Impact of age-adjusted Charlson comorbidity score on outcomes for patients with early-stage endometrial cancer

Efficacy and Safety of Rivaroxaban for Extremely Aged Patients with Venous Thromboembolism: A Retrospective, Cross-Sectional Real-World Study

Background

Rivaroxaban, a non-vitamin K antagonist oral anticoagulant, has become widely used for the management of venous thromboembolism (VTE) in adult patients. However, few trials have explored the efficacy and safety of rivaroxaban in VTE patients over 80 years of age. This necessitates further real-world studies of rivaroxaban across elderly populations.

Methods

We performed a retrospective single center study involving extremely aged VTE sufferers treated with rivaroxaban. The sample comprised 121 patients newly initiated on rivaroxaban diagnosed between January 2018 and January 2020. Patients were followed up for no less than 2 years. The effectiveness outcome was the disappearance of thromboembolism. The safety outcome was the incidence of major bleeding events. Comorbidities and complications were recorded throughout the entire study.

Results

The efficacy outcome occurred in 114 of 121 patients (94.21%) and the safety outcome occurred in 12 of 121 patients (9.91%). Increased hemorrhages were observed in patients with infection (15.15% vs 7.80%), but no significant difference was observed due to limited sample size (P=0.3053). Patients with an age-adjusted Charlson comorbidity index score higher than 6 points exhibited higher bleeding rates (14.08% vs 4.00%; P=0.0676) and lower thrombus cure rates (88.73% vs 100%; P=0.0203).

Key conclusions

Patients with infection should be more careful of bleeding events during rivaroxaban therapy. An age-adjusted Charlson comorbidity index score higher than 6, which predicted poor survival, indicated inferior safety and efficacy of rivaroxaban.

Aim

To investigate the efficacy and safety of Rivaroxaban in an aged venous thromboembolism patient population under real-world conditions.

The role of L1CAM as predictor of poor prognosis in stage I endometrial cancer: a systematic review and meta-analysis

INTRODUCTION

Molecular and genomic profiling in endometrial cancer is increasing popularity. L1 cell adhesion molecule (L1CAM) is frequently mutated in endometrial cancer. In this paper, we aim to evaluate the prognostic role of L1CAM in patients with stage I endometrial cancer.

METHODS

We performed a systematic review and meta-analysis searching in PubMed (MEDLINE), EMBASE, and Web of Science database to identify studies reporting the expression of L1CAM in endometrial cancer. The primary endpoint measure was to assess and evaluate the impact of L1CAM on survival outcomes. This study was performed according to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement.

RESULTS

Five studies were included. The pooled results suggested that L1CAM expression influences survival outcomes in stage I endometrial cancer. High L1CAM expression correlated with worse disease-free survival (HR 4.11, 95% CI 1.02-16.59, p = 0.047) and overall survival (HR 3.62, 95% CI 1.32-9.31, p = 0.012). High L1CAM level was also associated with a more aggressive FIGO grade and with older age.

CONCLUSION

This systematic review supported that L1CAM have a prognostic role in stage I endometrial cancer, thus providing a potential useful tool for tailoring the need of adjuvant therapy.

Treatment outcomes of early-stage endometrial cancer patients: A propensity score matching of vaginal brachytherapy versus pelvic radiotherapy

OBJECTIVES

This study aimed to report the treatment outcomes of radiation therapy for early-stage endometrial cancer patients. In addition, this study intended to identify high-risk factors that require pelvic radiotherapy (PRT) in addition to vaginal brachytherapy (VBT) for intermediate-risk endometrial cancer patients.

METHODS

Patients with early-stage endometrial cancer receiving postoperative VBT alone or with PRT were included. Propensity score matching was used to balance the two study groups. The primary endpoint was locoregional recurrence (LRR). Age-adjusted Charlson comorbidity index and substantial lymphovascular space invasion were selected for subgroup analyses to identify the benefits of PRT over VBT alone.

RESULTS

From 2005 to 2017, a total of 288 patients underwent analysis following propensity score matching. Of these, 144 received VBT and 144 received PRT. There was no significant difference in 5-year LRR between VBT and PRT for both intermediate (0% vs. 0%) and high-intermediate risk patients (3.5% VBT vs. 5.4% PRT; HR 0.54: 0.05-6.00; p = 0.616). The subgroup analyses revealed no significant factors favoring PRT over VBT. Patients with high comorbidities may have higher risks of non-cancer death after receiving PRT.

CONCLUSIONS

Postoperative VBT alone is sufficient for early-stage intermediate-risk endometrial cancer patients.

Should laparoscopy be revisited in the management of stage II endometrial cancer in the post-LACC era?

BACKGROUND

A recent randomized trial showed that laparoscopy had poorer outcomes compared with open surgery for early-stage cervical cancer. Whether this is of concern in endometrial cancer, when the cervix is involved has received little attention. This study aimed to investigate whether there is any difference on overall and cancer specific survival between patients treated with laparoscopy and laparotomy for stage II endometrial cancer.

METHODS

Data from patients with histologically proven stage II endometrial cancer who were treated between 2010 and 2019 in a single cancer center were reviewed. Demographic, histopathological characteristics and treatment modalities were recorded. Recurrence rate, cancer specific and overall survival were compared between patients that were treated with laparoscopic and open surgery.

RESULTS

From 47 patients with stage II disease, 33 (70%) were treated with laparoscopy and 14 (30%) with open surgery. There was no difference on age (P=0.86), BMI (P=0.76), Comorbidity Index Score (P=0.96), upstaging/upgrading after surgery (P=0.41), performance of lymphadenectomy (P=0.74), histological type (P=0.32), LVSI (P=0.15), depth of myometrial invasion (P=0.07), postoperative hospital stay (P=0.18) and administration of adjuvant treatment (P=0.11) between the two groups. Recurrence rate (P=0.756), overall (P=0.606) and cancer specific survival (P=0.564) were also comparable between laparoscopy and laparotomy groups.

CONCLUSIONS

Laparoscopic and open surgery seem to have comparable outcomes for stage II endometrial cancer. The oncological safety of laparoscopy for stage II endometrial cancer should be further investigated with a randomized controlled trial.

An institutional study: Does Body Mass Index influence surgical approach, surgical morbidities, and outcomes in endometrial cancer patients?

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.

The Prognostic Value of the Age-Adjusted Charlson Comorbidity Index Among the Elderly with Breast Cancer

Purpose

This study aimed to assess the effect of comorbidities on prognosis using the Age-adjusted Charlson Comorbidity Index (ACCI) among the elderly with breast cancer (BC).

Methods

This study included 745 patients divided into two groups following the ACCI score (≤3 vs >3). Multivariate logistic regression analysis was conducted for all kinds of outcomes, including BC-specific death (BCSD) and non-breast cancer-specific death (NBCSD). The Kaplan-Meier curves were plotted, and survival analysis was conducted for disease-free survival (DFS), overall survival (OS), BC-specific survival (BCSS), and non-BCSS (NBCSS).

Results

A significantly higher NBCSD was found in the high-score (ACCI > 3) group than in the low-score (ACCI < 3) group (p = 0.032). The multivariate logistic regression analysis revealed ACCI score as an independent affecting factor for all-cause death (hazard ratio [HR] = 0.42, 95% confidence interval [CI]: 0.22-0.83, p = 0.012) and NBCSD (HR = 0.41, 95% CI: 0.20-0.87, p = 0.020). The Kaplan-Meier curves revealed statistical differences only in NBCSS between the two groups (p = 0.039). Subgroup analysis revealed a worse prognosis in the high-score group for OS and NBCSS among hormone receptor-positive participants and those who without undergoing axillary dissection or receiving chemotherapy (all p < 0.05). Multivariate Cox regression analysis revealed ACCI as an independent prognostic predictor for OS (HR = 2.18, 95% CI: 1.22-3.92, p = 0.009) and NBCSS (HR = 2.04, 95% CI: 1.02-4.08, p = 0.044).

