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Mitric C, Yang K, Bhat G, Lheureux S, Laframboise S, Li X, Bouchard-Fortier G. Gestational trophoblastic neoplasia: does centralization of care impact clinical management? Int J Gynecol Cancer 2023; 33:1724-1732. [PMID: 37723102 DOI: 10.1136/ijgc-2023-004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVE International societies advocate for gestational trophoblastic neoplasia referral to designated expert centers. This study assessed the impact of centralization of trophoblastic care on clinical outcomes. METHODS A centralized program was implemented in 2018 at two affiliated academic hospitals, Princess Margaret Cancer Center and Mount Sinai Hospital. A retrospective analysis of patients treated between 2000 and 2022 was performed and the clinical outcomes were compared before (2000-2017) and after (2018-2022) centralization. Statistical analyses were performed with significance set as p<0.05. RESULTS A total of 94 patients with trophoblastic neoplasia were included: 60 pre-centralization and 34 post-centralization, 79.8% low-risk and 18.1% high-risk. Centralization led to significant improvement for: (1) accurate score documentation (from 37.9% to 89.3%,); (2) contraception counseling (from 67.2% to 96.7%); (3) median time from diagnosis to chemotherapy (from 9 days to 1 day); and (4) incomplete follow-up (from 20.7% to 3.3%) (all p<0.05). First-line chemotherapy for low-risk neoplasia was dactinomycin in 47.9% and 87.0% pre- and post-centralization, respectively (p=0.005). The median number of chemotherapy cycles decreased from seven to four (p=0.01), and the median number of consolidation cycles increased from two to three (p<0.001). Serum human chorionic gonadotropin (hCG) levels of 10 000-100 000 IU/L were significantly associated with longer time to hCG normalization and higher risk of resistance to first-line chemotherapy compared with hCG levels <1000 IU/L. CONCLUSION Centralization of trophoblastic neoplasia care leads to greater guideline compliance, faster chemotherapy initiation, fewer chemotherapy cycles with optimized consolidation, and enhanced surveillance completion. This supports the establishment of trophoblastic neoplasia expert centers.
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Affiliation(s)
- Cristina Mitric
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Kelsey Yang
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Gita Bhat
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephane Laframboise
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Xuan Li
- Department of Biostatistics, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
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Silva VARD, Maestá I, Costa RADA, Campos ADÁ, Braga A, Horowitz N, Elias KM, Berkowitz R. Geographical Health District and Distance Traveled Influence on Clinical Status at Admission of Patients with Gestational Trophoblastic Disease. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e384-e392. [PMID: 37595595 PMCID: PMC10438964 DOI: 10.1055/s-0043-1772179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/12/2023] [Indexed: 08/20/2023] Open
Abstract
OBJECTIVE To assess the potential relationship of clinical status upon admission and distance traveled from geographical health district in women with gestational trophoblastic disease (GTD). METHODS This is a cross-sectional study including women with GTD from the 17 health districts from the São Paulo state (I-XVII), Brazil, referred to the Botucatu Trophoblastic Disease Center (specialized center, district VI), between 1990 and 2018. At admission, hydatidiform mole was assessed according to the risk score system of Berkowitz et al. Gestational trophoblastic neoplasia was evaluated using the International Federation of Gynecology and Obstetrics / World Health Organization (FIGO/WHO) staging/risk score. Data on demographics, clinical status and distance traveled were collected. Multiple regression analyses were performed. RESULTS This study included 366 women (335 hydatidiform mole, 31 gestational trophoblastic neoplasia). The clinical status at admission and distance traveled significantly differed between the specialized center district and other districts. Patients referred from health districts IX (β = 2.38 [0.87-3.88], p = 0.002) and XVI (β = 0.78 [0.02-1.55], p = 0.045) had higher hydatidiform mole scores than those from the specialized center district. Gestational trophoblastic neoplasia patients from district XVI showed a 3.32 increase in FIGO risk scores compared with those from the specialized center area (β = 3.32, 95% CI = 0.78-5.87, p = 0.010). Distance traveled by patients from districts IX (200km) and XVI (203.5km) was significantly longer than that traveled by patients from the specialized center district (76km). CONCLUSION Patients from health districts outside the specialized center area had higher risk scores for both hydatidiform mole and gestational trophoblastic neoplasia at admission. Long distances (>80 km) seemed to adversely influence gestational trophoblastic disease clinical status at admission, indicating barriers to accessing specialized centers.
