care require a multifactorial approach to minimise adverse outcomes.
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Shafiee MN, Seedhouse C, Mongan N, Chapman C, Deen S, Abu J, Atiomo W. Up-regulation of genes involved in the insulin signalling pathway (IGF1, PTEN and IGFBP1) in the endometrium may link polycystic ovarian syndrome and endometrial cancer. Mol Cell Endocrinol 2016; 424:94-101. [PMID: 26802879 DOI: 10.1016/j.mce.2016.01.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/19/2016] [Accepted: 01/20/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Endometrial cancer (EC) is the most common gynaecological cancer amongst women in the UK. Although previous studies have found that women with polycystic ovary syndrome (PCOS) have at least a three-fold increase in endometrial cancer (EC) risk compared to women without PCOS, the precise molecular mechanisms which link between PCOS and EC remain unclear. It has been suggested that insulin resistance may contribute to the increased risk of EC in PCOS. The specific expression of genes related to the insulin-signalling pathway including the IGF system in the endometrium of women with PCOS has however never been measured and compared to that in women with EC without PCOS and control women without EC or PCOS. . OBJECTIVES To test the hypothesis that insulin signalling plays a key role in the development of EC in women with PCOS by measuring and comparing the expression of three key genes involved in the insulin signalling pathway (IGF1, PTEN and IGFBP1) in endometrial tissue obtained from three groups of women; PCOS without EC, women with EC without PCOS and non-PCOS women without EC (controls). We also aimed to determine the correlation between the gene expressions to various clinical variables among participants. METHODS This was a cross-sectional study of 102 women in 3 groups (PCOS, EC and controls) at a University teaching hospital in the United Kingdom. Clinical assessment (blood pressure, body mass index (BMI) and waist-hip-circumference ratio), venepuntures (fasting blood sugar, insulin, lipid profile, hormones) and endometrial tissue biopsies were taken in all participants. Endometrial tissue RNA extraction was performed before real time polymerase-chain-reaction for the genes of interest (IGF1, IGFBP1 and PTEN) was carried out. To compare the baseline characteristics of the study population, One-Way-ANOVA test or the Independent t-test was used. For variables that were not normally distributed, the Spearman correlation test was used to calculate the r value. A "p" value of <0.05 was considered statistically significant. RESULTS IGF1, IGFBP1 and PTEN gene expression were significantly up-regulated in the endometrium of PCOS and EC women compared to controls. However there was no significant difference in the expression of these genes in PCOS compared to EC endometrium. The BMI of women with PCOS and controls, were not significantly different (29.28 (± 2.91) vs 28.58 (± 2.62) kg/m(2)) respectively, women with EC however had a higher mean BMI (32.22 (± 5.70) kg/m(2)). PCOS women were younger (31.8 (± 5.97) years) than women with EC (63.44 (± 10.07) years) and controls (43.68 (± 13.12) years). The changes in gene expression were independent of BMI, waist hip ratio, estradiol and androgen levels. Protein validation test in the serum samples in the three groups were consistent with the gene findings. CONCLUSION Women with PCOS and EC have an increased endometrial expression of genes (IGF1, IGFBP1 and PTEN) involved in the insulin signalling pathway compared with control women. This may explain the increased risk of EC in PCOS women. This study provides a strong basis for clinical trials aiming to prevent EC in women with PCOS by investigating drugs targeting the insulin signalling pathway. This panel of genes may also serve as clinically useful early biomarkers which predict which women with PCOS will go on to develop EC.
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Affiliation(s)
- Mohamad Nasir Shafiee
- Division of Obstetrics and Gynaecology and Child Health, School of Medicine, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK; Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia, Faculty of Medicine, Cheras, Kuala Lumpur, 56000, Malaysia.