Conclusion

ACCI was indeed an effective indicator of the effects of comorbidities on survival among elderly patients with BC. However, the co-effect from age and comorbidities was not significant enough on cancer-specific prognosis, although it exerted a significant effect on treatments received.

Cytokine Levels and Severity of Illness Scoring Systems to Predict Mortality in COVID-19 Infection

Various scoring systems and cytokines have been cited as predicting disease severity in COVID-19 infection. This study analyzed the link between mortality rate, levels of cytokines, and scoring systems such as the Glasgow Coma Scale (GCS), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Charlson Comorbidity Index in patients infected with COVID-19. Adult patients infected with COVID-19 were followed up in the intensive care unit (ICU) and analyzed prospectively. We measured serum cytokine levels (Interleukin-10 (IL-10), Interleukin-8 (IL-8), Interleukin-6 (IL-6), Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α) and High mobility group box 1 (HMGB-1)) and recorded GCS, APACHE II, SOFA, and Charlson comorbidity index scores on admission to the ICU. Receiver operating curve (ROC) analysis was performed to predict mortality from IL-1β, IL-6 IL-10, IL-8, TNF-α, and HMGB-1 values. Study participants were grouped as follows: Group A, survivors, and Group B, deceased, during the 28-day follow-up. The mean age was 65.69 (±13.56) in Group A (n = 36) and 70.85 (±10.06) in Group B (n = 27). The female/male ratio was 23/40. Age, sex, body mass index (BMI), comorbid illnesses, GCS, APACHE II, SOFA, and Charlson scores, duration of hospitalization or ICU admission, therapeutic choices, and lymphocyte, PMNL, NLR, platelet, D-dimer, fibrinogen, GGT, CRP, procalcitonin, and lactate levels were similar between the groups. The frequency of acute kidney injury (AKI) was higher in Group B (p = 0.005). Serum IL-10, IL-8, IL-6, IL-1β, TNF-α, HMGB-1, ferritin, and LDH values were higher, and PaO₂/FiO₂ was lower in Group B than in Group A. ROC analysis showed that there was an association between serum IL-1β (>1015.7), serum IL-6 (>116.7), serum IL-8 (>258.4), serum IL-10 (>247.5), serum TNF-α (>280.7), and serum HMGB-1 (>23.5) and mortality. AKI gave rise to a greater risk of mortality (odds ratio: 7.081, p = 0.014). Mortality was associated with serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1 but not with GCS, APACHE II, SOFA, or Charlson comorbidity index scores. AKI increased the risk of mortality by seven times. Our findings suggest that cytokine levels (serum IL-10, IL-8, IL-6, IL-1β, TNF-α, and HMGB-1) were predictors of mortality in COVID-19 infection. In addition, our results might give an opinion about the course of COVID-19 infection.

Survival prediction among pathologic T4 bladder cancer patients following cytoreductive cystectomy: A retrospective single-center study

Objectives

This retrospective study aimed to describe our institutional experience with cytoreductive cystectomy (Cx) in patients with pathological T4 (pT4) bladder cancer (BCa) and to investigate the clinicopathologic factors that can predict patient survival outcomes.

Methods

We reviewed the baseline demographics, clinicopathologic features, perioperative complications, and follow-up data of 44 patients who underwent Cx for pT4 BCa at our institution between 2013 and 2021. The Kaplan-Meier curve and the log-rank test were used to analyze progression-free survival (PFS) and overall survival (OS). Univariate and multivariate analyses were performed using the Cox regression model.

Results

The median age of the patients was 68 years [95% confidence interval (CI) 49-81]. Overall, 21 patients (47.7%) were estimated to have a high age-adjusted Charlson comorbidity index (ACCI) score (>4), and nine patients (20.5%) had pT4b substage BCa. None of the patients died of complications within 30-90 days after surgery. Severe complications occurred in 16% (n = 7) of patients within 30-90 days. During a median follow-up of 51 months, disease progression was detected in 25 patients (56.8%), and 29 patients (65.9%) died of any cause. The median PFS and OS were 15.0 and 21.0 months, respectively. The Kaplan-Meier analysis indicated that patients with high ACCI scores or pT4b BCa had worse PFS (P = 0.003 and P = 0.002, respectively) and OS (P = 0.016 and P = 0.034, respectively) than those with low ACCI scores or pT4a BCa. On multivariate analysis, pT4b substage [hazard ratio (HR), 4.166; 95% CI, 1.549-11.206; P = 0.005] and ACCI score >4 (HR, 2.329; 95% CI, 1.105-4.908; P = 0.026) remained independent risk factors for PFS and OS, respectively.

Conclusion

Our study revealed that the pT4b substage is associated with a poor prognosis and that the ACCI score is a relevant and practical method to evaluate survival outcomes in patients with pT4 BCa after Cx.

Effect of the Age-Adjusted Charlson Comorbidity Index on the Survival of Esophageal Squamous Cell Carcinoma Patients after Radical Esophagectomy

We aimed to investigate whether the age-adjusted Charlson comorbidity index (ACCI) can predict the postoperative overall survival (OS) and cancer-specific survival (CSS) of esophageal squamous cell carcinoma (ESCC) patients. Between 1 July 2015 and 31 July 2021, a retrospective cohort study was conducted among patients with primary ESCC who underwent radical esophagectomy. A total of 352 patients were included, with median age of 63.00 (IQR (interquartile range) 56.00-68.00). The patients were divided into low (n = 300) and high (n = 52) ACCI groups based on the optimal cut-off value of 5 points. Chronic pulmonary disease (38.4%) was the most common comorbidity. The results of the multivariate Cox regression showed that the ACCI (HR = 1.63, 95%CI: 1.04-2.56), tumor size (HR = 1.67, 95%CI: 1.05-2.66), pTNM (II vs. I, HR = 4.74, 95%CI: 1.82-12.32; III vs. I, HR = 6.08, 95%CI: 2.37-15.60), and postoperative chemotherapy (HR = 0.60, 95%CI: 0.40-0.91) were significantly associated with the OS. Furthermore, the ACCI, tumor size, pTNM, and postoperative chemotherapy were also significantly associated with the CSS. Interactions were identified between the ACCI and postoperative chemotherapy, pTNM stage, and tumor size in relation to the OS and CSS. In conclusion, the ACCI may be an independent prognostic factor affecting the long-term prognosis of patients after radical esophagectomy.

Conditional estimates for uterine serous cancer: Tools for survivorship counseling and planning

OBJECTIVES

Develop conditional survival and risk-assessment estimates for uterine serous carcinoma (USC) overall and stratified by stage as tools for annual survivorship counseling and care planning.

METHODS

Patients in the National Cancer Data Base diagnosed between 2004 and 2014 with stage I-IV USC were eligible. Individuals missing stage or survival data or with multiple malignancies were excluded. Five-year conditional survival was estimated using the stage-stratified Kaplan-Meier method annually during follow-up. A standardized mortality ratio (SMR) estimated the proportion of observed to expected deaths in the U.S. adjusted for year, age, and race. The relationships between prognostic factors and survival were studied using multivariate Cox modeling at diagnosis and conditioned on surviving 5-years.

RESULTS

There were 14,575 participants, including 43% with stage I, 8% with stage II, 29% with stage III, and 20% with stage IV USC. Five-year survival at diagnosis vs. after surviving 5-years was 52% vs. 75% overall, 77% vs. 81% for stage I, 57% vs. 72% for stage II, 40% vs. 66% for stage III, and 17% vs. 60% for stage IV USC, respectively (P < 0.0001). Incremental improvements in 5-year conditional survival and reductions in SMR tracked with annual follow-up and higher stage. The adjusted risk of death at diagnosis vs. after surviving 5-years was 1.15 vs. 1.40 per 5-year increase of age, 1.26 vs. 1.68 for Medicaid insurance, 3.92 vs. 2.48 for stage III disease, and 6.65 vs. 2.79 for stage IV disease, respectively (P < 0.0001).

