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Chen W, Xia X, Xie X, Wei Y, Wu R, Cai W, Hong J. Nomogram for prognosis of elderly patients with cervical cancer who receive combined radiotherapy. Sci Rep 2023; 13:13299. [PMID: 37587180 PMCID: PMC10432519 DOI: 10.1038/s41598-023-39764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/30/2023] [Indexed: 08/18/2023] Open
Abstract
This retrospective study identified prognostic factors to help guide the clinical treatment of elderly patients (≥ 65 years) with cervical cancer who had undergone radiotherapy. A personalized model to predict 3- and 5-years survival was developed. A review was conducted of 367 elderly women with cervical cancer (staged II-III) who had undergone radiotherapy in our hospital between January 2012 and December 2016. The Cox proportional hazards regression model was used for survival analysis that considered age, hemoglobin, squamous cell carcinoma antigen, pathologic type, stage, pelvic lymph node metastasis status, and others. A nomogram was constructed to predict the survival rates. The median follow-up time was 71 months (4-118 months). The 3- (5-) years overall, progression-free, local recurrence-free, and distant metastasis-free survival rates were, respectively, 91.0% (84.4%), 92.3% (85.9%), 99.18% (99.01%), and 99.18% (97.82%). The following were significant independent prognostic factors for overall survival: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The C-index of the line chart was 0.699 (95% CI 0.652-0.746). The areas under the receiver operating characteristic curves for 3- and 5-years survival were 0.751 and 0.724. The nomogram was in good concordance with the actual survival rates. The independent prognostic factors for overall survival in elderly patients with cervical cancer after radiotherapy were: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The novel prognostic nomogram based on these factors showed good concordance with the actual survival rates and can be used to guide personalized clinical treatment.
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Affiliation(s)
- Wenjuan Chen
- Department of Radiation Oncology, Department of Gynecology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China.
| | - Xiaoyi Xia
- Department of Radiation Oncology, Department of Gynecology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Xingyun Xie
- Department of Radiation Oncology, Department of Gynecology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Yuting Wei
- Department of Radiation Oncology, Department of Gynecology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Rongrong Wu
- Department of Radiation Oncology, Department of Gynecology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Wenjie Cai
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, 362000, China
| | - Jinsheng Hong
- Department of Radiotherapy, Cancer Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China.
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Radiotherapy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
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So KA, Shim SH, Lee SJ, Kim TJ. Surgical Treatment Outcomes of Gynecologic Cancer in Older Patients: A Retrospective Study. J Clin Med 2023; 12:jcm12072518. [PMID: 37048601 PMCID: PMC10094859 DOI: 10.3390/jcm12072518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023] Open
Abstract
This study aimed to evaluate oncologic characteristics and surgical outcomes in older patients with gynecologic cancers. This retrospective study included patients aged ≥65 years who were diagnosed with gynecologic cancers and underwent surgical treatment between 2005 and 2020. We reviewed the medical records for age at diagnosis, body mass index, American Society of Anesthesiologists score, comorbidities, postoperative complications, cancer stage, histologic type, surgical treatment, postoperative outcome, and survival rate. Data were compared between groups according to the age at the time of diagnosis: <75 years (young-old) and ≥75 years (old-old). In total, 131 patients were identified: 53 (40.5%) with ovarian or primary peritoneal cancer (OC), 44 (33.6%) with endometrial cancer (EC), 30 (22.9%) with cervical cancer, and 4 (3.1%) with leiomyosarcoma. The patients’ mean age was 70 (range, 65–83) years; 106 (80.9%) were young-old and 25 (19.1%) were old-old. Postoperative complications occurred in 19 (14.5%) patients. Four patients died within six months after surgery, and three died because of disease progression. There was no difference in the survival rates between the two groups among those with OC and EC. Older patients with gynecologic cancers showed good surgical outcomes and tolerable postoperative complications. Therefore, we can safely offer surgical treatment to older patients.
