Search

Objective Neuroendocrine carcinomas of the cervix (NECC) are rare and thought to be aggressive. We performed a population-based analysis to examine the natural history, treatment patterns and outcomes of women with NECC compared to squamous cell carcinoma (SCCC) and adenocarcinoma (AC) of the cervix. Methods The National Cancer Database (NCDB) was utilized to identify women with NECC, SCCC, and AC treated from 1998 to 2011. Clinical, demographic, and treatment characteristics were compared between the groups. The association between tumor histology and survival was examined using Kaplan-Meier analyses and multivariable Cox proportional hazards regression models. Results We identified 127,332 patients, including 1,896 (1.5%) with NECC and 101,240 (79.5%) with SCCC and 24,196 (19.0%) with AC. Patients with NECC were younger, more often white, commercially insured, and diagnosed with metastatic disease at presentation compared to women with SCCC. Patients with early-stage NECC were more likely to receive adjuvant chemotherapy and radiation after surgery (P < 0.05 for both). In multivariable models stratified by stage and adjusted for clinical and demographic characteristics, the risk of death was higher for patients with NECC compared to SCCC for all stages of disease: stages IB–IIA (HR = 2.96; 95% CI, 2.48–3.52), stages IIB–IVA (HR = 1.70; 95% CI, 1.45–1.99) and stage IVB (HR = 1.14; 95% CI, 0.91–1.43). Conclusion NECC are aggressive tumors associated with an increased risk of death. Survival is inferior for NECC compared to squamous cell tumors for women with both early and advanced stage disease. [ABSTRACT FROM AUTHOR]

Objective Although 5-year survival for early-stage ovarian cancer is favorable, prognosis at recurrence is poor, necessitating appropriate initial management. We examined the patterns of care and the impact of the duration of chemotherapy on survival for women with early-stage ovarian cancer. Methods We used the SEER-Medicare database to identify women = 65 years of age with stage I ovarian cancer diagnosed from 1992 to 2009. Patients were categorized as low-risk (non-clear cell histology, stage IA or IB, grade 1 or 2) or high-risk (clear cell histology, grade 3, or stage IC). We used multivariable logistic regression models to determine predictors of chemotherapy use and duration and Cox proportional hazards models to evaluate the effect of chemotherapy use and duration on survival. Results We identified 1394 patients. Among low-risk patients, 32.9% received adjuvant chemotherapy and the use of chemotherapy increased with time. Among high-risk patients, 71.9% received adjuvant chemotherapy; 44.2% had = 3 months of treatment, and 55.8% had > 3 months of treatment. Older patients were less likely to receive chemotherapy, while those with higher stage and grade were more likely to receive chemotherapy (P < 0.05 for all). Among high-risk patients, the duration of chemotherapy did not impact overall (HR = 0.93, 95% CI, 0.67-1.27) or cancer specific (HR = 0.93; 95% CI, 0.61-1.42) survival. Conclusions Among early-stage ovarian cancer patients, practice patterns are widely divergent. Extended duration chemotherapy does not appear to impact survival for women with high-risk disease. [ABSTRACT FROM AUTHOR]

Objectives: Brachytherapy plays an important role in the treatment of cervical cancer. While small trials have shown comparable survival outcomes between high (HDR) and low-dose rate (LDR) brachytherapy, little data is available in the US. We examined the utilization of HDR brachytherapy and analyzed the impact of type of brachytherapy on survival for cervical cancer. Method: Women with stages IB2-IVA cervical cancer treated with primary (external beam and brachytherapy) radiotherapy between 2003-2011 and recorded in the National Cancer Database (NCDB) were analyzed. Generalized linear mixed models and Cox proportional hazards regression were used to examine predictors of HDR brachytherapy use and the association between HDR use and survival. Result: A total of 10,564 women including 2681 (25.4%) who received LDR and 7883 (74.6%) that received HDR were identified. Use of HDR increased from 50.2% in 2003 to 83.9% in 2011 (P > 0.0001). In a multivariable model, year of diagnosis was the strongest predictor of use of HDR. While patients in the Northeast were more likely to receive HDR therapy, there were no other clinical or socioeconomic characteristics associated with receipt of HDR. In a multivariable Cox model, survival was similar between the HDR and LDR groups (HR = 0.93; 95% CI 0.83-1.03). Similar findings were noted in analyses stratified by stage and histology. Kaplan-Meier analyses demonstrated no difference in survival based on type of brachytherapy for stage IIB (P = 0.68), IIIB (P = 0.17), or IVA (P = 0.16) tumors. Conclusions: The use of HDR therapy has increased rapidly. Overall survival is similar for LDR and HDR brachytherapy. [ABSTRACT FROM AUTHOR]