CONCLUSION

In USC, the evolution of conditional survival permits annual reassessments of prognosis to tailor survivorship counseling and care planning.

Impact of Type 2 Diabetes Mellitus on Endometrial Cancer Survival: A Prospective Database Analysis

Purpose

Type 2 diabetes mellitus (T2DM) is an established risk factor for endometrial cancer but its impact on endometrial cancer survival outcomes is unclear. The aim of this study was to investigate whether pre-existing T2DM impacts survival outcomes in endometrial cancer.

Patients and Methods

Women diagnosed with endometrial cancer were recruited to a single centre prospective cohort study. Relevant sociodemographic and clinico-pathological data were recorded at baseline. T2DM status was based on clinical and biochemical assessment, verified by general practitioner records and analysed in relation to overall, cancer-specific and recurrence-free survival using Kaplan-Meier estimation and multivariable Cox-regression.

Results

In total, 533 women with median age and BMI of 66 years (Interquartile range (IQR), 56, 73) and 32kg/m² (IQR 26, 39) respectively, were included in the analysis. The majority had low-grade (67.3%), early-stage (85.1% stage I/II), endometrial cancer of endometrioid histological phenotype (74.7%). A total of 107 (20.1%) had pre-existing T2DM. Women with T2DM had a two-fold increase in overall mortality (adjusted HR 2.07, 95%CI 1.21-3.55, p=0.008), cancer-specific mortality (adjusted HR 2.15, 95% CI 1.05-4.39, p=0.035) and recurrence rates (adjusted HR 2.22, 95% CI 1.08-4.56, p=0.030), compared to those without, in multivariable analyses.

Conclusion

T2DM confers an increased risk of death in endometrial cancer patients. Well-designed longitudinal studies with large sample sizes are now needed to confirm these findings.

Current and Emerging Prognostic Biomarkers in Endometrial Cancer

Endometrial cancer is the most common gynaecological malignancy in high income countries and its incidence is rising. Whilst most women with endometrial cancer are diagnosed with highly curable disease and have good outcomes, a significant minority present with adverse clinico-pathological characteristics that herald a poor prognosis. Prognostic biomarkers that reliably select those at greatest risk of disease recurrence and death can guide management strategies to ensure that patients receive appropriate evidence-based and personalised care. The Cancer Genome Atlas substantially advanced our understanding of the molecular diversity of endometrial cancer and informed the development of simplified, pragmatic and cost-effective classifiers with prognostic implications and potential for clinical translation. Several blood-based biomarkers including proteins, metabolites, circulating tumour cells, circulating tumour DNA and inflammatory parameters have also shown promise for endometrial cancer risk assessment. This review provides an update on the established and emerging prognostic biomarkers in endometrial cancer.

Overall survival after surgical staging by lymph node dissection versus sentinel lymph node biopsy in endometrial cancer: a national cancer database study

OBJECTIVE

Substituting lymphadenectomy with sentinel lymph node biopsy for staging purposes in endometrial cancer has raised concerns about incomplete nodal resection and detrimental oncological outcomes. Therefore, this study aimed to investigate the association between the type of lymph node assessment and overall survival in endometrial cancer accounting for node status and histology.

METHODS

Women with stage I-III endometrial cancer who underwent hysterectomy and lymph node assessment from January 2012 to December 2015 were identified in the National Cancer Database. Patients who underwent neoadjuvant therapy, had previous cancer, and whose follow-up was less than 90 days were excluded. Multivariable Cox proportional hazards regression analyses were performed to assess factors associated with overall survival.

RESULTS

Of 68 614 patients, 64 796 (94.4%) underwent lymphadenectomy, 1777 (2.6%) underwent sentinel node biopsy only, and 2041 (3.0%) underwent both procedures. On multivariable analysis, neither sentinel lymph node biopsy alone nor sentinel node biopsy followed by lymphadenectomy was associated with significantly different overall survival compared with lymphadenectomy alone (HR 0.92, 95% CI 0.73 to 1.17, and HR 0.91, 95% CI 0.77 to 1.08, respectively). When stratified by lymph node status, sentinel node biopsy alone or followed by lymphadenectomy was not associated with different overall survival, both in patients with negative (HR 0.95, 95% CI 0.73 to 1.24, and HR 1.04, 95% CI 0.85 to 1.27, respectively) or positive (HR 0.91, 95% CI 0.54 to 1.52, and HR 0.77, 95% CI 0.57 to 1.04, respectively) lymph nodes. These findings held true when sentinel node biopsy alone and sentinel node biopsy plus lymphadenectomy groups were merged, and on stratification by histotype (type one vs type 2) or inclusion of only complete lymphadenectomy (at least 10 pelvic nodes and at least one para-aortic node removed). In all analyses, age, Charlson-Deyo score, black race, AJCC pathological T stage, grade, lymphovascular invasion, brachytherapy, and adjuvant chemotherapy were independently associated with overall survival.

DISCUSSION

No difference in overall survival was found in patients with endometrial cancer who underwent sentinel node biopsy alone, sentinel node biopsy followed by lymphadenectomy, or lymphadenectomy alone. This observation remained regardless of node status, histotype, and lymphadenectomy extent.

Analysis of the Impact of Comorbidities on Endometrial Lesions Using the Charlson Comorbidity Index in Western Romania

Background and Objectives: This retrospective study aimed to identify the main comorbidities found in gynecological patients hospitalized for endometrial lesions and to analyze the relationships between these comorbidities and each type of endometrial lesion. The Charlson comorbidity index (CCI) was calculated, thus assessing the patient’s probability of survival in relation to the underlying disease and the existing comorbidities. Materials and Methods: During 2015–2019, 594 cases hospitalized for vaginal bleeding outside of pregnancy were included in the research. For all cases, the frequency of comorbidities was calculated, applying the Cox proportional hazard model, considering the hospitalizations (from the following year after the first outpatient or hospital assessment) as a dependent variable; age and comorbidities were considered as independent variables. Results: Analysis of variance (ANOVA) for mean age of patients enrolled after diagnosis and multiple comparisons (via the Tukey post-hoc test) indicate significant differences (p < 0.05) between the average age for endometrial cancer (EC) and that for the typical endometrial hyperplasia or other diagnoses. The most common comorbidities were hypertension (62.28%), obesity (35.01%), and diabetes (22.89%), followed by cardiovascular disease. An intensely negative correlation (r = −0.715281634) was obtained between the percentage values of comorbidities present in EC and other endometrial lesions. The lowest chances of survival were calculated for 88 (14.81% of the total) patients over 50 years (the probability of survival in the next 10 years being between 0 and 21%). The chances of survival at 10 years are moderately negatively correlated with age (sample size = 594, r = −0.6706, p < 0.0001, 95% confidence interval (CI) for r having values from −0.7126 to −0.6238) and strongly negatively correlated with the CCI (r = −0.9359, p < 0.0001, 95% CI for r being in the range −0.9452 to −0.9251). Conclusions: Using CCI in endometrial lesions is necessary to compare the estimated risk of EC mortality with other medical conditions.

Effect of age as a continuous variable in early-stage endometrial carcinoma: a multi-institutional analysis in China

Objective: To explore the effect of age at diagnosis as a continuous variable on survival and treatment choice of patients with early-stage endometrial carcinoma (EC).

Materials and Methods: We retrospectively analyzed data from patients with early-stage EC from January 1999 to December 2015 in multiple institutions in China. All patients received primary hysterectomy/bilateral salpingo-oophorectomy and adjuvant radiotherapy for EC confirmed pathology of stage I and II disease (FIGO 2009 staging). All patients were divided into low-risk, intermediate-risk, high-intermediate-risk and high-risk groups according to ESMO-ESGO-ESTRO risk classification.