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Gu Y, Cheng H, Cang W, Chen L, Yang J, Xiang Y. Comparison of oncological outcomes in elderly early-stage cervical cancer patients treated with radical surgery or radiotherapy: A real-world retrospective study with propensity score matching. Front Oncol 2023; 13:1019254. [PMID: 36874082 PMCID: PMC9975559 DOI: 10.3389/fonc.2023.1019254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
Objective To compare the oncological outcomes of radical surgery and radical radiotherapy in elderly (over 65 years) patients with early-stage cervical cancer (IB-IIA). Methods Elderly patients with stage IB-IIA cervical cancer treated at Peking Union Medical College Hospital from January 2000 to December 2020 were retrospectively reviewed. All patients were divided into the radiotherapy group (RT group) and the operation group (OP group) according to their primary intervention. Propensity score matching (PSM) analysis was performed to balance the biases. The primary outcome was overall survival (OS), and the secondary outcomes were progression-free survival (PFS) and adverse effects. Results A total of 116 patients were eligible for the study (47 in the RT group, and 69 in the OP group), and after PSM, 82 patients were suitable for further analysis (37 in the RT group, and 45 in the OP group). In the real-world setting, it was found that compared with radiotherapy, operation was more frequently selected for elderly cervical cancer patients with adenocarcinoma (P < 0.001) and IB1 stage cancer (P < 0.001). The 5-year PFS rates between the RT and OP groups were not significant (82.3% vs. 73.6%, P = 0.659), and the 5-year OS rate of the OP group was significantly better than that in the RT group (100% vs. 76.3%, P = 0.039), especially in patients with squamous cell carcinoma (P = 0.029) and tumor size of 2~4 cm with G2 differentiation (P = 0.046). There was no significant difference in PFS between the two groups (P = 0.659). In the multivariate analysis, compared with operation, radical radiotherapy was an independent risk factor of OS (hazard ratio = 4.970, 95% CI, 1.023~24.140, P = 0.047). No difference was observed in adverse effects between the RT and OP groups (P = 0.154) and in ≥grade 3 adverse effects (P = 0.852). Conclusion The study found that surgery was more frequently selected for elderly cervical cancer patients with adenocarcinoma and IB1 stage cancer in the real-world setting. After PSM to balance the biases, it showed that compared with radiotherapy, surgery could improve the OS of elderly early-stage cervical cancer patients and was an independent protective factor of OS in elderly early-stage cervical cancer patients.
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Affiliation(s)
- Yu Gu
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyan Cheng
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Chen
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Chen W, Xia X, Xie X, Wei Y, Wu R, Cai W, Hong J. Nomogram for prognosis of elderly patients with cervical cancer who receive combined radiotherapy.. [DOI: 10.21203/rs.3.rs-2367005/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Abstract
Objective: This retrospective study identified prognostic factors to help guide the clinical treatment of elderly patients (≥65 y) with cervical cancer who had undergone radiotherapy. A personalized model to predict 3- and 5-year survival was developed.
Methods: A review was conducted of 367 elderly women with cervical cancer (staged II-III) who had undergone radiotherapy in our hospital between January 2012 and December 2016. The Cox proportional hazards regression model was used for survival analysis that considered age, hemoglobin, squamous cell carcinoma antigen, pathologic type, stage, pelvic lymph node metastasis status, and others. A nomogram was constructed to predict the survival rates.
Results: The median follow-up time was 71 months (4-118 mo). The 3- (5-) year overall, progression-free, local recurrence-free, and distant metastasis-free survival rates were, respectively, 91.0% (84.4%), 92.3% (85.9%), 99.18% (99.01%), and 99.18% (97.82%). The following were significant independent prognostic factors for overall survival: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The C-index of the line chart was 0.699 (95% CI: 0.652-0.746). The areas under the receiver operating characteristic curves for 3- and 5-year survival were 0.751 and 0.724. The nomogram was in good concordance with the actual survival rates.
Conclusions: The independent prognostic factors for overall survival in elderly patients with cervical cancer after radiotherapy were: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The novel prognostic nomogram based on these factors can be an asset for personalized clinical management.