Abstract: Background: Despite institutional studies that suggest that radical hysterectomy for cervical cancer is well tolerated in the elderly, little population-level data are available on the procedure’s outcomes in older women. We performed a population-based analysis to determine the morbidity, mortality, and resource utilization of radical hysterectomy in elderly women with cervical cancer. Methods: Patients recorded in the Nationwide Inpatient Sample with invasive cervical cancer who underwent abdominal radical hysterectomy between 1998and 2010 were analyzed. Patients were stratified by age: <50, 50–59, 60–69, and ≥70years. We examined the association between age and the outcomes of interest using chi square tests and multivariable generalized estimating equations. Results: A total of 8199 women were identified, including 768 (9.4%) women age 60–69 and 462 (5.6%) women ≥70years of age. All cause morbidity increased from 22.1% in women <50, to 24.7% in those 50–59 years, 31.4% in patients 60–69 years and 34.9% in women > 70years of age (P<0.0001). Compared to women<50, those > 70 were more likely to have intraoperative complications (4.8% vs. 9.1%, P=0.0003), surgical site complications (10.9% vs. 17.5%, P<0.0001), and medical complications (9.9% vs. 19.5%, P<0.0001). The risk of non-routine discharge (to a nursing facility) was 0.5% in women <50 vs. 12.3% in women ≥70 (P<0.0001). Perioperative mortality women ≥70years of age was 30 times greater than that of women <50 (P<0.0001). Conclusion: Perioperative morbidity and mortality are substantially greater in elderly women who undergo radical hysterectomy for cervical cancer. Non-surgical treatments should be considered in these patients. [Copyright &y& Elsevier]

Abstract: Objective: The aim of this study was to estimate cost and outcomes associated with colposcopy following abnormal Pap for women with a history of cervical cancer. Methods: Decision models compared the costs and number of isolated local recurrences (ILR) detected using two strategies, colposcopy and no colposcopy, for women with a history of cervical cancer and low grade or high grade Pap. Clinical data for input were derived from a cohort of women with a history of cervical cancer undergoing surveillance Paps at 2 institutions. Costs were obtained using national reimbursement data. Results: Five hundred fifty-six patients underwent 2900 surveillance Paps. Twenty-seven of 50 women with a low grade Pap underwent colposcopy. One of 3 recurrences in the colposcopy group was an ILR diagnosed colposcopically. Colposcopy following low grade Pap costs $354 more and resulted in a lower rate of diagnosis of ILR compared to no colposcopy (3.7% vs 8.6%). Sixty of 78 women with a high grade Pap underwent colposcopy. Three of 15 recurrences in the colposcopy group were ILR diagnosed colposcopically. Colposcopy following high grade Pap costs $623 more than no colposcopy but resulted in a higher rate of diagnosis of ILR (5% vs 0%; $7481 per additional ILR). Conclusions: Colposcopy following low or high grade surveillance Pap smear adds substantial cost to the management of women with cervical cancer. Only colposcopy following a high grade Pap is associated with a higher probability that cervical cancer recurrence will be detected when salvageable. These findings support withholding colposcopy for abnormal surveillance Pap tests less than high grade. [Copyright &y& Elsevier]

Abstract: Objective: To examine racial/ethnic differences in treatment and survival in women diagnosed with invasive vulvar cancer in the United States. Methods: Women with invasive vulvar cancer were identified from the Surveillance, Epidemiology, and End Results database from 1/1/92 to 12/31/02. Statistical analysis using Chi-square, Fisher''s Exact Test, Kaplan–Meier survival methods, and Cox regression proportional hazards models was performed. Results: Of the 2357 cases of invasive vulvar cancer included in this study, 1974 (83.8%) were non-Hispanic white, 209 (8.9%) were non-Hispanic black, 119 (5.0%) were Hispanic, and 55 (2.3%) women were of another race/ethnicity. After adjustment for stage, black women were half as likely (OR=0.48, 95% CI 0.31–0. 74) to undergo surgery and 1.7 times more likely (OR=1.67, 95% CI 1.18–2.36) to receive radiation than white women. In multivariable analysis, surgical treatment reduced the risk of death from vulvar cancer by 46% (HR 0.54, 95% CI 0.43–0.67), whereas radiation was not shown to impact the risk of death (HR 0.99, 95% CI 0.84–1.19), after adjusting for age, race, stage, and grade. There was no significant difference in risk of death by race/ethnicity group after adjusting for the previously described variables. Conclusions: Based on this study, race/ethnicity is not an independent risk factor for poor prognosis in women diagnosed with invasive vulvar cancer, despite differences in treatment modality by race/ethnicity. Further research to define the factors contributing to differences in treatment selection according to race/ethnicity and the resulting impact on quality of life is warranted. [Copyright &y& Elsevier]