Results: The median follow-up time was 57months, and the 5-year cancer-specific survival (CSS) was 95.7%. Age as a continuous variable was an independent prognostic factor for CSS. With an increase in age, the hazard ratio (HR) for CSS increases gradually. Other independent prognostic factors included myometrial invasion (MI), grade, and chemotherapy. In the stratified analysis of age, the HRs of age on CSS in patients >70y were 5.516, 5.015, 4.469, 4.618, 5.334, and 5.821 after adjusting for cancer characteristics, local treatment, chemotherapy and treatment-related late toxicity. In patients 66-70-year-old, the HRs were 2.509, 2.074, 2.101, 2.091, 2.157 and 1.621 after adjusting for the above covariates. In patients ≤65y, there was no significant difference in the HR of age on CSS after adjustment.

Conclusion: Age as a continuous variable is an independent prognostic factor and 65 year-old may be the best cut-off point for CSS in patients with early-stage EC in the Asian population. Quality of life should be given greater weight in the choice of therapeutic schedule for those patients >70 y.

Relationship Between Different Risk Factor Patterns and Follow-Up Outcomes in Patients With ST-Segment Elevation Myocardial Infarction

Objective: Few studies have been concerned with the combined influences of the presence of multiple risk factors on follow-up outcomes in AMI patients. Our study aimed to identify risk factor patterns that may be associated with 1-year survival in male patients with ST-segment elevation myocardial infarction (STEMI). Methods: Data were from the China STEMI Care Project Phase 2 (CSCAP-2) collected between 2015 and 2018. A total of 15,675 male STEMI patients were enrolled in this study. Risk factor patterns were characterized using latent class analysis (LCA) according to seven risk factors. Associations between risk factor patterns and follow-up outcomes, including the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death, were investigated by Cox proportional hazard regression analysis. Results: We obtained four risk factor patterns as "young and middle-aged with low levels of multimorbidity," "middle-aged with overweight," "middle-aged and elderly with normal weight," and "elderly with high multimorbidity." Four patterns had significant differences in event-free survival (P < 0.001). As compared with the patients of "young and middle-aged with low levels of multimorbidity" pattern, the risk of incidence of MACCE and all-cause death were increased in patients of "middle-aged with overweight" pattern (All-cause death: HR = 1.70, 95% CI:1.29~2.23; MACCE: HR = 1.49, 95% CI:1.29~1.72), "middle-aged and elderly with normal weight" pattern (All-cause death: HR = 3.04, 95% CI: 2.33~3.98; MACCE: HR = 1.82, 95% CI: 1.56~2.12), and "elderly with high multimorbidity" pattern (All-cause death: HR = 5.78, 95% CI: 4.49~7.42; MACCE: HR = 2.67, 95% CI: 2.31~3.10). Conclusions: By adopting a Latent Class Analysis Approach, STEMI patients can be characterized into four risk factor patterns with significantly different prognosis. The data is useful for the improvement of community health management in each specific subgroup of patients, which indicates a particular risk factor pattern.

Utility of a modified age-adjusted Charlson Comorbidity Index in predicting cause-specific survival among patients with gastric cancer

INTRODUCTION

The current study aimed to evaluate the ability of a modified version of the age-adjusted Charlson Comorbidity Index (mACCI) in predicting cause-specific survival (CSS) among patients with gastric cancer who underwent curative gastrectomy and compared it with the conventional ACCI.

MATERIALS AND METHODS

Patients who underwent gastrectomy for gastric cancer from 2007 to 2016 (n = 2885) were included. A mACCI was established by excluding scores for other malignancies, such as other cancers, leukemia, and lymphoma. After determining the optimal cutoff ACCI and mACCI values for CSS, clinicopathological factors and survival outcomes were assessed according to the ACCI and mACCI.

RESULTS

Both ACCI and mACCI were identified as independent prognostic factors for overall survival (p < 0.001 and p < 0.001, respectively). However, only mACCI was identified as an independent prognostic factor for CSS (p < 0.001). The present study suggested that mACCI was a better indicator of CSS in patients with gastric cancer who underwent curative gastrectomy than ACCI.

CONCLUSION

Our findings showed that the mACCI was a strong predictor of CSS in patients with gastric cancer who underwent curative gastrectomy. We believe that the mACCI will become a novel marker that would guide treatment decisions for patients with gastric cancer suffering from comorbidities.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care

Background

Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death.

Methods

This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017.

Results

In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% ‐ 6.3%) vs. 1.4% (0.7% ‐ 2.3%) on admission (p < 0.001) and 7.6% (6.4% ‐ 8.9%) vs. 5.4% (4.0% ‐ 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms.

Conclusions

There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

Stereotactic body radiation therapy for empirically treated hypermetabolic lung lesions: a single-institutional experience identifying the Charlson score as a key prognostic factor

Background

Though pathologic evidence for non-small cell lung cancer (NSCLC) is preferred, many patients do not receive a biopsy prior to treatment with stereotactic body radiation therapy (SBRT). This study seeks to analyze the overall survival (OS), local control, and toxicity rates for such patients.

Methods

This retrospective review included patients empirically treated with SBRT for presumed non-metastatic NSCLC at a single institution. Inclusion criteria included a hypermetabolic pulmonary lesion noted on positron emission tomography (PET) imaging but no pathological evidence of NSCLC. Patients with another known metastatic tumor were excluded. Statistical analysis was conducted with Cox proportional hazards analysis, univariate analysis, and the Kaplan-Meier method.

Results

Ninety-one treatments in 90 unique patients met inclusion criteria. Patients were a median 77.9 years at the start of treatment and had a median Charlson score of 7. Pre-treatment standardized uptake value (SUV) was a median 4.5 and 1.5 after treatment. At a median follow-up of 12.9 months, 36-month local control of 91.3% was achieved. Twenty-four-month OS and progression-free survival were 65.4% and 44.8%, respectively. On univariate analysis, biologically effective dose (BED) ≥120 Gy was predictive of improved OS (P=0.001), with 36-month OS of 50.5% for patients with BED ≥120 Gy and only 31.6% for patients with BED <120 Gy. On Kaplan-Meier analysis, Charlson score ≥9 was predictive of decreased OS (P=0.04), and BED ≥120 Gy trended towards improved OS (P=0.08). Thirty-two cases of grade <3 toxicity were reported, and only two cases of grade 3 morbidity (fatigue) were noted.

Conclusions

Local control rates for empiric SBRT treatment for hypermetabolic, non-metastatic NSCLC are similar to those for biopsied NSCLC. OS is primarily dependent on a patient’s overall health status, which can be accurately assessed with the Charlson score. BED ≥120 Gy may also contribute to improved OS.

Does the Interval Between Hysterectomy and Start of Adjuvant Radiation Treatment Influence Survival in Women With Endometrial Carcinoma?: A National Cancer Database analysis

OBJECTIVE

The objective of this study was to analyze the impact of the time interval (TI) between hysterectomy and initiation of adjuvant radiation treatment (ART) on overall survival (OS) among women with early stage endometrial carcinoma (EC) using the National Cancer Database (NCDB).

MATERIALS AND METHODS

The NCDB was queried for women with the International Federation of Gynecology and Obstetrics (FIGO) stage I to II EC who underwent hysterectomy followed by ART. We examined the prognostic impact of TI on OS using the cutoff ≤8 or >8 weeks to initiate radiation treatment (RT). Two groups of patients were created. Kaplan-Meier curves were created for OS analysis. Predictors of OS were identified.

RESULTS

A total 16,520 women were identified. The median follow-up time for the entire cohort was 59.1 months. Median age was 63 years, and 82% were FIGO stage I. Pelvic external beam RT alone was used in 9569 (58%) and vaginal brachytherapy alone in 4265 women (26%). In total, 10,040 women (61%) received RT ≤8 weeks. Delay in initiating RT >8 weeks was associated with shorter 5-year OS (P=0.048). Independent predictors of shorter OS includes older age, African American race, higher comorbidity burden, higher tumor grade, the presence of lymphovascular invasion and stage II tumors. Although TI in initiating RT was a significant predictor for OS in univariate analysis, its independent significance of OS was lost on multivariate analysis (P=0.28).

