Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Time to Diagnosis and Treatment for Ovarian Cancer and Associations with Outcomes: A Systematic Review

Background: Ovarian cancer is commonly diagnosed symptomatically at an advanced stage. Better survival for early disease suggests improving diagnostic pathways may increase survival. This study examines literature assessing diagnostic intervals and their association with clinical and psychological outcomes. Methods: Medline, EMBASE, and EmCare databases were searched for studies including quantitative measures of at least one interval, published between January 1, 2000 and August 9, 2022. Interval measures and associations (interval, outcomes, analytic strategy) were synthesized. Risk of bias of association studies was assessed using the Aarhus Checklist and ROBINS-E tool. Results: In total, 65 papers (20 association studies) were included and 26 unique intervals were identified. Interval estimates varied widely and were impacted by summary statistic used (mean or median) and group focused on. Of Aarhus-defined intervals, patient (symptom to presentation, n = 23; range [median]: 7-168 days) and diagnostic (presentation to diagnosis, n = 22; range [median]: 7-270 days) were most common. Nineteen association studies examined survival or stage outcomes with most, including five low risk-of-bias studies, finding no association. Conclusions: Studies reporting intervals for ovarian cancer diagnosis are limited by inconsistent definitions and reporting. Greater utilization of the Aarhus statement to define intervals and appropriate analytic methods is needed to strengthen findings from future studies.

Evaluation of the impact of a protocol for immediate vulvar reconstruction after vulvectomy

Vulvar cancers are usually diagnosed at an advanced stage and require wide surgical resections in the form of vulvectomy. Immediate vulvar reconstruction can potentially reduce the reoperation rate and postoperative complications. With this objective, we introduced a protocol for immediate vulvar reconstruction. This study, five years after its introduction, assesses the impact of this intervention on the postoperative evolution of vulvectomy patients. In January 2017 we introduced a protocol for immediate vulvar reconstruction that considered four criteria of high risk for postoperative dehiscence. Patients who meet the criteria were reconstructed at the time of the vulvectomy. To assess the impact of the protocol, we prospectively registered all included patients over a 5 years period (2017-2022). As a control group, we reviewed the vulvectomised patients at our centre from January 2012 to January 2017 (5 years) who would have met the protocol. No statistically significant differences were found in the epidemiological data (age, diabetes mellitus diagnosis, and obesity diagnosis) or in the tumour characteristics (tumour size). We obtained a statistically significant difference in the incidence of complications and need for reintervention, in favour of the reconstruction group. Our study shows the medical and economic benefits for vulvar cancer patients of immediate vulvar reconstruction.

The effect of 1-day multidisciplinary clinic on breast cancer treatment

PURPOSE

A delay in breast cancer treatment is associated with inferior survival outcomes; however, no clear guidelines exist defining the appropriate time frame from diagnosis to definitive treatment of breast cancer. A multidisciplinary approach for breast cancer treatment can minimize the time from diagnosis to first treatment. We hypothesized single-day multidisciplinary clinic (MDC) may accelerate the time to first treatment on complex breast cancer cases at our institution.

METHODS

We identified patients who were treated at Johns Hopkins for stage II or III breast cancer, who were at least 18 years of age, and were seen in a new single-day MDC with coordination between two or three specialties or by specialists from varying disciplines on different days (IDC). Patients who initiated treatment between May 2015 (initiation of MDC clinic) and December 2017 were included in our study.

RESULTS

A total of 296 patient records were reviewed independently. The mean (SD) patient age was 55 (13) years. The median time to first neoadjuvant chemotherapy (NACT) was significantly reduced for patients seen in the MDC (12.7 days), compared to those seen at the IDC (24.4 days, logrank p < 0.001). The median time to definitive surgery was similar between groups (31 and 32 days for the MDC and IDC cohorts, respectively).

CONCLUSIONS

A single-day MDC visit is associated with a reduced time from diagnosis to NACT. Further studies are needed to determine if a shorter interval can improve the management and the outcome of complex breast cancer cases.

The impact of structural factors on diagnostic delay in diffuse large B-cell lymphoma

BACKGROUND

Reducing diagnostic delays in cancer has been a major interest worldwide; however, the literature on diagnostic delays in lymphoma remains scarce. Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin's lymphoma. We aimed to determine whether certain structural factors predicted diagnostic delays in DLBCL and whether diagnostic delays impacted overall survival (OS).

METHODS

Data were extracted via a retrospective cohort design from a single academic tertiary care referral center. A total of 104 patients were included. Time from first symptoms to diagnosis of <3 months was defined as "early diagnosis" and ≥3 months as "delayed diagnosis". Analysis was performed with student's t-test, chi-square testing, binomial logistic regression, and Kaplan-Meier log-rank testing.