Abstract: Objective: To compare clinico-pathologic variables and protein expression of potential regulatory components in patients who develop type II endometrial cancer with and without antecedent tamoxifen. Methods: Clinico-pathologic variables were compared for all surgically staged patients (2000–2008) with grade 3 endometrioid, papillary serous, clear cell, and carcinosarcoma of the uterus based on tamoxifen exposure [Tam (+) vs. Tam (−)]. Overall survival was analyzed using a multivariable Cox regression model and Kaplan–Meier estimates. Protein expression of ERα, PR, mTOR, p-mTOR, IGF-1R, EGFR, VEGF and HER-2/neu was compared by immunohistochemistry using a semiquantitative scoring system. Results: Of 115 patients with high grade endometrial cancers, 15 received tamoxifen. These patients were older at diagnosis than Tam (−) patients. A higher percentage of Tam (+) patients had carcinosarcoma compared to Tam (−) patients (60% vs. 30%, P=0.038). Overall survival for Tam (+) patients was shorter than Tam (−) patients (16.6 vs. 32.2months, P=0.004). The hazard ratio for death for Tam (+) patients was 2.53 (P=0.014), controlling for age and stage. Intensity and extent of staining were similar for ERα, PR, VEGF, EGFR, p-mTOR and HER-2/neu. The average expression score for IGF-1R and mTOR in the Tam (+) group was significantly higher than the Tam (−) group: 10.3 vs 7.0, P=0.001 and 6.0 vs 3.1, P=0.029, respectively. Conclusion: There are differences in the biology of type II endometrial cancers that develop in women with prior tamoxifen exposure. Tamoxifen associated cancers show higher expression of IGF-1R and mTOR, which should be further investigated. [Copyright &y& Elsevier]

Abstract: Background: Laparoendoscopic single-site surgery (LESS) represents one of the latest innovations in minimally invasive surgery and has several potential applications in gynecologic oncology surgery. The purpose of this surgical video is to demonstrate the indication and technique for LESS radical hysterectomy for the treatment of early stage cervical cancer. Case: A 48year-old menopausal woman with a body mass index of 29 was diagnosed with a well differentiated, Stage IB1 cervical adenocarcinoma. She underwent a LESS radical hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy through a 2.0 centimeter (cm) umbilical incision. Estimated blood loss was 200ml and total operative time was 251min. No perioperative complications occurred and the patient was discharged the day after surgery. Final pathology revealed a residual 1.5cm tumor with a depth of invasion of 5.8mm and no lymph vascular space invasion. The parametria, ovaries and 16 lymph nodes were negative for malignancy. All margins, including a vaginal margin 3.5cm from the cervical tumor, were negative. Her umbilical incision healed well and was not visible at her 4week post operative visit. She did not require adjuvant therapy and is without evidence of disease 6months after surgery. Conclusions: The performance of LESS radical hysterectomy is feasible and safe in select women with apparent early-stage cervical cancer. In an effort to optimize operative and long-term oncologic outcomes, it is critical to continue exploring novel surgical approaches for the treatment of gynecologic cancers. [Copyright &y& Elsevier]

Failure to deliver guideline-concordant treatment may contribute to disparities among Hispanic/Latinx cervical cancer patients. This study investigated the association between survival rates in Hispanic/Latinx subpopulations and the provision of guideline-concordant care. We analyzed patients with primary cervical cancer from 2004 to 2019 (National Cancer Database). We developed nine quality metrics based on FIGO staging (2009). Clinical and demographic covariates were analyzed using Chi-squared tests. Adjusted associations between receipt of guideline-concordant care and races and ethnicities were analyzed using multivariable marginal Poisson regression models. Adjusted Cox proportional hazard models were utilized to evaluate survival probability. A total of 95,589 patients were included. Hispanic/Latinx and Non-Hispanic Black (NHB) populations were less likely to receive guideline-concordant care in four and five out of nine quality metrics, respectively. Nonetheless, the Hispanic/Latinx group exhibited better survival outcomes in seven of nine quality metrics. Compared to Mexican patients, Cuban patients were 1.17 times as likely to receive timely initiation of treatment in early-stage disease (RR 1.17, 95% CI 1.04–1.37, p < 0.001). Puerto Rican and Dominican patients were, respectively, 1.16 (RR 1.16, 95% CI 1.07–1.27, p < 0.001) and 1.19 (RR 1.19, 95% 1.04–1.37, p > 0.01) times as likely to undergo timely initiation of treatment in early-stage disease. Patients of South or Central American (RR 1.18, 95% CI 1.10–1.27, p < 0.001) origin were more likely to undergo timely initiation of treatment in locally advanced disease. Significant differences in survival were identified among our cohort despite the receipt of guideline concordant care, with notably higher survival among Hispanic/Latinx populations. • Disparities in receiving guideline-concordant care among Hispanic/Latinx subpopulations with cervical cancer are frequent. • Hispanic/Latinx populations have higher survival rates despite disparities in receipt of guideline-concordant care. • Differences in receipt of guideline-concordant care and survival are prevalent among Hispanic/Latinx subpopulations. [ABSTRACT FROM AUTHOR]