CONCLUSION

Our study suggests that TI between hysterectomy and initiation of ART was not an independent predictor of OS in women with early stage EC.

Trends in hysterectomy-corrected uterine cancer mortality rates during 2002 to 2015: mortality of nonendometrioid cancer on the rise?

Corpus uteri cancer is the most common gynecological malignancy in most developed countries. The disease is typically diagnosed at an early stage, is of endometrioid histologic subtype, and has a fairly good prognosis. Here, we describe hysterectomy-corrected mortality rates of corpus uteri cancer, overall and stratified by age, stage and histologic subtype. Using data from nationwide Danish registries, we calculated uncorrected and hysterectomy-corrected age-standardized mortality rates of corpus uteri cancer among women ≥35 years during 2002 to 2015. Individual-level hysterectomy status was obtained from national registries; hysterectomy-corrected mortality rates were calculated by subtracting posthysterectomy person-years from the denominator, unless hysterectomy was performed due to corpus uteri cancer. Correction for hysterectomy resulted in a 25.5% higher mortality rate (12.3/100000 person-years vs 9.8/100000 person-years). Mortality rates were highest in women aged 70+, irrespective of year of death, histologic subtype and stage. A significant decline was observed in overall hysterectomy-corrected mortality rates from 2002 to 2015, particularly among women aged 70+. Mortality rates of endometrioid cancer declined significantly over time (annual percent change [APC]: -2.32, 95% CI -3.9, -0.7, P = .01), whereas rates of nonendometrioid cancer increased (APC: 5.90, 95% CI: 3.0, 8.9, P < .001). With respect to stage, mortality rates increased significantly over time for FIGOI-IIa (APC: 6.18 [95% CI: 1.9, 10.7] P = .01) but remained unchanged for FIGO IIb-IV. In conclusion, increasing mortality rates of nonendometrioid cancer paralleled the previously observed rise in incidence rates of this histologic subtype. Given the poor prognosis of nonendometrioid cancer, more studies are needed to clarify the underlying reason for these findings.

Predictive Value of the Age-Adjusted Charlson Comorbidity Index for Outcomes After Hepatic Resection of Hepatocellular Carcinoma

BACKGROUND

This study aimed to evaluate the impact of the age-adjusted Charlson comorbidity index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC).

METHODS

We assessed 763 patients who underwent hepatic resection for HCC. The ACCI scores were categorized as follows: ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7.

RESULTS

A multivariate analysis showed that the odds ratios for postoperative complications in ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 0.71 (p = 0.41) and 4.15 (p < 0.001), respectively. The hazard ratios for overall survival of ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 1.52 (p = 0.023) and 2.45 (p < 0.001), respectively. The distribution of deaths due to HCC-related, liver-related, and other causes was 68.2%, 11.8%, and 20% in ACCI ≤ 5 group, 47.2%, 13.9%, and 38.9% in ACCI = 6 group, and 27.3%, 9.1%, and 63.6% in ACCI ≥ 7 group (p = 0.053; ACCI ≤ 5 vs. = 6, p = 0.19; ACCI = 6 vs. ≥ 7, p < 0.001; ACCI ≤ 5 vs. ≥ 7). In terms of the treatment for HCC recurrence in ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7 groups, adaptation rate of surgical resection was 20.1%, 7.3%, and 11.1% and the rate of palliative therapy was 4.3%, 12.2%, and 22.2%, respectively.

CONCLUSIONS

The ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC. These findings will help physicians establish a treatment strategy for HCC patients with comorbidities.

Robotic vs laparoscopic right colectomy – the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUND

Several studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.

AIM

To investigate the outcomes of RRH vs LRH with regard to age and comorbidities.

METHODS

We retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.

RESULTS

LOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036).

CONCLUSION

RRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Impact of the Age-adjusted Charlson comorbidity index on the short- and long-term outcomes of patients undergoing curative gastrectomy for gastric cancer

Background: The aim of this study was to determine whether or not the short- and long-term outcomes were affected by the age-adjusted Charlson comorbidity index (ACCI) in patients who underwent curative resection for gastric cancer.

Methods: The patients were retrospectively selected from among the medical records of consecutive patients who underwent curative gastrectomy with nodal dissection for gastric cancer at Yokohama City University and Kanagawa Cancer Center from January 2000 to August 2015.

Results: A total of 2254 patients were eligible for inclusion in the present study. One thousand six hundred fifty-six patients had an ACCI of <6 points (ACCI low group), while 598 had a score of ≥6 points (ACCI high group). The median age (p<0.001) and American Society of Anesthesiologists physical status (ASA-PS) score (p<0.001) of the ACCI high group were higher in comparison to the ACCI low group. The incidence of surgical complications in the ACCI high group was significantly higher than that in the ACCI low group (12.0% vs. 7.2%, p<0.001). Univariate and multivariate analyses demonstrated that an ACCI high classification was a significant risk factor for postoperative complications. In addition, the 5-year OS rates of the ACCI low and ACCI high groups were 85.4% and 74.1%, respectively. The difference was statistically significant (p<0.001). The univariate and multivariate analyses demonstrated that an ACCI high classification was a significant prognostic factor for OS.

Conclusions: Our results support that a high ACCI value is an independent risk factor for the short- and long-term outcomes of patients with gastric cancer. To improve the survival of patients with gastric cancer, it is necessary to carefully plan the perioperative care and the surgical strategy according to the ACCI.

Prognostic Value of the Geriatric Nutritional Risk Index in Patients Exceeding 70 Years Old with Esophageal Squamous Cell Carcinoma

To investigate the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in esophageal squamous cell carcinoma (ESCC) patients treated with radiotherapy (RT) or definitive concurrent chemoradiotherapy (dCRT). Fifty-two ESCC patients were included from July 2014 to December 2018. RT was delivered at a dose of 1.8-2.0 Gy per day to a total dose of 50-60 Gy. Tumor response was assessed using the RECIST 1.1 system. Overall survival (OS) and progression-free survival (PFS) were calculated and compared with the Kaplan-Meier method. Multivariate analysis of predictive factors of response and survival was performed using a logistic regression and a Cox model, respectively. In multivariate analysis, GNRI score (HR 0.278, P = 0.036) was the only independent prognostic factor for tumor response. As for survival outcomes, GNRI score (OS: HR 0.505, P = 0.028; PFS: HR 0.583, P = 0.045) and treatment modality (OS: HR 0.356, P = 0.015; PFS: HR 0.392, P = 0.0014) were both independent prognostic factors for better OS and PFS. Additionally, there was no correlation between GNRI score and treatment modality (Spearman's ρ = 0.200; P = 0.154). In conclusion, routine use of the GNRI criteria may help in the risk stratification of elderly patients undergoing RT/dCRT. The dCRT treatment could provide survival benefits for elderly ESCC patients.

Age-adjusted Charlson Comorbidity Index (ACCI) is a significant factor for predicting survival after radical gastrectomy in patients with gastric cancer

INTRODUCTION

To assess the ability of the Age-Adjusted Charlson Comorbidity Index (ACCI) to predict survival after radical gastrectomy in patients with gastric cancer (GC).

METHOD

Data from patients with GC who underwent radical gastrectomy from January 2008 to December 2012 in Fujian Medical University Union Hospital were retrospectively analyzed. Patients were categorized into either high ACCI group or low ACCI group based on the effect of ACCI on long-term GC prognosis. 1:1 propensity score matching (PSM) was used to reduce confounding bias. To further analyze the impact of ACCI on the long-term prognosis of patients after radical gastrectomy, a nomogram was built based on the Cox proportional hazards regression model.