| | - Claire Seedhouse
- Department of Haematology, Clinical Sciences Building, University of Nottingham, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nigel Mongan
- School of Veterinary Medicine and Science, University of Nottingham, LE12 5RD, UK
| | - Caroline Chapman
- Division of Medical Sciences and Graduate Entry Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, NG5 1PB, UK
| | - Suha Deen
- Department of Pathology, Queen's Medical Centre, Nottingham University Hospital, Nottingham, NG7 2UH, UK
| | - Jafaru Abu
- Department of Obstetrics and Gynaecology, City Hospital, Nottingham University Hospital, Nottingham, NG5 1PB, UK
| | - William Atiomo
- Division of Obstetrics and Gynaecology and Child Health, School of Medicine, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
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Beck TL, Morse CB, Gray HJ, Goff BA, Urban RR, Liao JB. Route of hysterectomy and surgical outcomes from a statewide gynecologic oncology population: is there a role for vaginal hysterectomy? Am J Obstet Gynecol 2016; 214:348.e1-9. [PMID: 26470825 DOI: 10.1016/j.ajog.2015.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 09/20/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy (VH) as the preferred route for removal of the uterus. It is not known if advantages of VH for benign indications apply to women with gynecologic cancer. OBJECTIVE The goal of this study was to assess trends in surgical approach to hysterectomy among gynecologic cancer patients and to evaluate outcomes by approach. We hypothesized that, among gynecologic oncology patients, postoperative complications and hospital stay would differ by surgical approach, and that advantages of VH for benign indications may not apply to gynecologic cancer patients. STUDY DESIGN We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 through 2013 using the Comprehensive Hospital Abstract Reporting System. Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or VH. We determined rate of surgical approach by year and the association with length of stay, 30-day readmission rate, and perioperative complications. RESULTS We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2698 (26.7%) LH, and 7073 (69.9%) AH. Patients undergoing AH had more comorbidities than patients with VH or LH (Charlson Comorbidity Index ≥2: 11.3%, 7.9%, and 8.1%, respectively; P < .001). From 2004 through 2013 AH and VH declined (94.4-47.9% and 4.4-0.8%, respectively; P < .001) while LH increased from 1.2-51.4% in 2013 (P < .001). Mean length of stay was 4.6 days for women undergoing AH and was 1.9 days shorter for VH (95% confidence interval, 1.6-2.3 days) and 2.6 days shorter for LH (95% confidence interval, 2.4-2.7 days) (P < .001). Risk of 30-day readmission for patients undergoing LH was 40% less likely compared to AH but not different for VH vs AH. CONCLUSION AH and LH remain the preferred routes for hysterectomy in gynecologic oncology. Over the past decade, there has been a significant shift to LH with lower 30-day readmission and complication rates. There may be a limited role for VH in select patients. Current efforts to standardize the surgical approach to hysterectomy should not apply to patients with known or suspected gynecologic cancer.
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The Impact of Obesity on the 30-day Morbidity and Mortality After Surgery for Ovarian Cancer. Int J Gynecol Cancer 2016; 26:276-81. [DOI: 10.1097/igc.0000000000000619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Bouwman F, Smits A, Lopes A, Das N, Pollard A, Massuger L, Bekkers R, Galaal K. The impact of BMI on surgical complications and outcomes in endometrial cancer surgery--an institutional study and systematic review of the literature. Gynecol Oncol 2015; 139:369-76. [PMID: 26407479 DOI: 10.1016/j.ygyno.2015.09.020] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We aimed to evaluate the association between body mass index (BMI), perioperative complications and outcomes in endometrial cancer (EC) patients at our institution. In addition, we performed a systematic review to compare our results to the literature. METHODS This was a retrospective study of surgically managed EC patients between January 2006 and January 2015. Patient characteristics, surgical complications and intra- and postoperative outcomes were evaluated across BMI groups; BMI <30kg/m(2), BMI ≥30kg/m(2) and BMI ≥40kg/m(2). The systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS In total, we identified 627 women of which 514 were included; 249 women had a BMI of <30kg/m(2), 195 women had a BMI of 30-39.9kg/m(2), and 70 women were morbidly obese (BMI ≥40kg/m(2)). Obese women (BMI ≥30kg/m(2)) had significantly more postoperative surgical complications, including wound complications and antibiotics use, which was confirmed by the systematic review. The increase in complications mainly occurred in open surgery and morbidly obese patients were at highest risk. Obesity did not impact other outcomes including 30-day mortality. CONCLUSION Obesity is associated with an increased risk of surgical morbidity in EC patients, and is most profound in open surgery and among the morbidly obese. Laparoscopic surgery may well prevent the majority of postoperative complications in this group of patients, and should therefore be the favoured approach.
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Affiliation(s)
| | - Anke Smits
- Royal Cornwall Hospital Trust, Truro, Cornwall, United Kingdom
| | - Alberto Lopes
- Royal Cornwall Hospital Trust, Truro, Cornwall, United Kingdom
| | - Nagindra Das
- Royal Cornwall Hospital Trust, Truro, Cornwall, United Kingdom
| | - Adam Pollard
- European Centre for the Environment and Human Health, University of Exeter Medical School, Truro, Cornwall, United Kingdom
| | | | | | - Khadra Galaal
- Royal Cornwall Hospital Trust, Truro, Cornwall, United Kingdom.
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Benedetto C, Salvagno F, Canuto EM, Gennarelli G. Obesity and female malignancies. Best Pract Res Clin Obstet Gynaecol 2015; 29:528-40. [DOI: 10.1016/j.bpobgyn.2015.01.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 01/28/2015] [Indexed: 12/26/2022]
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