To investigate whether routine cervical screening using human papillomavirus (HPV) and cytology co-testing effectively identifies women with endometrial (EC) or ovarian (OvC) cancer. In 2003, Kaiser Permanente Northern California implemented triennial co-testing in women aged ≥30 years. Index screening results (n = 2,385,729) were linked to subsequent EC (n = 3434) and OvC (n = 1113) diagnoses from January 1, 2003 to December 31, 2017. EC were categorized as type 1 or 2, and, selectively, EC and OvC diagnoses were stratified on whether symptoms were present at the time of the co-test. Fractions and absolute risks of EC or OvC of each co-testing result were calculated. Most EC (82.18%) and OvC (88.68%) were preceded by a negative HPV and negative cytology co-test. More EC were preceded by atypical squamous cells of undetermined significance (ASC-US) or more severe (ASC-US+) cytology and negative HPV test (n = 290) (8.44% of EC) compared to a negative cytology and a positive HPV test (n = 31) (0.89% of EC) (p < 0.001). The absolute risk of any EC diagnosis following ASC-US+ and negative HPV test was 0.48%. Atypical glandular cells (AGC) cytology and a negative HPV result preceded 6.92% of any EC diagnosis, with an absolute risk of 4.02%, but preceded only 1.13% of type 2 EC cases, with an absolute risk of 0.24%, in asymptomatic women. AGC cytology and a negative HPV result preceded 1.44% of OvC, with an absolute risk of 0.28%. Abnormal cervical screening tests, even AGC cytology, rarely precedes and poorly predict women with EC or OvC. • More than 80% of endometrial cancers were preceded by a negative HPV and cytology co-test. • More than 80% of ovarian cancers were preceded by a negative HPV and cytology co-test. • Abnormal cytology, even atypical glandular cells, is poorly predictive of endometrial and ovarian cancer. [ABSTRACT FROM AUTHOR]

To evaluate whether the receipt of evidence-based care could mitigate survival disparities among Medicaid recipients and uninsured women with cervical cancer. The National Cancer Database was utilized to identify women with cervical cancer treated from 2004 to 2016. Eight quality metrics were determined. Survival outcomes were examined stratified by insurance status and stage. To measure the impact of guideline-concordant care on the mitigation of disparities, we compared survival outcomes of the overall cohort to one that was perfectly adherent to all quality metrics. A total of 103,400 patients were identified; 47.0% of patients had private insurance, 21.5% Medicaid and 9.2% uninsured. Medicaid and uninsured patients were significantly less likely than privately insured patients to receive timely completion of radiation and timely initiation of treatment; uninsured patients were also significantly less likely to receive treatment for locally advanced disease. Medicaid and uninsured patients were also less likely to receive lymph node assessment and primary chemoradiation. Medicaid and uninsured patients had an increased risk of mortality compared to privately insured patients (aHR = 1.36, 95% CI 1.31–1.41 and aHR 1.29, 95% CI 1.23–1.36 respectively). While the receipt of these quality metrics was associated with improved survival, Medicaid and uninsured women who received guideline-concordant care were still at an increased risk of death compared to women with private insurance (aHR = 1.38, 95% CI 1.35–1.49 and aHR = 1.24; 95% CI, 1.16–1.32 respectively). Medicaid and uninsured patients were less likely to receive evidence-based care and were at increased risk of mortality at all stages compared to privately insured patients. The receipt of quality care does not eliminate insurance status-based disparities among women with cervical cancer. • Medicaid and uninsured patients are less likely to receive timely completion of radiation and timely initiation of treatment. • While evidence-based care improves survival, underinsured women are at increased risk of mortality at all stages of disease. • Receipt of guideline-concordant care does not eliminate insurance status-based disparities among women with cervical cancer. [ABSTRACT FROM AUTHOR]

Objective We examined the influence of modifiable (intraoperative factors and complications) and non-modifiable (clinical and demographic characteristics) factors on length of stay (LOS) for women who underwent hysterectomy for uterine cancer. Methods The National Surgical Quality Improvement Program database was used to identify women who underwent hysterectomy for uterine cancer from 2006 to 2015. The association between demographic, preoperative, intraoperative, and postoperative factors and LOS was examined. The primary outcome was prolonged LOS (>75th an3 > 90th percentiles). Model fit statistics were used to assess the importance of each group of characteristics. Results Of 19,084 women identified, 6082 (31.9%) underwent abdominal and 13,002 (68.1%) underwent minimally invasive hysterectomy. In the abdominal hysterectomy group, the 75th and 90th percentiles for LOS were 5 and 8 days, respectively. All risk factors combined accounted for 23.6% of the variation in LOS >75th percentile. Demographic characteristics explained 4.0%, preoperative factors 7.0%, intraoperative factors 7.9%, and postoperative characteristics 9.7% of variation in prolonged LOS. In the minimally invasive group, the 75th and 90th percentiles for LOS were 1 and 2 days, respectively. The combined risk factors explained 16.2% of the variation in prolonged LOS. Demographic characteristics accounted for 6.2%, preoperative factors 4.1%, intraoperative factors 6.9%, and postoperative characteristics 1.3% of variation in prolonged LOS. Similar patterns were seen when prolonged LOS was defined as >90th percentile. Conclusion Perioperative risk factors account for approximately one quarter of the variation in prolonged LOS. Overall, a substantial proportion of the variation in LOS remains unexplained by measurable patient and hospital factors which may limit the utility of LOS as a quality metric for endometrial cancer. [ABSTRACT FROM AUTHOR]

