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Objective: To investigate associations between air particulate matter of ≤2.5 μm in diameter (PM 2.5 ) and ovarian cancer., Design: County-level ecological study., Setting: Surveillance, epidemiology, and end results from a collection of state-level cancer registries across 744 counties. Data from the Environmental Protection Agency's network for PM 2.5 monitoring was used to calculate trailing 5- and 10-year PM 2.5 county-level values. County-level data on demographic characteristics were obtained from the American Community Survey., Population: A total of 98 751 patients with histologically confirmed ovarian cancer as a primary malignancy from 2000 to 2016., Methods: Generalised linear regression models were developed to estimate the association between PM 2.5 and PM 10 levels, over 5- and 10-year periods of exposure, and ovarian cancer risk, after accounting for county-level covariates., Main Outcome Measures: Risk ratios for associations between ovarian cancer (both overall and specifically epithelial ovarian cancer) and PM 2.5 levels., Results: For the 744 counties included, the average PM 2.5 level from 1990 through 2018 was 11.75 μg/m 3 (SD = 3.7) and the average PM 10 level was 22.7 μg/m 3 (SD = 5.7). After adjusting for county-level covariates, the overall annualised ovarian cancer incidence was significantly associated with increases in 5-year PM 2.5 (RR = 1.11 per 10 units (μg/m 3 ) increase, 95% CI 1.06-1.16). Similarly, when the analysis was limited to epithelial cell tumours and adjusted for county-level covariates there was a significant association with trailing 5-year PM 2.5 exposure models (RR = 1.12 per 10 units increase, 95% CI 1.08-1.17). Likewise, 10-year PM 2.5 exposure was associated with ovarian cancer overall and with epithelial ovarian cancer., Conclusions: Higher county-level ambient PM 2.5 levels are associated with 5- and 10-year incidences of ovarian cancer, as measurable in an ecological study., (© 2023 John Wiley & Sons Ltd.)

Objective: Patients with recurrent endometrial cancer treated with carboplatin and paclitaxel whose disease progresses have few effective treatment options. Based on promising clinical trial data, the anti-programmed cell death 1 (anti-PD-1) antibody dostarlimab was recently granted accelerated approval for endometrial cancer by the US Food and Drug Administration. We developed a decision model to examine the cost-effectiveness of dostarlimab for patients with progressive/recurrent deficient mismatch repair (dMMR) endometrial cancer whose disease has progressed with first-line chemotherapy., Design: Cost-effectiveness study., Population: Hypothetical cohort of 6000 women with progressive/recurrent dMMR endometrial cancer., Methods: The initial decision point in the Markov model was treatment with dostarlimab, pembrolizumab or pegylated liposomal doxorubicin (PLD). Model probabilities, and cost and utility values were derived with assumptions drawn from published literature. Effectiveness was estimated as average quality-adjusted life years (QALYs) gained. One-way, two-way and probabilistic sensitivity analyses were performed to vary the assumptions across a range of plausible values., Main Outcome Measures: The primary outcome was the incremental cost-effectiveness ratio (ICER)., Results: Pegylated liposomal doxorubicin (PLD) was the least costly strategy, at $55,732, followed by dostarlimab ($151,533) and pembrolizumab ($154,597). Based on a willingness-to-pay threshold of $100,000/QALY, PLD was cost-effective compared with dostarlimab, with an ICER of $331,913 per QALY gained for dostarlimab, whereas pembrolizumab was ruled out by extended dominance (less effective, more costly), compared with dostarlimab. In one-way sensitivity analyses, dostarlimab was cost-effective when its cost was reduced to $4905 (52% reduction). These results were robust in a variety of sensitivity analyses., Conclusions: Dostarlimab is associated with greater survival compared with other treatments for women with recurrent dMMR endometrial cancer. Although the agent is substantially more costly, dostarlimab became cost-effective when its cost was reduced to $5489 per cycle., (© 2022 John Wiley & Sons Ltd.)