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Affiliation(s)
- Wenjuan Chen
- Department of Radiation Oncology, Department of Gynecology,Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital
| | - Xiaoyi Xia
- Department of Radiation Oncology, Department of Gynecology,Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital
| | - Xingyun Xie
- Department of Radiation Oncology, Department of Gynecology,Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital
| | - Yuting Wei
- Department of Radiation Oncology, Department of Gynecology,Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital
| | - Rongrong Wu
- Department of Radiation Oncology, Department of Gynecology,Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital
| | - Wenjie Cai
- Department of Radiation Oncology, First Hospital of Quanzhou Affiliated to Fujian Medical University
| | - Jingsheng Hong
- Department of Radiotherapy, Cancer Center,The First Affiliated Hospital of Fujian Medical University
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Pecorino B, D’Agate MG, Scibilia G, Scollo P, Giannini A, Di Donna MC, Chiantera V, Laganà AS. Evaluation of Surgical Outcomes of Abdominal Radical Hysterectomy and Total Laparoscopic Radical Hysterectomy for Cervical Cancer: A Retrospective Analysis of Data Collected before the LACC Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13176. [PMID: 36293758 PMCID: PMC9603513 DOI: 10.3390/ijerph192013176] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 05/03/2023]
Abstract
Although a surgical approach is one of the key treatments for stages IA1-IIA2, results of the Laparoscopic Approach to Cervical Cancer (LACC) published in 2018 radically changed the field, since minimally invasive surgery was associated with a four-fold higher rate of recurrence and a six-fold higher rate of all-cause death compared to an open approach. We aimed to evaluate surgical outcomes of abdominal radical hysterectomy (ARH) and total laparoscopic radical hysterectomy (TLRH) for cervical cancer, including data collected before the LACC trial. In our retrospective analysis, operative time was significantly longer in TLRH compared to ARH (p < 0.0001), although this disadvantage could be considered balanced by lower intra-operative estimated blood loss in TLRH compared with ARH (p < 0.0001). In addition, we did not find significant differences for intra-operative (p = 0.0874) and post-operative complication rates (p = 0.0727) between ARH and TLRH. This was not likely to be influenced by age and Body Mass Index, since they were comparable in the two groups (p = 0.0798 and p = 0.4825, respectively). Finally, mean number of pelvic lymph nodes retrieved (p = 0.153) and nodal metastases (p = 0.774), as well as death rate (p = 0.5514) and recurrence rate (p = 0.1582) were comparable between the two groups. Future studies should be aimed at assessing whether different histology/grades of cervical cancer, as well as particular subpopulations, may have significantly different outcomes using minimally invasive surgery or laparotomy, with or without neoadjuvant chemotherapy.
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Affiliation(s)
- Basilio Pecorino
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, University of Enna “Kore”, 95126 Catania, Italy
| | - Maria Gabriella D’Agate
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, University of Enna “Kore”, 95126 Catania, Italy
| | - Giuseppe Scibilia
- Obstetrics and Gynecology, “Giovanni Paolo II” Hospital, 97100 Ragusa, Italy
| | - Paolo Scollo
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, University of Enna “Kore”, 95126 Catania, Italy
| | - Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in “Translational Medicine and Oncology”, Sapienza University, 00185 Rome, Italy
| | - Mariano Catello Di Donna
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, 90127 Palermo, Italy
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
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Yunokawa M, Onda T, Ishikawa M, Yaegashi N, Kanao H. Current treatment status of older patients with gynecological cancers. Jpn J Clin Oncol 2022; 52:825-832. [PMID: 35640242 DOI: 10.1093/jjco/hyac082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/29/2022] [Indexed: 11/14/2022] Open
Abstract
The percentage of older patients with gynecological malignancies has recently been on the rise. Although prospective studies focusing on the treatment of older patients have been conducted for ovarian cancer, mainly in Europe, there have been scarce literature on cervical and endometrial cancers, and information on their treatment is currently lacking. One of the characteristics of older patients is that not only their performance status but also other factors, such as physical, mental and social factors, cause a large variability, and individual differences in their response to treatments. One of the major issues in the treatment of older patients is how to objectively measure these individual differences and link them to the appropriate treatment selection. In this review, clinical evidence for the guided treatment of older patients with gynecological cancer will be reviewed.