Objective Little is known about the influence of hospital procedural volume on racial disparities for uterine cancer. We examined whether the magnitude of the survival differential between black and white women varied based on hospital procedural volume for endometrial cancer. Methods We utilized the National Cancer Data Base to examine women with endometrial cancer from 1998 to 2012. Annualized hospital procedural volume was calculated and hospitals grouped into volume-based quartiles. Multivariable models were developed to examine differences in two and five-year survival between black and white women across the hospital volume categories. Patients were classified as early or advanced stage and as type I (low grade, endometrioid) or type II (high grade endometrioid, other histologies) cancers. Results We identified 243,422 (75.0%) white and 27,764 (8.6%) black women treated at 1059 hospitals. Regardless of hospital volume, black women had decreased survival. For each tumor class, the absolute difference in adjusted two-year survival between black and white women decreased with increasing hospital volume. For example, for women with early-stage, type I tumors, the adjusted two-year survival differential between blacks and whites was −1.4% (95%CI, −2.4 to −0.5%) at low volume centers and decreased to −0.5% (95%CI, −0.9 to 0%) at high-volume hospitals ( P < 0.0001). For advanced stage, type I tumors, the adjusted survival differential decreased from −12.4% (95%CI, −24.0 to −0.9%) to 1.2% (95%CI, −2.9 to 5.3%) at high volume hospitals ( P < 0.0001). Conclusion Black race is an independent predictor of mortality. The impact of race on mortality is mitigated, albeit not eliminated, by increasing hospital volume. [ABSTRACT FROM AUTHOR]

Objective Early-stage uterine papillary serous carcinoma (UPSC) has a poor prognosis and high recurrence rate. While adjuvant chemotherapy is generally recommended, the role of radiation is uncertain. We examined the association between vaginal brachytherapy and whole pelvic radiation and survival in women treated with and without adjuvant chemotherapy. Methods The National Cancer Data Base was used to identify women with stage I-II UPSC treated between 1998 and 2012. Trends in use of chemotherapy, brachytherapy, and external beam radiation over time were examined. The association between these treatments and mortality were examined using multivariable Cox proportional hazards models. Results A total of 7325 patients were identified. Overall, 2779 (37.9%) received chemotherapy. The use of vaginal brachytherapy increased from 7.2% in 1998 to 29.1% in 2012 (P < 0.0001), while use of external beam radiation decreased from 18.2% to 11.7% over the same period (P < 0.0001). Use of chemotherapy was associated with a 22% reduction in mortality (HR = 0.78; 95% CI, 0.69–0.88). While brachytherapy was associated with decreased mortality (HR = 0.67; 95% CI, 0.57–0.78), use of external beam radiation was not associated with survival (HR = 1.03; 95% CI, 0.92–1.17). Stratified by stage, use of chemotherapy was associated with decreased mortality for women with stage IB and II tumors, but not for stage IA neoplasms. Vaginal brachytherapy was associated with reduced mortality for stage IA and II neoplasms. Conclusion For women with early-stage UPSC, chemotherapy is associated with improved survival. Vaginal brachytherapy was also associated with improved survival, however, there was little benefit to use of external beam radiation. [ABSTRACT FROM AUTHOR]

Objectives While lymphvascular space invasion (LVSI) is a risk factor for nodal metastasis in endometrial cancer, the magnitude of risk is poorly described. We examined the risk of nodal metastasis associated with LVSI for various combinations of tumor grade and depth of invasion and examined the effect of LVSI on survival. Methods We identified patients with T1A (< 50% myoinvasion) and T1B (> 50% myoinvasion) endometrioid adenocarcinomas of the endometrium diagnosed between 2010 and 2012 and recorded in the National Cancer Database. The risk of nodal metastasis associated with LVSI stratified by grade and stage is reported. The association of LVSI and survival was examined using Kaplan–Meier analyses and Cox proportional hazards models. Results We identified 25,907 patients, including 3928 (15.2%) with LVSI. Among patients with LVSI, 21.0% had positive lymph nodes, compared to 2.1% in patients without LVSI (P < 0.0001). In analyses stratified by stage and grade, LVSI was associated with increased risks of LN metastasis by a magnitude of 3 to over 10-fold. In a multivariable model controlling for clinical and demographic characteristics, the risk ratio of nodal disease with LVSI was 9.29 (95% CI, 7.29–11.84) for T1A tumors and 4.64 (95% CI 3.99–5.39) for T1B tumors. LVSI was associated with decreased survival even after adjustment for the presence of lymph node metastases (HR = 1.92, 95% CI 1.56–2.36). Conclusions LVSI is independently associated with lymph node metastases in women with apparent early-stage endometrial cancer and an independent predictor of survival even after adjustment for the presence of lymph node metastases. [ABSTRACT FROM AUTHOR]

