Interaction of race and socioeconomic status as risk modulators of treatment delay and cancer-specific mortality in uterine cancer

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Background: The majority of studies of uterine cancer combine high and low-grade histologies and do not sample a diverse cohort of patients. In many studies race is treated as biologic construct, when it may be better thought of as a proxy for socioeconomic inequity and deprivation. Socioeconomic (SE) deprivation may play a significant role in the disease trajectory of women with uterine cancer. Methods: Data were drawn from the Metropolitan Detroit Cancer Surveillance System which covers a tri-county area of approximately 4 million people. We included non-Hispanic Black (NHB) and White (NHW) women diagnosed with uterine cancer between 2010 and 2018. Poorly differentiated and undifferentiated endometrioid, serous, clear cell, mixed, carcinosarcoma and mucinous histologies were considered high grade. Patients diagnosed by death certificate, or with unknown stage or histology were excluded. Socioeconomic status was assessed using the Yost Score, an area-level composite measure of socioeconomic deprivation derived from census-tract data at cancer diagnosis. Lower Yost quintile indicates higher deprivation. Competing risk analysis was used to determine risk of uterine cancer specific mortality (reported as subdistribution hazard ratio [SHR]) and to assess statistical interaction between race and Yost score. Results: A total of 4,840 patients were identified. Race conferred significant increased risk of cancer-specific mortality (SHR 2.11, p < 0.0001). Race and Yost score interacted to increase risk of cancer-specific mortality in NHB women in the lowest Yost quintile (SHR 2.23, p < 0.0001) compared to NHW and NHB women in the highest quintiles. The interaction between race and Yost score persisted only among women with low grade cancers (SHR 1.7, p = 0.04). Time from diagnosis to surgery increased as Yost score decreased. Women in the lowest Yost quintile had lower likelihood of receiving surgery within 6 weeks of diagnosis (OR 0.74, p = 0.001). This effect persisted among women with low grade cancer (NHB OR 0.75, p = 0.014; lowest Yost quintile OR 0.68, p < 0.0001). An association between race, Yost score and delays in time to surgery was not seen among women with high grade cancers. Conclusions: Race and Yost score, an area-based measure of socioeconomic deprivation, are associated with increased cancer-specific mortality risk among women with low grade cancer. NHB race and high socioeconomic deprivation are associated with delayed primary surgery. The interaction between race and socioeconomic deprivation may underlie known disparities in uterine cancer survival, particularly in low grade disease where there is the greatest opportunity for timely curative surgery.

Association between cystoscopy at the time of hysterectomy performed by a gynecologic oncologist and delayed urinary tract injury

OBJECTIVE

Guidance regarding the use of cystoscopy at the time of hysterectomy is lacking in gynecologic oncology. We compare the rate of delayed urinary tract injury in women who underwent cystoscopy at the time of hysterectomy performed by a gynecologic oncologist for benign or malignant indication with those who did not.

METHODS

This was a retrospective cohort study of patients who had a hysterectomy performed by a gynecologic oncologist recorded in the National Surgical Quality Improvement Program between January 2014 and December 2017. The primary outcome was delayed urinary tract injury in the 30-day post-operative period. Secondary outcomes were operative time and urinary tract infection rate. The exposure of interest was cystoscopy at the time of hysterectomy and bivariable tests were used to examine associations.

RESULTS

We identified 33 355 women who underwent hysterectomy for benign (41%; n=13 621) or malignant (59%; n=19 734) indications performed by a gynecologic oncologist. Surgical approach was open (39%; n=12 974), laparoscopic or robotic-assisted laparoscopic (55%; n=18 272), and vaginal or vaginally-assisted (6%; n=2109). Overall, 12% of women (n=3873) underwent cystoscopy at the time of surgery; cystoscopy was more commonly performed in laparoscopic (15%; n=2829) and vaginal (12%; n=243) approaches than with open hysterectomy (6%; n=801) (p<0.001). There was no difference in the rate of delayed urinary tract injury in patients who underwent cystoscopy at the time of surgery compared with those who did not (0.4% vs 0.3%, p=0.32). However, patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (3% vs 2%, RR 1.3, 95% CI 1.1 to 1.6). In cases where cystoscopy was performed, median operative time was increased by 9 min (137 vs 128 min, p<0.001).

CONCLUSION

Cystoscopy at the time of hysterectomy performed by a gynecologic oncologist does not result in a lower rate of delayed urinary tract injury compared with no cystoscopy.

Risk factors for potentially avoidable readmissions following gynecologic oncology surgery

OBJECTIVE

Determine the incidence and identify factors associated with potentially avoidable hospital readmissions due to uncontrolled symptoms or minor complications after surgery for gynecologic cancers.

METHODS

Women who underwent major abdominal or pelvic surgery for a gynecologic malignancy between 2015 and 2017 were identified from the National Surgical Quality Improvement Program targeted hysterectomy dataset. Hospital readmissions within 30 days of surgery were categorized as indicated readmissions or potentially avoidable readmissions by three independent reviewers. Demographic, clinical, and operative covariates were evaluated to determine their association with type of readmission using bivariable tests and adjusted multinomial logistic regression models.