RESULTS

A total of 1476 patients were included in the analysis. After PSM, there was no statistically significant differences in tumor location, tumor size and tumor stage between low ACCI group (429 cases) and high ACCI group (429 cases) (all P > 0.05). Before and after PSM, the incidence of postoperative complications in high ACCI group was significantly higher than that in low ACCI group (P < 0.05). The 5-year overall survival rate (OS) in low ACCI group was significantly higher than that in high ACCI group. Multivariate analysis showed that ACCI was an independent risk factor for OS (P < 0.05). The Harrell's C-statistics (C-index) of TNMA, a prognostic evaluation system combining ACCI and TNM staging system, was significantly higher than that of TNM staging system in both the modeling and validation groups (all P < 0.05).

CONCLUSIONS

ACCI was an independent risk factor for the long-term prognosis of GC patients after radical gastrectomy that could effectively improve the predictive efficacy of the TNM staging system for GC.

The age-adjusted Charlson comorbidity index as a predictor of survival in surgically treated vulvar cancer patients

Objective

To evaluate the impact of age-adjusted Charlson comorbidity index (ACCI) in predicting disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) among surgically treated patients with vulvar carcinoma. The secondary aim is to evaluate its impact as a predictor of the pattern of recurrence.

Methods

We retrospectively evaluated data of patients that underwent surgical treatment for vulvar cancer from 1998 to 2016. ACCI at the time of primary surgery was evaluated and patients were classified as low (ACCI 0–1), intermediate (ACCI 2–3), and high risk (>3). DFS, OS and CSS were analyzed using the Kaplan-Meir and the Cox proportional hazard models. Logistic regression model was used to assess predictors of distant and local recurrence.

Results

Seventy-eight patients were included in the study. Twelve were classified as low, 36 as intermediate, and 30 as high risk according to their ACCI. Using multivariate analysis, ACCI class was an independent predictor of worse DFS (hazard ratio [HR]=3.04; 95% confidence interval [CI]=1.54–5.99; p<0.001), OS (HR=5.25; 95% CI=1.63–16.89; p=0.005) and CSS (HR=3.79; 95% CI=1.13–12.78; p=0.03). Positive nodal status (odds ratio=8.46; 95% CI=2.13–33.58; p=0.002) was the only parameter correlated with distant recurrence at logistic regression.

Conclusion

ACCI could be a useful tool in predicting prognosis in surgically treated vulvar cancer patients. Prospective multicenter trials assessing the role of ACCI in vulvar cancer patients are warranted.

A Simplified Risk Stratification Method for Women With Stage I Endometrial Carcinoma

OBJECTIVES

Available risk stratification methods for women with endometrial carcinoma are controversially defined. We sought to develop a simplified and an individualized prognostic index for cancer recurrence in women with International Federation of Gynecology and Obstetrics (FIGO) stage I endometrial carcinoma, solely of endometrioid histology.

MATERIALS AND METHODS

We identified 976 women who underwent a hysterectomy and did not receive any adjuvant therapy. Cox proportional hazards model was used to identify independent predictors of recurrence. Prognostic groups were created based on the number of independent predictors of recurrence (0, 1, or 2 or 3 risk factors). These groups were then validated using a separate cohort of 611 women treated at another academic institution. The model's performance for predicting cancer recurrence was measured by the concordance probability estimate along with a 95% confidence interval.

RESULTS

Median follow-up was 65 months. The final recurrence model included 3 risk groups based on 3 independent predictors of recurrence (tumor grade 2 or 3, the presence of lymphovascular space invasion and stage IB). Five-year recurrence rates were 4%, 16%, and 44% for groups 0, 1, and 2 or 3, respectively. The performance of the model was very good with a concordance probability estimate of 0.72 and 0.80 for the development and validation cohorts, respectively.

CONCLUSIONS

On the basis of 3 well-known prognostic factors, we have developed and externally validated a simplified prognostic model that accurately predicts cancer recurrence in women with stage I endometrial carcinoma. This simplified predictive tool may be helpful in estimating individualized risk of recurrence and guide counseling with regard to adjuvant treatment.

Impact of age at diagnosis on racial disparities in endometrial cancer patients

INTRODUCTION

Although black patients with endometrial cancer (EC) have worse survival compared with white patients, the interaction between age/race has not been examined. The primary objective was to evaluate the impact of age at diagnosis on racial disparities in disease presentation and outcome in EC.

METHODS

We evaluated women diagnosed with EC between 1991 and 2010 from the Surveillance, Epidemiology, and End Results. Mutation status for TP53 or PTEN, or with the aggressive integrative, transcript-based, or somatic copy number alteration-based molecular subtype were acquired from the Cancer Genome Atlas. Logistic regression model was used to estimate the interaction between age and race on histology. Cox regression model was used to estimate the interaction between age and race on survival.

RESULTS

78,184 white and 8518 black patients with EC were analyzed. Median age at diagnosis was 3-years younger for black vs. white patients with serous cancer and carcinosarcoma (P<0.0001). The increased presentation of non-endometrioid histology with age was larger in black vs. white patients (P<0.0001). The racial disparity in survival and cancer-related mortality was more prevalent in black vs. white patients, and in younger vs. older patients (P<0.0001). Mutations in TP53, PTEN and the three aggressive molecular subtypes each varied by race, age and histology.

CONCLUSIONS

Aggressive histology and molecular features were more common in black patients and older age, with greater impact of age on poor tumor characteristics in black vs. white patients. Racial disparities in outcome were larger in younger patients. Intervention at early ages may mitigate racial disparities in EC.

Type I Versus Type II Endometrial Cancer: Differential Impact of Comorbidity

Objective

Two distinct types of endometrial carcinoma (EC) with different etiology, tumor characteristics, and prognosis are recognized. We investigated if the prognostic impact of comorbidity varies between these 2 types of EC. Furthermore, we studied if the recently developed ovarian cancer comorbidity index (OCCI) is useful for prediction of survival in EC.

Materials and Methods

This nationwide register-based cohort study was based on data from 6487 EC patients diagnosed in Denmark between 2005 and 2015. Patients were assigned a comorbidity index score according to the Charlson comorbidity index (CCI) and the OCCI. Kaplan-Meier survival statistics and adjusted multivariate Cox regression analyses were used to investigate the differential association between comorbidity and overall survival in types I and II EC.

Results

The distribution of comorbidities varied between the 2 EC types. A consistent association between increasing levels of comorbidity and poorer survival was observed for both types. Cox regression analyses revealed a significant interaction between cancer stage and comorbidity indicating that the impact of comorbidity varied with stage. In contrast, the interaction between comorbidity and EC type was not significant. Both the CCI and the OCCI were useful measurements of comorbidity, but the CCI was the strongest predictor in this patient population.

Conclusions

Comorbidity is an important prognostic factor in type I as well as in type II EC although the overall prognosis differs significantly between the 2 types of EC. The prognostic impact of comorbidity varies with stage but not with type of EC.

Improved Outcome of High-Grade, Early 1-Stage Endometrioid Endometrial Carcinoma With Adjuvant Chemotherapy and Radiotherapy: Comparison of 2 Treatment Strategies

OBJECTIVE

Patients with high-grade endometrioid endometrial carcinoma have a high risk of recurrence, even in early stage. To determine the benefit of a more aggressive adjuvant treatment approach, different treatment strategies of 2 referral centers were compared.

MATERIALS AND METHODS

Outcome of all patients with International Federation of Gynecology and Obstetrics IB and II high-grade endometrioid endometrial carcinoma treated between 2008 and 2012, at the Gynecological Oncology Center South (GOCS) were compared with patients treated at the British Columbia Cancer Agency (BCCA). All patients underwent primary surgical treatment. Adjuvant treatment consisted of radiotherapy dependent on final pathology (GOCS), or adjuvant chemotherapy and pelvic radiotherapy (BCCA).