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Affiliation(s)
- Mayu Yunokawa
- Department of Gynecology, The Cancer Institute Hospital of JFCR, Tokyo, Japan
- Department of Medical Oncology, The Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Takashi Onda
- Department of Gynecological Oncology & Gynecology, Sanno Hospital, Tokyo, Japan
| | - Mitsuya Ishikawa
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Hiroyuki Kanao
- Department of Gynecology, The Cancer Institute Hospital of JFCR, Tokyo, Japan
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7
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Impact of frailty in benign gynecologic surgery: a systematic review. Int Urogynecol J 2021; 32:2921-2935. [PMID: 34357431 DOI: 10.1007/s00192-021-04942-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Frailty has been associated with increased risks of perioperative complications. This systematic review explores the associations between preoperative frailty and perioperative complications in benign gynecologic surgery. METHODS A comprehensive, systematic literature search was conducted using the PubMed interface for Medline, Embase, and Scopus databases through August 12, 2020. Articles were included if they described the utilization of frailty assessment tools in benign gynecologic patients in the pre- or perioperative setting. Study quality and evidence were evaluated by the Cochrane Risk of Bias Tool in Non-Randomized Studies and Grading of Recommendations, Assessments, Development, and Evaluations criteria. RESULTS One thousand one hundred twenty unique citations were identified, and five studies assessing frailty and perioperative outcomes were included. Three retrospective cohort studies utilized the American College of Surgeons National Surgical Quality Improvement Program database to assess the impact of frailty on perioperative outcomes in hysterectomies and pelvic organ prolapse repair procedures. One retrospective cohort study utilized a California database to assess frailty in prolapse repair surgeries. One cross-sectional study assessed frailty in new urogynecology patient visits. Four of these studies found that preoperative frailty is associated with an increased risk of perioperative complications. Overall, the evidence from the included studies is of low quality and at moderate to critical risk of bias. CONCLUSIONS There are few studies assessing the impact of frailty on perioperative complications in benign gynecologic surgery. This review demonstrates that preoperative frailty is significantly associated with adverse perioperative outcomes, but additional studies are needed to further explore this association.
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Xie S, Pan S, Zou S, Zhu H, Zhu X. Characteristics and Treatments of Patients Aged 65 Years or Over with Cervical Cancer. Clin Interv Aging 2020; 15:841-851. [PMID: 32606624 PMCID: PMC7293398 DOI: 10.2147/cia.s255305] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/11/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Although the mortality of elderly women with cervical cancer is high, their characteristics and prognosis have not attracted sufficient attention. This study aims to clarify the prognostic factors of cervical cancer patients aged ≥65. Patient and Methods The incidences and characteristics of patients diagnosed with cervical cancer (aged ≥65 and <65) during 2004–2015 were obtained through the Surveillance, Epidemiology, and End Results Program (SEER) database. The differences of distributions of characteristics between two age groups were compared by chi-squared (χ2) test. Kaplan–Meier survival method, Log-rank test, Cox-regression and visual nomogram were utilized for survival analysis. Results The annual incidences of two age groups with cervical cancer were (5.5–7.5)/100,000 and (3.4–3.9)/100,000, respectively, during 2004–2015. The 1-year and 5-year cancer-specific survival rates of old patients were both lower than those of young patients (P <0.001). The proportions of unmarried state and advanced International Federation of Gynecology and Obstetrics (FIGO) stage in old patients were higher than those in relatively young patients, and fewer elderly patients received surgery. Univariate and multivariate survival analysis showed non-squamous cell carcinoma, poor differentiation and late FIGO stage were independent poor prognostic factors for patients aged ≥65. Treatments improved the outcomes of elderly patients, and the effect of surgery was better than non-surgical treatment on elderly patients with FIGO I. Besides, geriatric score and survival probability could be accomplished by our nomogram with a c-index of 0.7945. Conclusion Delayed diagnosis and insufficient treatment were two distinct features of elderly patients and correlated with their poor clinical outcomes. More attention and active treatments should be adopted in elderly women based on their general condition.
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Affiliation(s)
- Shangdan Xie
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Shuya Pan
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Shuangwei Zou
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Haiyan Zhu
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xueqiong Zhu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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Kissel M, Rambeau A, Achkar S, Lecuru F, Mathevet P. Challenges and advances in cervix cancer treatment in elder women. Cancer Treat Rev 2020; 84:101976. [PMID: 32006796 DOI: 10.1016/j.ctrv.2020.101976] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/18/2023]
Abstract
With population ageing, cancer treatments in elder patients is becoming a true public health care issue. There is an authentic dilemma between patient's frailty, residual life expectancy and the toll that take anticancer treatments. Since elder patients are almost always excluded from clinical trials, it is hard to get robust scientific data on the tolerability of oncologic treatments and to set in place recommendations. Cervix cancer is traditionally diagnosed in younger women but it has a 2nd incidence peak between 60 and 70 years old. Cervix cancer in elder patients is a subject to many questions in terms of screening and is a therapeutic challenge. This article reviews literature data on these different aspects, from screening to surgery, from radiotherapy to brachytherapy, from chemotherapy to supportive care, from immunotherapy to geriatric assessment. We tried to show how modern therapeutic innovations may benefit elder patients. Expected benefits in terms of efficacy and toxicity may overcome the long-lasting tendency to undertreatment in elder patients and improve their quality of life after cancer treatment. In 2020, there seems to be less and less reasons justifying that elder women with cervix cancer may not receive the appropriate treatment.