RESULTS

"Delayed diagnosis" was more likely with lower stage, lower international prognostic index (IPI), and further distance from referral center (OR 0.66, CI 0.46-0.95; OR 0.69, CI 0.51-0.94; OR 1.008, CI 1.001-1.015). Patients of "other" ethnicity and without medical insurance were more likely to have significant diagnostic delays and worse overall survival (P = 0.002 and P = 0.007, respectively). Diagnostic delays of ≥3 months did not predict worse OS. However, delays of >6 months did predict worse OS.

CONCLUSION

Our data suggest that excessive diagnostic delays of more than 6 months, ethnic minority status, and uninsured status in DLBCL may lead to worse outcomes. Efforts should be undertaken to reduce excessive diagnostic delays. More investigation needs to be done on the impacts of diagnostic delays in both DLBCL and other aggressive lymphomas.

Impact of somatic molecular profiling on clinical trial outcomes in rare epithelial gynecologic cancer patients

OBJECTIVES

Conducting clinical trials in rare malignancies is challenging due to the limited number of patients and differences in biologic behavior. We investigated the feasibility and clinical utility of using genomic profiling for rare gynecologic malignancies.

METHODS

Rare epithelial gynecologic cancer patients were analyzed for somatic variants through an institutional molecular profiling program using the Sequenom MassArray platform or the TruSeq Amplicon Cancer Panel on the MiSeq platform. Clinical trial outcomes by RECIST 1.1, and time on treatment were evaluated.

RESULTS

From March 2012 to November 2015, 767 gynecologic patients were enrolled and 194 (27%) were classified as rare epithelial malignancies. At least one somatic mutation was identified in 72% of patients, most commonly in TP53 (39%), KRAS (28%) and PIK3CA (27%). A total of 14% of patients were treated on genotype-matched trials. There were no significant differences in overall response rate between genotype-matched versus unmatched trials, nor in median time on treatment between genotype trials and the immediate prior systemic standard treatment. Among 13 evaluable Low Grade Serous ovarian cancer patients treated on genotype-matched trials with MEK inhibitor-based targeted combinations, there were four partial responses.

CONCLUSIONS

Somatic molecular profiling is feasible and enables the identification of patients with rare gynecologic cancers who are candidates for genotype-matched clinical trials. Genotype-matched trials, predominantly MEK-based combinations in KRAS and/or NRAS mutant Low Grade Serous ovarian cancer patients, and genotype-unmatched trials, have shown potential clinical activity. Prospective trials with integrated genotyping are warranted to assess the clinical utility of next generation sequencing tests as a standard clinical application in rare malignancies.

Vulvar cancer: Two pathways with different localization and prognosis

BACKGROUND

Two etiologic pathways for vulvar squamous cell carcinoma (SCC) are described: in a background of lichen sclerosus and/or differentiated vulvar intraepithelial neoplasia and related to high-risk human papillomavirus (HPV) infection with high grade squamous intraepithelial lesion (HSIL) as precursor. The aim was to compare the predilection site and survival of HPV-related to non HPV-related vulvar SCCs.

METHODS

Data of patients treated for primary vulvar SCC at the Radboudumc between March 1988 and January 2015 were analyzed. All histological specimens were tested for HPV with the SPF₁₀/DEIA/LiPA₂₅ system assay and p16^INK4a staining was performed using CINtec® histology kit. Vulvar SCCs were considered HPV-related in case of either >25% p16^INK4a expression and HPV positivity or >25% p16^INK4a expression and HSIL next to the tumor without HPV positivity. Tumor localization, disease specific survival (DSS), disease free survival (DFS) and overall survival (OS) of patients with HPV-related and non HPV-related vulvar SCC were compared.

RESULTS

In total 318 patients were included: 55 (17%) had HPV-related (Group 1) and 263 (83%) had non HPV-related vulvar SCC (Group 2). Tumors in Group 1 were significantly more often located at the perineum compared to Group 2, 30% and 14%, respectively (p=0.001). The DSS, DFS and OS were significantly better in HPV-related than in non HPV-related vulvar SCC patients.

CONCLUSION

HPV-related vulvar SCCs are more frequently located at the perineum and have a favorable prognosis compared to non HPV-related vulvar SCCs. Both localization and HPV-relation could explain this favorable prognosis. HPV-related vulvar SCC seems to be a separate entity.