RESULTS

A total of 116 patients were treated at the GOCS (n = 61) and BCCA (n = 55). Patient cohorts were comparable for clinicopathological factors, except for age at diagnosis and lymphadenectomy. Radiotherapy was applied in 70.5% at the GOCS compared with 100% at the BCCA. All BCCA patients received chemotherapy compared with 3.3% at GOCS. The BCCA treatment strategy resulted in a significant reduced recurrence rate when compared with GOCS, 10.9% and 36.1%, respectively. There was no significant difference in the recurrence rate between patients with (n = 48) and without a lymphadenectomy (n = 68). Yet, numbers are relatively low. Because most recurrences were distant 78.6% (22/28), adjuvant chemotherapy resulted in reduced disease-related mortality.

CONCLUSIONS

Adjuvant chemotherapy and radiotherapy in early-stage high-grade endometrioid endometrial carcinoma results in improved disease-specific and overall survival compared to radiotherapy alone. Yet, due to the relatively low numbers, validation of these findings is needed in large prospective trials.

Predictive value of the age-adjusted Charlston co-morbidity index on peri-operative complications, adjuvant chemotherapy usage and survival in patients undergoing debulking surgery after neo-adjuvant chemotherapy for advanced epithelial ovarian cancer

The aim of this study was to determine whether the age-adjusted Charlston co-morbidity index (ACCI) can predict post-operative complications, adjuvant chemotherapy usage and overall survival (OS) in patients with advanced epithelial ovarian cancer (AOC) treated with neoadjuvant chemotherapy (NACT). A review was performed of all cytoreductive surgeries performed between 16/8/07-3/2/14 for AOC at a UK Cancer Centre. All surgeries were stratified by ACCI into three groups: Low (0-1), Intermediate (2-3) and High (≥4). Of the 293 cases the ACCI distribution was: 74 (25.26%) low, 164 (55.97%) intermediate and 55 (18.77%) high. Patients with a high ACCI were less likely to receive adjuvant chemotherapy (p = .023), more likely to receive fewer adjuvant cycles (p = .0057) but no more likely to experience complications. Median OS for patients with a low, intermediate and high ACCI was 44.58 (95%CI 36.98-52.19), 34.65 (95%CI 29.48-39.82) and 33.37 (95%CI 17.47-49.27) months. ACCI was associated with OS (p < .01) confirmed on multivariate analysis (p = .03). The ACCI is, therefore, a marker of survival in these patients and predicts adjuvant chemotherapy usage. Impact statement The Age-Adjusted Charlston Co-morbidity Index has previously been identified as a predictor of survival in both medical and surgical conditions. Recently it has also been validated in patients undergoing primary cytoreductive surgery for advanced ovarian cancer. This study is the first to validate the Age-Adjusted Charlston Co-morbidity Index in patients undergoing cytoreductive surgery following neoadjuvant chemotherapy. Our findings demonstrate that it can be used to not only predict overall survival in women undergoing debulking surgery after neo-adjuvant chemotherapy but also predicts the uptake and commencement of adjuvant chemotherapy. Such findings are important considerations to enable an informed patient choice regarding interval surgery in the more co-morbid patients. More importantly, although the ACCI can be used as a marker of overall survival, even in the most co-morbid of patients there remains a significant survival advantage following surgery to the extent that it should not be contraindicated in this cohort. The ACCI is being increasingly incorporated into various clinical trials as a standard demographic measure and this study validates its inclusion in patients undergoing interval debulking surgery.

Age-adjusted Charlson comorbidity index score as predictor of survival of patients with digestive system cancer who have undergone surgical resection

Comorbidities have considerable effects on survival outcomes. The primary objective of this retrospective study was to examine the association between age-adjusted Charlson comorbidity index (ACCI) score and postoperative in-hospital mortality in patients with digestive system cancer who have undergone surgical resection of their cancers. Using electronic hospitalization summary reports, we identified 315,464 patients who had undergone surgery for digestive system cancer in top-rank (Grade 3A) hospitals in China between 2013 and 2015. The Cox proportional hazard regression model was applied to evaluate the effect of ACCI score on postoperative mortality, with adjustments for sex, type of resection, anesthesia methods, and caseload of each healthcare institution. The postoperative in-hospital mortality rate in the study cohort was 1.2% (3,631/315,464). ACCI score had a positive graded association with the risk of postoperative in-hospital mortality for all cancer subtypes. The adjusted HRs for postoperative in-hospital mortality scores ≥ 6 for esophagus, stomach, colorectum, pancreas, and liver and gallbladder cancer were 2.05 (95% CI: 1.45–2.92), 2.00 (95% CI: 1.60–2.49), 2.54 (95% CI: 2.02–3.21), 2.58 (95% CI: 1.68–3.97), and 4.57 (95% CI: 3.37–6.20), respectively, compared to scores of 0–1. These findings suggested that a high ACCI score is an independent predictor of postoperative in-hospital mortality in Chinese patients with digestive system cancer who have undergone surgical resection.

The effect of a uterine manipulator on the recurrence and mortality of endometrial cancer: a multi-centric study by the Italian Society of Gynecological Endoscopy

BACKGROUND

Although widely adopted, the use of a uterine manipulator during laparoscopic treatment of endometrial cancer represents a debated issue, and some authors hypothesize that it potentially may cause an increased risk of relapse, particularly at specific sites.

OBJECTIVE

Our aim was to evaluate the risk and site of disease recurrence, overall survival, and disease-specific survival in women who had laparoscopic surgery with and without the use of a uterine manipulator.

STUDY DESIGN

Data were reviewed from consecutive patients who had laparoscopic surgery for endometrial cancer staging in 7 Italian centers. Subjects were stratified according to whether a uterine manipulator was used during surgery; if so, the type of manipulator was identified. Multivariable analysis to correct for possible confounders and propensity score that matched the minimize selection bias were utilized. The primary outcome was the risk of disease recurrence. Secondary outcomes were disease-specific and overall survival and the site of recurrence, according to the use or no use of the uterine manipulator and to the different types of manipulators used.

RESULTS

We included 951 patients: 579 patients in the manipulator group and 372 patients in the no manipulator group. After a median follow-up period of 46 months (range,12-163 months), the rate of recurrence was 13.5% and 11.6% in the manipulator and no manipulator groups, respectively (P=.37). Positive lymph nodes and myometrial invasion of >50% were associated independently with the risk of recurrence after adjustment for possible confounders. The use of a uterine manipulator did not affect the risk of recurrence, both at univariate (odds ratio, 1.18; 95% confidence interval, 0.80-1.77) and multivariable analysis (odds ratio, 1.00; 95% confidence interval, 0.60-1.70). Disease-free, disease-specific, and overall survivals were similar between groups. Propensity-matched analysis confirmed these findings. The site of recurrence was comparable between groups. In addition, the type of uterine manipulator and the presence or not of a balloon at the tip of the device were not associated significantly with the risk of recurrence.

CONCLUSION

The use of a uterine manipulator during laparoscopic surgery does not affect the risk of recurrence and has no impact on disease-specific or overall survival and on the site of recurrence in women affected by endometrial cancer.

Age-adjusted charlson comorbidity index score as predictor of prolonged postoperative ileus in patients with colorectal cancer who underwent surgical resection

Comorbidities had considerable effects on the development of postoperative ileus (POI). The primary aim of the present study was to determine the influence of the age-adjusted Charlson comorbidity index (ACCI) score on the risk of prolonged POI in patients with colorectal cancer who underwent surgical resection. Using the electronic Hospitalization Summary Reports, we identified 11,397 patients with colorectal cancer who underwent surgical resection from 2013 through 2015. Logistic regression models were applied to evaluate the effect of the ACCI score on the risk of prolonged POI. The ACCI score had a positive graded association with the risk of prolonged POI in both colon and rectal cancer (P for trend < 0.05). Among patients with rectal cancer, after adjusting for potential confounders, those with an ACCI score of 4-5 had a 108% higher risk of prolonged POI than those with an ACCI score of 0-1 (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.09-3.98), and those with an ACCI score of ≥ 6 had a 130% higher risk (OR, 2.30; 95% CI, 1.08-4.89). Among patients with colon cancer, those with an ACCI score of ≥ 6 had a 47% greater risk of prolonged POI than those with an ACCI score of 0-1 (OR, 1.47; 95% CI, 1.07-2.02). These findings suggested that a higher ACCI score was an independent predictor of the development of prolonged POI.