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Affiliation(s)
- M Kissel
- Radiation Oncology Department, Institut Gustave Roussy, Villejuif, France.
| | - A Rambeau
- Department of Medical Oncology, Centre François Baclesse, ARCHADE, Caen, France
| | - S Achkar
- Radiation Oncology Department, Institut Gustave Roussy, Villejuif, France
| | - F Lecuru
- Department of Gynecologic Oncology, Georges Pompidou European Hospital, Paris, France
| | - P Mathevet
- Gynecology Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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10
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Sammarco AG, Morgan DM, Kamdar NS, Swenson CW. Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse. Int Urogynecol J 2018; 30:753-759. [PMID: 29934768 DOI: 10.1007/s00192-018-3696-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/11/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary. STUDY DESIGN The Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. "Pessary offer" was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated. RESULTS The adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12-1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30-2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16-1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar. CONCLUSIONS Overall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling-suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.
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Affiliation(s)
- Anne G Sammarco
- Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Daniel M Morgan
- Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Neil S Kamdar
- Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI, USA.,Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, Michigan Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
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11
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Dos Reis R, Andrade CEMC, Frumovitz M, Munsell M, Ramirez PT. Radical Hysterectomy and Age: Outcomes Comparison Based on a Minimally Invasive vs an Open Approach. J Minim Invasive Gynecol 2018. [PMID: 29530834 DOI: 10.1016/j.jmig.2018.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To compare outcomes of radical hysterectomy (RH) across age groups based on surgical approach: minimally invasive surgery (MIS) vs laparotomy (LP). DESIGN Cross-sectional retrospective review (Canadian Task Force classification II-2). SETTING Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center. PATIENTS Patients with early-stage cervical cancer who underwent RH at a tertiary cancer center between 1990 and 2013. INTERVENTIONS Patients were stratified by age group (<50, 50-59, and ≥60 years) and by surgical approach (minimally invasive surgery [MIS] vs laparotomy [LP]). MEASUREMENTS AND MAIN RESULTS Patients with early-stage cervical cancer who underwent RH were retrospectively reviewed to obtain demographic data, surgical data, and clinical outcomes. We used the Fisher exact, Wilcoxon rank-sum, and Cochran-Mantel-Haenszel tests to compare categorical and continuous variables stratified by surgical approach and age group. A total of 548 patients were evaluated, including 427 (77.9%) who underwent LP (age <50, 84.3%; 50-59, 11.2%; ≥60, 4.5%) and 121 (22.1%) who underwent MIS (age <50, 71.9%; 50-59, 17.3%; ≥60, 10.8%). In the MIS group, 71 patients (58.7%) underwent laparoscopy and 50 (41.3%) underwent robotic surgery. Patients in the MIS group were significantly older and heavier than those in the LP group. The operative time was significantly longer in the MIS group. There was no between-group difference in intraoperative complications in any of the 3 age groups. LP patients had more infectious complications (respiratory, systemic, and wound) than MIS patients in the <50-year age group (53.3% vs 21.8%). The difference between the LP and MIS groups with respect to the postoperative noninfectious complication rate was greatest in the ≥60-year age group (p = .0324). CONCLUSION The between-group difference in postoperative noninfectious complication rate in the oldest age group was twice that in either of the other 2 age groups (p = .0324), even though the MIS patients were older, heavier, and had a longer operative time compared with the LP patients.
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Affiliation(s)
- Ricardo Dos Reis
- Gynecologic Oncology Department, Barretos Cancer Hospital, São Paulo, Brazil
| | | | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, Houston, Texas
| | - Mark Munsell
- Division of Quantitative Sciences, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, Houston, Texas.