Potential delay in the diagnosis of vulvar cancer and associated risk factors in women treated in German gynecological practices

The goal of this study was to estimate a potential delay in the diagnosis of vulvar cancer and identify associated risk factors in women treated in gynecological practices in Germany. The current study sample included 1,652 women from 218 gynecological practices who received an initial diagnosis of vulvar cancer (ICD 10: C51) between January 2000 and December 2015 (index date). After applying several exclusion criteria, 505 non-cancer controls were matched (1:1) to 505 vulvar cancer cases based on age, health insurance status, and index date. The primary outcome was the delay in vulvar cancer diagnosis in women who had received an initial diagnosis of diseases of Bartholin's gland, inflammation of vagina and vulva, or other specified noninflammatory disorders of vulva, including atrophy, hypertrophy, and cyst. A logistic regression model was used to estimate the association between vulvar cancer and pre-defined diagnoses. The mean age was 60.8 years (SD = 15.6 years), and 4.8% of women had private health insurance coverage. Inflammation of vagina and vulva was diagnosed 328 days (SD = 95 days) prior to the detection of vulvar cancer. This delay was 186 days (SD = 196 days) in patients affected by diseases of Bartholin’s gland and 300 days (SD = 116 days) in those with other specified noninflammatory disorders of vulva including atrophy, hypertrophy, and cyst. The risk of vulvar cancer was positively associated with inflammation of vagina and vulva (OR = 2.28) and other specified noninflammatory disorders of vulva (OR = 5.39). The mean potential delay of vulvar cancer diagnosis ranged from 186 to 328 days.

Diagnostic and referral intervals for Manitoba women with epithelial ovarian cancer - the Manitoba Ovarian Cancer Outcomes (MOCO) study group: a retrospective cross-sectional study

BACKGROUND

Epithelial ovarian cancer has the highest mortality of all gynecologic cancers. The poor survival rates are often attributed to the advanced stage at which most of these cancers are detected. We sought to examine the effects of patient demographics, comorbidities and presenting symptoms on diagnostic and referral intervals by location of first presentation (emergency department v. elsewhere) and to identify factors that affect these intervals.

METHODS

We performed a retrospective analysis of chart and medical record data for ovarian cancers, with the exceptions of sex cord and germ cell tumours, diagnosed between 2004 and 2010 in Manitoba, Canada. Data were collected on baseline characteristics, time to diagnosis and referral, number and type of physician visits and emergency department visits.

RESULTS

The final cohort consisted of 601 patients. Sixty-three percent of patients received their diagnosis within 60 days of initial presentation, and 75.2% had their cancer diagnosed within 2 physician encounters. The median diagnostic interval for all stages of patients presenting to the emergency department was 7 days, compared with 55 days for patients presenting elsewhere. Early stage patients not presenting to the emergency department had their diagnosis a median of 34.0 days later than patients with advanced disease (95% confidence interval [CI] 22.22 to 45.69, p < 0.0001). The presence of some symptoms was associated with shortened diagnostic intervals. Patients with serous, clear-cell or endometrioid histotypes were less likely to have first presentation beginning in the emergency department (odds ratio [OR] 0.40, 95% CI 0.24 to 0.64, p = 0.0001; OR 0.28, 95% CI 0.14 to 0.59, p = 0.007) than those with unclassified epithelial histotype.

INTERPRETATION

For this group of patients, the main factor associated with diagnostic and referral intervals is presentation to the emergency department. These patients likely required more urgent attention for their more symptomatic disease, leading to quicker diagnosis and referral patterns, despite poorer prognosis.

Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review

BACKGROUND

It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations.

METHODS

Systematic review of the literature and narrative synthesis.

RESULTS

We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma.

CONCLUSIONS

This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.

Effect of desire to have a baby on risk acceptance in Turkish infertile women

The aim of this study was to assess whether the desire to escape the psychological condition created by infertility (to have a baby) affected risk-taking behavior, with the possible relationship between ovarian cancer and infertility as the "accepted risk" to overcome infertility. 229 infertile and 204 fertile women who were patients at the Gulhane Military Medical Academy were administered a semistructured questionnaire. Increased ovarian cancer risk was accepted by 67.2% of the infertile women in order to have baby. There was no significant relation between the woman's age, duration of infertility, knowledge of the preventability and curability of ovarian cancer, or acceptable risk. These results indicate the importance to Turkish women of overcoming infertility.

[Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]

INTRODUCTION

The prostate cancer is an important cause of men's mortality in our society.

PURPOSE

To know the time of delay in to realise the surgical treatment of the prostate cancer.

MATERIALS AND METHODS

Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process.

RESULTS

Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7.

CONCLUSIONS

There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.