Age-adjusted Charlson Comorbidity Index scores predict major adverse cardiovascular events and all-cause mortality among systemic lupus erythematosus patients

Objective:

Cardiovascular events are the most frequent cause of death or disability among people with systemic lupus erythematosus (SLE). However, the causes of this increased the risk of major adverse cardiovascular events (MACEs) are not completely understood. The Age-adjusted Charlson Comorbidity Index (ACCI) is a prognostic classification that was initially developed for patients who have a number of comorbid conditions and the ACCI has been validated in many clinical settings.

Materials and Methods:

In this study, 5998 patients were enrolled from the National Health Research Institute Database of Taiwan. All the patients' sequential clinical data related to their diagnosis of SLE were reviewed from 2004 to 2007 to determine their risk of MACE occurrence and of all-cause mortality using their ACCI scores.

Results:

The predictive accuracy of the ACCI scores in relation to MACE occurrence among SLE patients was estimated and the C-statistic for this curve was found to be 0.687 (95% confidence interval [CI]: 0.664–0.709). The distribution of ACCI scores for MACE patients was 4.7%, 10.3%, 11.4%, and 21.5% for those with ACCI scores in the ranges of 0–1, 2–3, 4–5, and >6, respectively. A plot of the cumulative risk also showed a much higher risk among SLE patients with an ACCI score of >6. When patients were divided into different groups based on their ACCI scores, those with ACCI scores of >6 had an adjusted hazards ratio of 4.88 (95% CI: 3.84–6.19; P < 0.001) as compared to those with ACCI scores of 0–1.

Conclusion:

SLE patients with higher ACCI scores have a significantly higher risk of a MACE and of all-cause mortality. Our results suggested that ACCI scores may be useful as an index for estimating global cardiovascular risk among patients with SLE.

The impact of lymphadenectomy on survival endpoints in women with early stage uterine endometrioid carcinoma: A matched analysis

OBJECTIVES

The role of pelvic lymphadenectomy (LA) in women with stage I endometrial carcinoma (EC) is controversial. The objective of this study is to investigate the prognostic impact of LA on survival endpoints in matched cohorts of women with stage I EC solely of endometrioid histology. Survival endpoints included recurrence-free (RFS), disease-specific (DSS) and overall survival (OS).

METHODS AND MATERIALS

Patients with FIGO stage I EC who underwent hysterectomy with LA as part of their surgical staging between 1/1990 and 6/2015 were matched to a similar group that underwent hysterectomy without lymphadenectomy (NLA), based on stage, grade and adjuvant management. Univariate and multivariate modeling with Cox regression analysis was carried out for predictors of survival endpoints.

RESULTS

870 women constituted the study cohort (435 in each group). Median number of dissected lymph node in the LA group was 9 (range, 5-75). There was no statistically significant difference between the two groups in regards to 5-year OS (87.2% for LA vs. 91.7% for NLA) (p=0.36), DSS 97.7% vs. 98% (p=0.54) and RFS (93.7% vs. 90% (p=0.08), respectively. Lymphadenectomy was not a predictor of any of the studied survival endpoints. On multivariate analysis for the entire cohort, older age, deep myometrial invasion and higher tumor grade were predictors of worse RFS. For DSS, higher tumor grade, lower uterine segment (LUS) involvement and FIGO stage IB were significant predictors of worse outcome. For OS, older age and LUS involvement were the only two independent predictors for shorter OS.

CONCLUSIONS

After matching for FIGO stage, grade and adjuvant management, it appears that lymphadenectomy in women with stage I EC does not impact survival endpoints.

Predictive Capacity of 3 Comorbidity Indices in Estimating Survival Endpoints in Women With Early-Stage Endometrial Carcinoma

Objective

The negative impact of comorbidity on survival in women with endometrial carcinoma (EC) is well-known. Few validated comorbidity indices are available for clinical use, such as the Charlson Comorbidity Index (CCI), the Age-Adjusted CCI (AACCI), and the Adult Comorbidity Evaluation-27 (ACE-27). The aim of the study is to determine which index best correlates with survival endpoints in women with EC.

Materials and Methods

We identified 1132 women with early-stage EC treated at an academic center. Three scores were calculated for each patient using CCI, AACCI, and ACE-27 at the time of hysterectomy. Univariate and multivariable modeling was used to determine predictors of survival.

Results

For each of the studied comorbidity indices, the highest scores were significantly correlated with poorer overall survival. The hazard ratio of death from any cause was 3.92 for AACCI, 2.25 for CCI, and 1.57 for ACE-27. All 3 indices were independent predictors of overall survival with a P value of less than 0.001 on multivariate analysis. In addition, lymphovascular space invasion, lower uterine segment involvement, and tumor grade were predictors of overall survival. Lymphovascular space invasion, grade (P < 0.001), and high AACCI score were the only significant predictors of recurrence-free survival (RFS). Lymphovascular space invasion and tumor grade were the only 2 predictors of disease-specific survival.

Conclusions

Although all 3 studied comorbidity indices were significant predictors of overall survival in women with early-stage EC, AACCI showed a stronger association. It should be considered for evaluating comorbidity in women with early-stage EC.

Medication Reconciliation in Oncological Patients: A Randomized Clinical Trial

BACKGROUND

Medication reconciliation is considered to be an important strategy for increasing the safety of medication use. However, few studies have been carried out showing the effect of a medication reconciliation program on the incidence of reconciliation errors (REs) in oncological patients treated in the outpatient setting.

OBJECTIVE

To measure the effect of a medication reconciliation program on the incidence of reconciliation error that reached the patient (RERP) in cancer patients receiving chemotherapy as outpatients.

METHODS

A randomized, prospective, controlled study was carried out to identify the proportion of patients with at least 1 RERP. Medication reconciliation (intervention group) was compared with standard practice (control group) in patients starting new chemotherapy and who were receiving at least 1 home medication before the start of chemotherapy. A prespecified analysis of factors capable of influencing the occurrence of RE in oncological patients was also carried out.

RESULTS

A total of 147 patients were included (76 in the intervention group and 71 controls) in this study. There were 3 (4%) patients with RERP (primary endpoint) in the intervention group and 21 (30%) patients in the control group (relative risk [RR] = 0.13, 95% CI = 0.04-0.43; P = 0.0009). The prespecified analysis of the effects of the Eastern Cooperative Oncology Group performance status (ECOG), Charlson Comorbidity Index score, and degree of poly-medication upon the number of patients with RE showed the Charlson Comorbidity Index to be unrelated to RE occurrence. However, the risk of RE was greater in patients with ECOG ≥ 2 (RR = 2.18, 95% CI = 1.4-3.4; P = 0.018) and among patients with major poly-medication (RR = 2.49, 95% CI = 1.52-4.09; P <0.001).

CONCLUSIONS

Medication reconciliation results in a marked decrease in RERP in cancer patients. The factors that may influence RE occurrence in oncological patients have not been fully established, although parameters such as the degree of poly-medication and performance status may play a role.

DISCLOSURES

No outside funding supported this study. The authors declare that they have no affiliations with or financial interests in any company, product, or service described in the manuscript. Study concept and design were contributed by Sierra-Sánchez, Martínez-Bautista, Baena-Cañada, and González-Carrascosa Vega. Martínez-Bautista, García-Martín, Suárez-Carrascosa, and González-Carrascosa Vega collected the data, which was interpreted by Sierra-Sánchez, Martínez-Bautista, Baena-Cañada, and González-Carrascosa Vega. The manuscript was written by Sierra-Sánchez and González-Carrascosa Vega and revised by Sierra-Sánchez, Martínez-Bautista, Baena-Cañada, and González-Carrascosa Vega.