Objective: To examine the patterns and outcomes of sentinel lymph node (SLN) assessment in women with endometrial cancer., Design: Retrospective cohort study., Setting: United States inpatient and outpatient hospital services., Population: Women with endometrial cancer who underwent a laparoscopic or robotic-assisted hysterectomy., Methods: The Perspective Database from 2012 to 2018 was used. Performance of lymph node dissection was classified as SLN mapping, lymph node dissection or no nodal evaluation. Adjusted regression models were developed to examine the association between SLN mapping and morbidity and cost., Main Outcome Measures: Utilisation rates, morbidity and cost of both lymph node dissection and SLN mapping., Results: Among 45 381 patients, SLN mapping was performed for 7768 patients (17.1%), lymph node dissection was performed for 23 214 patients (51.2%) and no lymphatic evaluation was performed for 14 399 patients (31.7%). SLN mapping increased from 1.8% in 2012 to 35.3% in 2018, whereas the rate of lymph node dissection decreased from 63.5% to 39.1% (p < 0.001). Among women who underwent nodal evaluation, residence in the west, White race and use of robotic-assisted hysterectomy were associated with SLN mapping (p < 0.05 for all). The complication rate was 5.9% for SLN mapping, compared with 7.3% in those that underwent lymph node dissection (aRR 0.85, 95% CI 0.77-0.95). The median hospital costs for women who underwent SLN mapping ($10 479) and lymph node dissection ($10 747) were higher than for those who did not undergo nodal assessment ($9149) (p < 0.001)., Conclusions: The performance of SLN mapping is increasing for endometrial cancer. Compared with lymph node dissection, SLN mapping is associated with lower morbidity. SLN mapping significantly increases the costs compared with hysterectomy alone., Tweetable Abstract: SLN mapping is increasing rapidly for endometrial cancer and is associated with decreased perioperative morbidity., (© 2021 John Wiley & Sons Ltd.)

Objective: Cervical cancer screening guidelines have evolved over time with the incorporation of human papillomavirus (HPV) testing along with cytology. Current screening guidelines recommend cytological screening every 3 years or HPV testing with or without cytology every 5 years in women age 30-65 years. We examined the use of cervical cancer screening among average-risk Medicaid beneficiaries., Design: Retrospective cohort study., Population: Women age 30-64 years at average risk for cervical cancer who underwent cervical cancer screening with cytology, co-testing or primary HPV testing from 2013 to 2016., Methods: The IBM Watson Health Multi-State Medicaid MarketScan Database was used. Subsequent screening rates within 3 years of the index test were examined., Main Outcome Measure: The rate of repeat cervical cancer screening was analysed using a cumulative incidence function., Results: A total of 265 083 patients were identified. Overall, 43.1% (n = 114 312) had index co-testing, 55.2% (n = 146 309) had cytology and 1.7% (n = 4462) had primary HPV testing. The cumulative incidence of early, repeat cervical cancer screening was 3.9% at 12 months, 22.7% at 24 months and 33.3% at 36 months. During the period from 12 to 24 months after follow up, 20.9% of women underwent repeat screening while 19.4% underwent repeat screening 24-36 months after the index test. Among women who did not undergo repeat cervical cancer screening, a yearly gynaecological examination was performed in only 16 627 (10.7%) during year 2 and in 11 116 (8.8%) during year 3., Conclusion: Among average-risk Medicaid beneficiaries, cervical cancer screening is frequently overused. Women who do not undergo cervical cancer screening are unlikely to undergo routine gynaecological examination., Tweetable Abstract: Among average-risk Medicaid beneficiaries, cervical cancer screening is frequently overused., (© 2021 John Wiley & Sons Ltd.)

Objective: While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses., Design: Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management., Methods: The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings., Main Outcome Measures: The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs)., Results: MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses., Conclusion: MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses., Tweetable Abstract: MIS is a cost-effective management strategy for women with suspicious ovarian masses., (© 2021 John Wiley & Sons Ltd.)

Human microbiome research has shown commensal bacteria to be a major factor in both wellness and disease pathogenesis. Interest in the microbiome has recently expanded beyond the gut to include a multitude of other organ systems for which the microbiome may have health implications. Here, we review the role of the vaginal microbiome in health and disease, with a particular focus on gynaecologic malignancies. Further, we suggest that it may be possible to expand the use of probiotics in the treatment of gynaecological cancers., Tweetable Abstract: A review of the research to date on the relation between the vaginal microbiome and gynaecological cancers., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Uterine leiomyosarcoma (LMS) are rare but aggressive tumours with poor clinical outcomes regardless of stage. Most tumours are identified by histopathology at time of surgery, and pre-operative diagnosis remains a clinical challenge. Management of early-stage LMS relies on surgical resection. Cytotoxic chemotherapy remains the mainstay of therapy for advanced-stage, recurrent or metastatic LMS, and includes single or combination doxorubicin-, ifosfamide- or gemcitabine-based regimens. Recent interest in genetic biomarkers led to developments of targeted therapies for LMS, although more research is needed to understand the molecular complexities underlying LMS to guide the development of novel treatment strategies., Tweetable Abstract: The diagnosis and treatment of uterine LMS is challenging. Novel biomarkers offer hope for future therapies., (© 2017 Royal College of Obstetricians and Gynaecologists.)

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., (© 2015 Royal College of Obstetricians and Gynaecologists.)