RESULTS

A total of 20,986 women were identified. 19,814 (94.4%) were not readmitted, 894 (4.3%) were indicated readmissions, and 278 (1.3%) were potentially avoidable readmissions. Among those readmitted, 24% were potentially avoidable readmissions. Presence of ascites, increasing length of stay, and discharge to facility were associated with an increased risk of indicated and potentially avoidable readmissions. Age < 60 years old (RR 1.4, 95%CI 1.1-1.8), BMI ≥ 30 (RR 1.7, 95%CI 1.3-2.3), history of abdominal/pelvic surgery (RR 1.6, 95%CI 1.2-2.1), cervical cancer (RR 2.1, 95%CI 1.4-3.1), and open surgery (RR 2.1, 95%CI 1.4-3.2) were associated with an increased risk of a potentially avoidable readmission but not with increased risk of an indicated readmission. Median time to readmission did not differ between the two readmission groups (indicated = 8 days; avoidable = 7 days; p = .72).

CONCLUSIONS

Among women with gynecologic cancer, 24% of all unplanned readmissions were attributed to uncontrolled symptoms or minor complications that were potentially avoidable. Age <60 years old, history of previous abdominal/pelvic surgery, obesity, cervical cancer, and open surgery were associated with an increase in risk of a potentially avoidable readmission.

High proportion of extrapulmonary tuberculosis in a low prevalence setting: a retrospective cohort study

OBJECTIVES

The proportion of extrapulmonary tuberculosis (EPTB) cases in the United States (US) has been rising due to a slower rate of decline in EPTB compared to pulmonary tuberculosis (PTB). The purpose of this study was to characterise the clinical and treatment differences between EPTB and PTB patients, and identify patient factors associated with EPTB.

STUDY DESIGN

We performed a retrospective cohort study of active tuberculosis (TB) cases treated at the Baltimore City Health Department between 2008 and 2013.

METHODS

We categorised patients as having 'only PTB' (infection in the lung parenchyma), 'EPTB/PTB' (infection in the lung and an additional site), and 'only EPTB' (infection not involving the lung). Pearson's chi-squared tests were used to evaluate categorical variables and compare clinical and demographic differences between only PTB, only EPTB, and EPTB/PTB patients. Student t-tests and one-way analysis of variance tests were utilised to assess continuous variables and to compare treatment differences.

RESULTS

One hundred and sixty-three patients were treated for TB; 39.3% had some form of EPTB (either EPTB/PTB or only EPTB). There was no difference found between EPTB, PTB, and EPTB/PTB patients with respect to HIV status, gender, race, foreign-born status, or mean age. Patients with only EPTB were less likely than patients with some form of PTB (only PTB or EPTB/PTB) to present with cough (30.4% vs 61.5%; P < 0.001), night sweats (10.9% vs 39.3%; P < 0.001), and weight loss (28.3% vs 47.9%; P = 0.023). Patients with some form of EPTB were also more likely to be hospitalised postdiagnosis compared to patients with only PTB (39.1% vs 20.2%; P = 0.009), and to have longer mean durations of treatment (37.9 weeks [SD = 11.1] vs 31.8 weeks [SD = 8.1]; P < 0.001).

CONCLUSIONS

EPTB patients present with atypical symptoms, undergo prolonged treatment, and experience increased hospitalisations. In order to improve diagnostic algorithms and treatment modalities, EPTB must be further characterised.

Susceptibility-weighted imaging in pediatric arterial ischemic stroke: a valuable alternative for the noninvasive evaluation of altered cerebral hemodynamics

BACKGROUND AND PURPOSE

SWI provides information about blood oxygenation levels in intracranial vessels. Prior reports have shown that SWI focusing on venous drainage can provide noninvasive information about the degree of brain perfusion in pediatric arterial ischemic stroke. We aimed to evaluate the influence of the SWI venous signal pattern in predicting stroke evolution and the development of malignant edema in a large cohort of children with arterial ischemic stroke.

MATERIALS AND METHODS

A semiquantitative analysis of venous signal intensity on SWI and diffusion characteristics on DTI was performed in 16 vascular territories. The mismatch between areas with SWI-hypointense venous signal and restricted diffusion was correlated with stroke progression on follow-up. SWI-hyperintense signal was correlated with the development of malignant edema.

RESULTS

We included 24 children with a confirmed diagnosis of pediatric arterial ischemic stroke. Follow-up images were available for 14/24 children. MCA stroke progression on follow-up was observed in 5/6 children, with 2/8 children without mismatch between areas of initial SWI hypointense venous signal and areas of restricted diffusion on DTI. This mismatch showed a statistically significant association (P = .03) for infarct progression. Postischemic malignant edema developed in 2/10 children with and 0/14 children without SWI-hyperintense venous signal on initial SWI (P = .07).

CONCLUSIONS

SWI-DTI mismatch predicts stroke progression in pediatric arterial ischemic stroke. SWI-hyperintense signal is not useful for predicting the development of malignant edema. SWI should be routinely added to the neuroimaging diagnostic protocol of pediatric arterial ischemic stroke.