Objective To evaluate surveillance methods and their utility in detecting recurrence of disease in a high grade endometrial cancer population. Methods We performed a multi-institutional retrospective chart review of women diagnosed with high grade endometrial cancer between the years 2000 and 2011. Surveillance data was abstracted and analyzed. Surveillance method leading to detection of recurrence was identified and compared by stage of disease and site of recurrence. Results Two hundred and fifty-four patients met the criteria for inclusion. Vaginal cytology was performed in the majority of early stage patients, but was utilized less in advanced stage patients. CA-125 and CT imaging were used more frequently in advanced stage patients compared to early stage. Thirty-six percent of patients experienced a recurrence and the majority of initial recurrences (76%) had a distant component. Modalities that detected cancer recurrences were: symptoms (56%), physical exam (18%), surveillance CT (15%), CA-125 (10%), and vaginal cytology (1%). All local recurrences were detected by symptoms or physical exam findings. While the majority of loco-regional and distant recurrences (68%) were detected by symptoms or physical exam, 28% were detected by surveillance CT scan or CA 125. One loco-regional recurrence was identified by vaginal cytology but no recurrences with a distant component detected by this modality. Conclusions Symptoms and physical examination identify the majority of high grade endometrial cancer recurrences, while vaginal cytology is the least likely surveillance modality to identify a recurrence. The role of CT and CA-125 surveillance outside of a clinical trial needs to be further reviewed [ABSTRACT FROM AUTHOR]

To evaluate the clinical utility of tertiary cytoreductive surgery (TCS) in recurrent ovarian cancer. MEDLINE via PubMed, Embase (Elsevier), ClinicalTrials.gov , Scopus (Elsevier) and Web of Science for studies from inception to 4/09/2021. Studies reporting disease specific survival (DSS) and overall survival (OS) among women who underwent optimal cytoreductive surgery as compared to those who had a suboptimal cytoreductive surgery at time of TCS were abstracted. Study quality was assessed with the Quality In Prognosis Studies (QUIPS) tool. The data were extracted independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between survival and surgical outcomes. 10 studies met all the criteria for inclusion in the systematic review. Patients with optimal tertiary cytoreductive surgery had better DSS (HR = 0.35; 95% CI, 0.19–0.64, P < 0.001), with low heterogeneity (I2 = 0%, P = 0.41) when compared to those with suboptimal tertiary cytoreductive surgery. Pooled results from these studies also demonstrated a better OS (HR = 0.34; 95% CI, 0.15–0.74, P < 0.007) with moderate heterogeneity (I2 = 59%, P = 0.09) when compared to patients with a suboptimal tertiary cytoreductive surgery. This remained significant in a series of sensitivity analyses. Due to the limited number of studies, we were unable to do further subgroup analyses looking at outcomes comparing tertiary cytoreductive surgery to chemotherapy. In this systematic review and meta-analysis of observational studies examining tertiary cytoreductive surgery for recurrent ovarian cancer, optimal tertiary cytoreductive surgery was associated with improved OS and DSS survival compared to suboptimal tertiary cytoreductive surgery. • There is limited data on tertiary cytoreductive surgery for recurrent ovarian cancer. • A systematic review of the literature identified ten studies evaluating the role of tertiary cytoreductive surgery. • Optimal cytoreductive surgery was associated with improved OS and DSS compared to suboptimal tertiary cytoreductive surgery [ABSTRACT FROM AUTHOR]

Fragmentation occurs when a patient receives care at more than one hospital, and the long-term effects in ovarian cancer are unknown. We examined the association between fragmentation of primary debulking surgery (PDS) and adjuvant chemotherapy (AC) and overall survival (OS). The National Cancer Database was used to identify women with stage II-IV epithelial ovarian cancer between 2004 and 2016 who underwent PDS followed by AC. Fragmentation was defined as receipt of AC at a different institution than where PDS was performed. After propensity score weighting, proportional hazard models were developed to estimate the association between fragmented care and OS. Of the 36,300 patients identified, 13,347 (36.8%) had fragmented care. Patient factors associated with fragmentation included older age, higher income, and longer travel distance for PDS; hospital factors included PDS performed at a community center or a facility with lower annual surgical volume (P < 0.05, all). Fragmentation was associated with a 15% risk of 30-day delay to AC (aRR 1.15, 95% CI 1.09–1.22). In a propensity scoring weighted analysis, mortality was reduced when AC was fragmented (HR 0.95, 95% CI 0.92–0.97). Sensitivity analyses indicated fragmentation was associated with improved survival in metropolitan residents. Stratified analyses indicated patients who traveled 50 miles or more with PDS and AC at the same institution had the worst OS. Fragmentation of PDS and AC has no adverse effects on long-term survival. Survival outcomes were worst for those who received care at the same institution 50 miles or more away. • Fragmentation of the initial phase of ovarian cancer care was common and occurs in 36.8% of women. • Fragmentation of care did not negatively affect survival and mortality was slightly reduced. • Patients who traveled ≥50 miles for surgery and chemotherapy had the worst survival. [ABSTRACT FROM AUTHOR]