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Affiliation(s)
| | - Izildinha Maestá
- Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
- Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, São Paulo State University, Botucatu, SP, Brazil.
| | - Roberto Antonio de Araújo Costa
- Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
- Scientific Initiation Program by the São Paulo Research Foundation, Botucatu Medical School, São Paulo, SP, Brazil.
| | - Aline de Ávila Campos
- Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
- Scientific Initiation Program by the São Paulo Research Foundation, Botucatu Medical School, São Paulo, SP, Brazil.
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of the Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.
| | - Neil Horowitz
- Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Kevin M. Elias
- Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Ross Berkowitz
- Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
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Winter MC, Tidy JA, Singh K, Sarwar N, Aguiar X, Seckl MJ. Efficacy analysis of single-agent carboplatin AUC4 2-weekly as second-line therapy for methotrexate-resistant (MTX-R) low risk gestational trophoblastic neoplasia (GTN). Gynecol Oncol 2023; 175:66-71. [PMID: 37327541 DOI: 10.1016/j.ygyno.2023.05.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Approximately one-third of patients with low-risk Gestational Trophoblastic Neoplasia (WHO 0-6) develop methotrexate-resistance (MTX-R). In the UK, subsequent treatment with either actinomycin-D (ActD) or multi-agent combination chemotherapy has depended on whether the hCG was above or below an hCG threshold. To reduce exposure to combination chemotherapy (CC), over the years the UK service has raised this threshold as well as using single-agent carboplatin AUC6 3-weekly at MTX-R instead of CC. Updated results for carboplatin demonstrate an 86% complete hCG response (hCG CR) but associated with haematological dose-limiting toxicity. METHODS In 2017, single-agent carboplatin became the national standard second-line treatment following MTX-R at hCG of >3000 IU/L. Carboplatin was changed to two-weekly AUC4 scheduling and continued until normal hCG plus 3 consolidation cycles. For patients failing to respond, CC (Etoposide-Actinomycin-D or EMA-CO) was introduced. RESULTS 22 evaluable patients with a median hCG at MTX-R of 10,147 IU/L (IQR 5527-19,639) received carboplatin AUC4 2-weekly (median no. of cycles = 6, IQR 2-8). Of these, 36% achieved a hCG CR. All 14 non-CR patients were cured with subsequent CC; 11 and 2 patients with 3rd line and 4th line CC respectively and 1 patient following 5th line CC and hysterectomy. Overall survival remains 100%. CONCLUSION Carboplatin is not sufficiently active in the second-line treatment of low-risk MTX-resistant GTN. New strategies are required to increase hCG CR and spare more toxic CC regimens.
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Affiliation(s)
- Matthew C Winter
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK; Department of Oncology and Metabolism, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Kam Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
| | - Michael J Seckl
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
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Albright BB, Ellett T, Knochenhaur HE, Goins EC, Monuszko KA, Kaplan SJ, Previs RA, Moss HA, Havrilesky LJ, Davidson BA. Treatments and outcomes in high-risk gestational trophoblastic neoplasia: A systematic review and meta-analysis. BJOG 2023; 130:443-453. [PMID: 36648416 PMCID: PMC10066712 DOI: 10.1111/1471-0528.17374] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND High-risk gestational trophoblastic neoplasia (GTN) is rare and treated with diverse approaches. Limited published institutional data has yet to be systematically reviewed. OBJECTIVES To compile global high-risk GTN (prognostic score ≥7) cohorts to summarise treatments and outcomes by disease characteristics and primary chemotherapy. SEARCH STRATEGY MEDLINE, Embase, Scopus, ClinicalTrials.gov and Cochrane were searched through March 2021. SELECTION CRITERIA Full-text manuscripts reporting mortality among ≥10 high-risk GTN patients. DATA COLLECTION AND ANALYSIS Binomial proportions were summed, and random-effects meta-analyses performed. MAIN RESULTS From 1137 records, we included 35 studies, representing 20 countries. Among 2276 unique high-risk GTN patients, 99.7% received chemotherapy, 35.8% surgery and 4.9% radiation. Mortality was 10.9% (243/2236; meta-analysis: 10%, 95% confidence interval [CI] 7-12%) and likelihood of complete response to primary chemotherapy was 79.7% (1506/1890; meta-analysis: 78%, 95% CI: 74-83%). Across 24 reporting studies, modern preferred chemotherapy (EMA/CO or EMA/EP) was