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12
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Patterns of Care and Outcome of Elderly Women Diagnosed With Cervical Cancer in the Developing World. Int J Gynecol Cancer 2018; 26:1246-51. [PMID: 27465885 DOI: 10.1097/igc.0000000000000756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Scarce data exist about the impact of age in cervical cancer (CC) patients in the developing world. The objective of the current study was to examine the patterns of care and outcome of elderly patients treated in a developing country. Medical records of patients treated from 2006-2009 at the Brazilian National Cancer Institute were reviewed. Patients were divided between women 70 years or older and women younger than 70 years. The χ tests were used and odds ratios were calculated. Survival was examined using the Kaplan-Meier method. Single and multivariate Cox proportional hazards modeling were used. A total of 1482 patients were analyzed: 1339 patients younger than 70 years and 143 patients 70 years or older. A marked difference in treatment was noted, even after stratifying by disease stage. Only 21% of the older patients underwent surgical treatment compared with 27.6% of the younger. After adjusting for confounding variables, the hazard ratio for death from CC in the elderly was 1.05 (95% confidence interval, 0.81-1.36; P = 0.11). These results corroborate previous data from developed countries: elderly patients have more advanced disease at diagnosis, and age is an important factor in the allocation of treatment for patients with CC. Worse outcome seemed to be mainly the result of more advanced stage and treatment allocation rather than age itself.
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13
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Yuan J, Malin B, Modave F, Guo Y, Hogan WR, Shenkman E, Bian J. Towards a privacy preserving cohort discovery framework for clinical research networks. J Biomed Inform 2017; 66:42-51. [PMID: 28007583 PMCID: PMC5316314 DOI: 10.1016/j.jbi.2016.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/06/2016] [Accepted: 12/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The last few years have witnessed an increasing number of clinical research networks (CRNs) focused on building large collections of data from electronic health records (EHRs), claims, and patient-reported outcomes (PROs). Many of these CRNs provide a service for the discovery of research cohorts with various health conditions, which is especially useful for rare diseases. Supporting patient privacy can enhance the scalability and efficiency of such processes; however, current practice mainly relies on policy, such as guidelines defined in the Health Insurance Portability and Accountability Act (HIPAA), which are insufficient for CRNs (e.g., HIPAA does not require encryption of data - which can mitigate insider threats). By combining policy with privacy enhancing technologies we can enhance the trustworthiness of CRNs. The goal of this research is to determine if searchable encryption can instill privacy in CRNs without sacrificing their usability. METHODS We developed a technique, implemented in working software to enable privacy-preserving cohort discovery (PPCD) services in large distributed CRNs based on elliptic curve cryptography (ECC). This technique also incorporates a block indexing strategy to improve the performance (in terms of computational running time) of PPCD. We evaluated the PPCD service with three real cohort definitions: (1) elderly cervical cancer patients who underwent radical hysterectomy, (2) oropharyngeal and tongue cancer patients who underwent robotic transoral surgery, and (3) female breast cancer patients who underwent mastectomy) with varied query complexity. These definitions were tested in an encrypted database of 7.1 million records derived from the publically available Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). We assessed the performance of the PPCD service in terms of (1) accuracy in cohort discovery, (2) computational running time, and (3) privacy afforded to the underlying records during PPCD. RESULTS The empirical results indicate that the proposed PPCD can execute cohort discovery queries in a reasonable amount of time, with query runtime in the range of 165-262s for the 3 use cases, with zero compromise in accuracy. We further show that the search performance is practical because it supports a highly parallelized design for secure evaluation over encrypted records. Additionally, our security analysis shows that the proposed construction is resilient to standard adversaries. CONCLUSIONS PPCD services can be designed for clinical research networks. The security construction presented in this work specifically achieves high privacy guarantees by preventing both threats originating from within and beyond the network.
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Affiliation(s)
- Jiawei Yuan
- Department of Electrical, Computer, Software, & Systems Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL, United States
| | - Bradley Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States
| | - François Modave
- Health Outcomes & Policy, University of Florida, Gainesville, FL, United States
| | - Yi Guo
- Health Outcomes & Policy, University of Florida, Gainesville, FL, United States
| | - William R Hogan
- Health Outcomes & Policy, University of Florida, Gainesville, FL, United States
| | - Elizabeth Shenkman
- Health Outcomes & Policy, University of Florida, Gainesville, FL, United States
| | - Jiang Bian
- Health Outcomes & Policy, University of Florida, Gainesville, FL, United States.