To explore trends of ovarian conservation (OCN) over time in young women with early stage leiomyosarcoma (LMS) and examine the association between OCN and survival. Patients under the age of 50 who were diagnosed with stage I LMS who underwent hysterectomy with and without oophorectomy between 2010 and 2016 were identified in the National Cancer Database (NCDB). Performance of oophorectomy vs. OCN was determined using surgery codes. Trends of OCN were reported. Multivariable regression models were fit to estimate predictors of OCN. An inverse probability of treatment weighted propensity score method was used to examine the association between all-cause mortality and OCN. Overall, 225 patients (28%) underwent OCN. Rates of OCN decreased from 41.2% (2010) to 14.3% (2016); this finding was consistent across age groups: <35, 35–39, 40–44, and 45–49 years. Race, insurance, and stage did not affect performance of OCN. Women with poorly differentiated tumors were less likely to undergo OCN compared to well-differentiated tumors (aRR 0.59; 95% CI 0.40–0.86). After propensity score weighting, there was no association between OCN and mortality (HR 1.19, 95% CI 0.80–1.77). Five-year survival for the OCN group was 67.1% (95% CI 59.8–75.2%) compared to 72.2% for the oophorectomy group (95% CI 67.2–77.5%). OCN for early stage LMS in premenopausal women has decreased over time. There was no association between OCN and mortality among women with stage I LMS. OCN should be considered in premenopausal women with stage I LMS given the health benefits. Ovarian Conservation Paper Highlights • Standard therapy for women with leiomyosarcoma entails hysterectomy with resection of intraabdominal disease • The rates of ovarian conservation for premenopausal women with uterine-confined leiomyosarcoma have decreased over time • There is no association between performance of ovarian conservation and all-cause mortality • Ovarian conservation should be considered in premenopausal women with leiomyosarcoma confined to the uterus [ABSTRACT FROM AUTHOR]

We used a novel machine learning algorithm to develop a precision prognostication system for endometrial cancer. The Ensemble Algorithm for Clustering Cancer Data (EACCD) unsupervised machine learning algorithm was applied to women with endometrioid endometrial cancer in the Surveillance, Epidemiology, and End Results database from 2004 to 2015. The prognostic system was created based on TNM stage, grade, and age. The concordance (C-index) was used to cut dendrograms and create prognostic groups. Kaplan-Meier cancer-specific survival was employed to visualize the survival function of EACCD-based prognostic groups and AJCC groups. A total of 46,773 women were identified. Using the machine learning algorithm with TNM stage, grade, and three age groups, eleven prognostic groups were generated with a C-index of 0.8380. The five-year survival rates for the eleven groups ranged from 37.9–99.8%. To simplify the classification system further, using visual inspection of the data we created a modified EACCD grouping, and combined the top six survival groups into three new prognostic groups. The new five-year survival rates for these eight modified prognostic groups included: 99.1% for group 1, 96.5% for group 2, 92.2% for group 3, 84.8% for group 4, 72.7% for group 5, 61.1% for group 6, 52.6% for group 7, and 37.9% for group 8. The C-index for the modified eight prognostic groups was 0.8313. This novel machine learning algorithm demonstrates improved prognostic prediction for patients with endometrial cancer. Using machine learning for endometrial cancer allows for the integration of multiple factors to develop a precision prognostication system. • This novel machine learning algorithm demonstrates improved prognostic prediction for patients with endometrial cancer. • Using machine learning for endometrial cancer allows for the integration of multiple clinical factors into staging. • A machine learning for endometrial cancer allows for development of a precision prognostication system. [ABSTRACT FROM AUTHOR]

The optimal adjuvant therapy for stage III endometrial cancer is unknown. Studies have suggested that combination therapy with chemotherapy and radiation is associated with improved survival. We examined early and late-term toxicities associated with chemotherapy (CT), external beam radiotherapy (RT), or combination chemoradiotherapy for stage III uterine cancer. The SEER-Medicare database was used to identify women age ≥ 65 years with stage III uterine cancer who received adjuvant CT, RT, or chemoradiotherapy from 2000 to 2015. The associations between therapy and early and late-term toxicities identified with billing claims, hospitalizations and emergency department visits were examined using multivariable regression models. A total of 2185 patients were identified including 574 (26.3%) who received CT, 636 (29.1%) who received RT, and 975 (44.6%) who received chemoradiotherapy. The proportion of patients receiving chemoradiotherapy or CT increased over time. During the first 6 and 12 months of adjuvant therapy, RT was associated with a lower risk of early-term toxicity compared to chemoradiotherapy (aRR = 0.59, 95%CI 0.49–0.70 and aRR = 0.76, 95%CI 0.67–0.86, respectively) while CT shared a similar risk of early toxicities as chemoradiotherapy. CT and RT shared a similar risk of late-term toxicities compared to chemoradiotherapy. CT and RT alone were associated with a higher hazard for overall mortality than chemoradiotherapy (aHR = 1.27, 95% CI 1.10–1.47 and aHR = 1.25, 95% CI 1.08–1.44, respectively). Chemoradiotherapy is associated with lower mortality compared to single modality therapy and has a similar risk of early and late term toxicities compared to CT, though higher risk of early toxicities compared to RT. • Use of adjuvant chemoradiotherapy and chemotherapy compared to radiation has increased over time. • Chemoradiotherapy is associated with lower mortality compared to single modality therapy. • Chemoradiotherapy has a similar risk of early and late term toxicities compared to chemotherapy alone. [ABSTRACT FROM AUTHOR]