associated with lower mortality (overall: 8.8 versus 9.5%; comparative meta-analysis: 8.1 versus 12.4%, OR 0.42, 95% CI: 0.20-0.90%, 14 studies) and higher likelihood of complete response (overall: 76.6 versus 72.8%; comparative meta-analysis: 75.9 versus 60.7%, OR 2.98, 95% CI: 1.06-8.35%, 14 studies), though studies focused on non-preferred regimens reported comparable outcomes. Mortality was increased for ultra-high-risk disease (30 versus 7.5% high-risk; meta-analysis OR 7.44, 95% CI: 4.29-12.9%) and disease following term delivery (20.8 versus 7.3% following molar pregnancy; meta-analysis OR 2.64, 95% CI: 1.10-6.31%). Relapse rate estimates ranged from 3 to 6%. CONCLUSIONS High-risk GTN is responsive to several chemotherapy regimens, with EMA/CO or EMA/EP associated with improved outcomes. Mortality is increased in patients with ultra-high-risk, relapsed and post-term pregnancy disease.
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Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Tressa Ellett
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Hope E. Knochenhaur
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Emily C. Goins
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Karen A. Monuszko
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Samantha J. Kaplan
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Rebecca A. Previs
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Brittany A. Davidson
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
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Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Ramírez LAC, Maestá I, Bianconi MI, Jankilevich G, Otero S, Mejía CRV, Cortés-Charry R, Elias KM, Horowitz NS, Seckl M, Berkowitz RS. Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:746-754. [PMID: 35760362 PMCID: PMC9948113 DOI: 10.1055/s-0042-1748974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. METHODS Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. RESULTS A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p = 0.019). CONCLUSION 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.
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Affiliation(s)
- Luz Angela Correa Ramírez
- Postgraduation Program in Tocogynecology of Botucatu Medical School, São Paulo State University Julio de Mesquita Filho - UNESP, Support Program for Foreign Doctoral Students (PAEDEx/UNESP) Botucatu, SP, Brazil.,Clinical Department, Universidad de Caldas, Manizales, Caldas, Colombia
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University Julio de Mesquita Filho - UNESP, Botucatu, SP, Brazil
| | - María Inés Bianconi
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Jankilevich
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Silvina Otero
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Rafael Cortés-Charry
- Department of Obstetrics and Gynecology, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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7
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Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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8
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Braga A, Elias KM, Horowitz NS, Berkowitz RS. Treatment of high-risk gestational trophoblastic neoplasia and chemoresistance/relapsed disease. Best Pract Res Clin Obstet Gynaecol 2021; 74:81-96. [PMID: 33622563 DOI: 10.1016/j.bpobgyn.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/05/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
High-risk gestational trophoblastic neoplasia (GTN) has an increased risk of developing chemoresistance to single-agent chemotherapy; therefore, the primary treatment should be a multiagent etoposide-based regimen, preferably EMA/CO. After remission (normalization of human chorionic gonadotropin - hCG), at least three consolidation courses of EMA-CO are needed to reduce the risk of relapse. Chemoresistance is diagnosed during treatment if hCG levels plateau/increase, in two consecutive values over a two-week period. When this occurs after remission, in the absence of a new pregnancy, there is a relapse. In both cases, after re-assessment of the extent of disease, EMA-EP is the most common chemotherapy choice. Even in these cases, remission rates are high. After remission is achieved, hCG should be measured monthly for a year. Pregnancy can be allowed after 12 months from remission. The follow-up of these patients in referral centers minimizes the chance of death from this disease and should be encouraged.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University and Antonio Pedro University Hospital of Fluminense Federal University), Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil.
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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