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14
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Youngerman BE, Zacharia BE, Hickman ZL, Bruce JN, Solomon RA, Benzil DL. Making Milestones. Neurosurgery 2016; 79:492-8. [DOI: 10.1227/neu.0000000000001126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Lin MY, Kondalsamy-Chennakesavan S, Bernshaw D, Khaw P, Narayan K. Carcinoma of the cervix in elderly patients treated with radiotherapy: patterns of care and treatment outcomes. J Gynecol Oncol 2016; 27:e59. [PMID: 27550405 PMCID: PMC5078822 DOI: 10.3802/jgo.2016.27.e59] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/18/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this analysis was to examine the management of cervix cancer in elderly patients referred for radiotherapy and the results of treatment in terms of overall survival (OS), relapse-free survival (RFS), and treatment-related toxicities. METHODS Patients were eligible if they were aged ≥75 years, newly diagnosed with cervix cancer and referred for radiotherapy as part of their treatment. Patient details were retrieved from the gynaecology service database where clinical, histopathological treatment and follow-up data were prospectively collected. RESULTS From 1998 to 2010, 126 patients aged ≥75 years, met selection criteria. Median age was 81.5 years. Eighty-one patients had definitive radiotherapy, 10 received adjuvant radiotherapy and 35 had palliative radiotherapy. Seventy-one percent of patients had the International Federation of Gynecology and Obstetrics stage 1b-2b disease. Median follow-up was 37 months. OS and RFS at 3 years among those treated with curative intent were 66.6% and 75.9% respectively with majority of patients dying without any evidence of cervix cancer. Grade 2 or more late toxicities were: bladder 5%, bowel 11%, and vagina 27%. Eastern Cooperative Oncology Group (ECOG) status was a significant predictor of OS and RFS with each unit increment in ECOG score increased the risk of death by 1.69 times (p<0.001). CONCLUSION Following appropriate patient selection, elderly patients treated curatively with radiotherapy for cervix cancer have good disease control. Palliative hypofractionated regimens are well tolerated in patients unsuitable for radical treatment.
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Affiliation(s)
- Ming Yin Lin
- Gynae-Oncology Unit, Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Srinivas Kondalsamy-Chennakesavan
- Gynae-Oncology Unit, Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,Rural Clinical School, The University of Queensland School of Medicine, Toowoomba, Queensland, Australia
| | - David Bernshaw
- Gynae-Oncology Unit, Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Pearly Khaw
- Gynae-Oncology Unit, Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kailash Narayan
- Gynae-Oncology Unit, Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
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16
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Rodrigues MJ, Zapardiel I, Frélaut M, Brain E, Falandry C. A call for specific geriatric data on cervical cancers. Future Oncol 2016; 12:1101-4. [PMID: 26955977 DOI: 10.2217/fon-2016-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Maxime Frélaut
- Department of Medical Oncology, Institut Curie, Paris, France
| | - Etienne Brain
- Department of Medical Oncology, Institut Curie, Saint-Cloud, France
| | - Claire Falandry
- Geriatrics & Oncology Unit, Lyon Sud University Hospital, CarMEN Laboratory, Lyon University, France
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17
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Youngerman BE, Chan AK, Mikell CB, McKhann GM, Sheth SA. A decade of emerging indications: deep brain stimulation in the United States. J Neurosurg 2016; 125:461-71. [PMID: 26722851 DOI: 10.3171/2015.7.jns142599] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an emerging treatment option for an expanding set of neurological and psychiatric diseases. Despite growing enthusiasm, the patterns and implications of this rapid adoption are largely unknown. National trends in DBS surgery performed for all indications between 2002 and 2011 are reported. METHODS Using a national database of hospital discharges, admissions for DBS for 14 indications were identified and categorized as either FDA approved, humanitarian device exempt (HDE), or emerging. Trends over time were examined, differences were analyzed by univariate analyses, and outcomes were analyzed by hierarchical regression analyses. RESULTS Between 2002 and 2011, there were an estimated 30,490 discharges following DBS for approved indications, 1647 for HDE indications, and 2014 for emerging indications. The volume for HDE and emerging indications grew at 36.1% annually in comparison with 7.0% for approved indications. DBS for emerging indications occurred at hospitals with more neurosurgeons and neurologists locally, but not necessarily at those with the highest DBS caseloads. Patients treated for HDE and emerging indications were younger with lower comorbidity scores. HDE and emerging indications were associated with greater rates of reported complications, longer lengths of stay, and greater total costs. CONCLUSIONS DBS for HDE and emerging indications underwent rapid growth in the last decade, and it is not exclusively the most experienced DBS practitioners leading the charge to treat the newest indications. Surgeons may be selecting younger and healthier patients for their early experiences. Differences in reported complication rates warrant further attention and additional costs should be anticipated as surgeons gain experience with new patient populations and targets.
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Affiliation(s)
- Brett E Youngerman
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Charles B Mikell
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Sameer A Sheth
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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Abstract
OBJECTIVE While the last 3 decades have seen numerous advances in the treatment of cervical cancer, it remains unclear if population-level survival has improved. We examined relative survival, the ratio of survival in cervical cancer patients to matched controls over time. STUDY DESIGN Patients with cervical cancer diagnosed from 1983 through 2009 and recorded in the Surveillance, Epidemiology, and End Results database were examined. Survival models were adjusted for age, race, stage, year of diagnosis, and time since diagnosis. Changes in stage-specific relative survival for patients with cervical cancer compared to the general population matched by age, race, and calendar year were examined over time. RESULTS A total of 46,932 patients were identified. For women with stage I tumors, the excess hazard ratio for women diagnosed in 2009 was 0.91 (95% confidence interval [CI], 0.86-0.95) compared to 2000, 0.81 (95% CI, 0.73-0.91) compared to 1990, and 0.75 (95% CI, 0.64-0.88) compared to 1983. For patients with stage III tumors, the excess hazard ratios for patients diagnosed in 2009 (relative to those diagnosed in 2000, 1990, and 1983) were 0.83 (95% CI, 0.80-0.87), 0.68 (95% CI, 0.62-0.75), and 0.59 (95% CI, 0.52-0.68). Similar trends in improved survival over time were noted for women with stage II tumors. There were no statistically significant improvements in relative survival over time for women with stage IV tumors. CONCLUSION Relative survival has improved over time for women with stage I-III cervical cancer, but has changed little for those with metastatic disease.
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19
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George EM, Burke WM, Hou JY, Tergas AI, Chen L, Neugut AI, Ananth CV, Hershman DL, Wright JD. Measurement and validation of frailty as a predictor of outcomes in women undergoing major gynaecological surgery. BJOG 2015; 123:455-61. [PMID: 26301606 DOI: 10.1111/1471-0528.13598] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Frailty is the loss of physical or mental reserve that impairs function, often in the absence of a defined comorbidity. Our aim was to determine whether a modified frailty index (mFI) correlates with morbidity and mortality in patients undergoing hysterectomy. DESIGN Retrospective cohort study. SETTING Hospitals across the USA participating in the National Surgical Quality Improvement Program (NSQIP). SAMPLE Patients who underwent hysterectomy from 2008 to 2012. METHODS An mFI was calculated using 11 variables in NSQIP. The associations between mFI and morbidity and mortality were assessed. Model fit statistics (c-statistics) were utilised to evaluate the ability of mFI to distinguish outcomes. MAIN OUTCOME MEASURE Wound infection, severe complications and mortality. RESULTS A total of 66 105 patients were identified. Wound complications increased from 2.4% in patients with an mFI of zero to 4.8% in those with mFI ≥ 0.5 (P < 0.0001). Similarly, severe complications increased from 0.98% to 7.3% (P < 0.0001), overall complications rose from 3.7% to 14.5% (P < 0.0001) and mortality increased from 0.06% to 3.2% (P < 0.0001) for patients with a frailty index of zero compared with those with an index of ≥ 0.5. Versus chance, the goodness-of-fit c-statistics suggested that mFI increases the ability to detect wound complications by 11.4%, severe complications by 22.0% and overall complications by 11.0%. CONCLUSIONS The mFI is easily reproducible from routinely collected clinical data and predictive of outcomes in patients undergoing hysterectomy. Frailty may be useful in the preoperative risk assessment of women undergoing gynaecological surgery. TWEETABLE ABSTRACT Frailty may be useful in the preoperative risk assessment of women undergoing gynaecological surgery.
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Affiliation(s)
- E M George
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - W M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - J Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - A I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - L Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - A I Neugut
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - C V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - D L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - J D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
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