To examine patterns of patient travel among women with ovarian cancer and to explore the association between travel distance and short and long-term outcomes. Women with stage II–IV epithelial ovarian cancer diagnosed from 2004 to 2016 who underwent primary surgery were identified in the National Cancer Database. Mixed-effect log-linear models and proportional hazards models were developed to evaluate the association between travel distance and short and long-term outcomes after propensity score weighting. A further analysis was performed to compare patients who traveled a short distance to a low volume center (Local) to patients who traveled farther to a high volume hospital (Travel). We identified 56,834 patients treated in 1201 hospitals. Hispanic women were 58% and black women 64% less likely than white women to travel to a center in the greatest distance quartile for care. Similarly, Medicaid recipients (vs. commercially insured) were less likely to travel to a quartile four hospital (compared to Q1 of distance traveled). Of all patients, 90-day mortality was significantly lower in patients who traveled farther (Q4 vs. Q1; P < 0.0001). Compared to women in the Local group, patients in the Travel group had a decreased 30-day readmission rate. There was no difference in 30-day, 90-day, or 5-year mortality when comparing the Local to the Travel group. Travel distance for ovarian cancer surgery has increased over time. While there may be some short-term benefits in traveling to a regional center for care, there was little difference in long term outcomes based on travel distance. • Travel distance for ovarian cancer surgery has increased over time, consistent with regionalization of care. • 30-Day readmission rate decreased sequentially with increasing travel distance. • Black and Hispanic patients were more likely to travel shorter distances to receive care at lower volume centers • Patients with Medicaid insurance were more likely to travel shorter distances to receive care at lower volume centers. [ABSTRACT FROM AUTHOR]

To examine the risk of nodal metastases in a contemporary cohort of women based on pathologic risk factors including histology, depth of invasion, tumor grade, and lymphovascular space invasion. Women with endometrial cancer who underwent hysterectomy from 2004 to 2016 who were registered in the National Cancer Database were analyzed. Patients were stratified by T stage: T1A (<50% myometrial invasion), T1B (>50% myometrial invasion) and T2 (cervical involvement). Lymph node metastases were assessed in relation to tumor T stage and grade, and further stratified by lymphovascular space invasion. We identified 161,960 patients. The rate of nodal metastases within the endometrioid histology cohort was 2.2% for T1A cancers, 12.8% for T1B cancers and 19.9% for T2 cancers. For stage TIA cancers, the percent of patients with positive nodes increased from 1.1% for grade 1 cancers, to 2.9% for grade 2 cancers to 4.8% for grade 3 cancers. The corresponding rates of nodal metastases for stage T1B cancers were 8.6%, 13.7%, and 16.9%, respectively. For T1A cancers without lymphovascular space invasion, nodal metastases ranged from 0.6% in those with grade 1 cancers to 3.0% for grade 3 cancers. The corresponding risk of nodal disease ranged from 11.8% to 13.9% for T1A cancers with lymphovascular space invasion. There was a sequential increase in the risk of lymph node metastases based on depth of uterine invasion, tumor grade, and the presence of lymphovascular space invasion. The overall rate of nodal metastasis is lower than reported in the original GOG 33. • The risk of lymph node metastases increases with depth of uterine invasion, grade, and lymphovascular space invasion. • The rate of lymph node metastases was higher for women with serous and clear cell carcinomas. • The overall rate of nodal metastasis is lower than reported in the original GOG 33. [ABSTRACT FROM AUTHOR]

Neuroendocrine carcinoma of the endometrium (NECE) is a rare malignancy. We examined the natural history and outcomes of women with NECE compared to patients with poorly differentiated endometrioid endometrial cancer (EC). The National Cancer Database (NCDB) was used to identify women with NECE and women with poorly differentiated EC from 2004 to 2015. Clinical, demographic, and treatment characteristics were compared between groups. Kaplan-Meier survival curves and multivariable Cox proportional hazard regression models were used to identify associations between tumor histology and survival. A total of 28,291 women with EC and 364 women with NECE were identified. Patients with NECE were more often non-white and presented with later stage disease compared to patients with EC. Women with NECE were more likely to receive adjuvant chemotherapy (60.2% vs. 29.6%), but were less likely to receive radiation (28.0% vs. 47.6%) (P < 0.001 for both). Median survival was 17 months (95% CI, 12–23) for NECE and 144 months (95% CI, 140–148) for EC. 5-year survival was 38.3% (95% CI, 32.7–43.8%) for NECE vs. 68.8% (95% CI, 68.2–69.4%) for EC. In a multivariable model, the hazard ratio for death for women with NECE compared to EC was 2.32 (95% CI, 1.88–2.88). Similar findings were noted when the analysis was limited to women with stage I (HR = 1.62; 95% CI, 1.01–2.61), and stage III (HR = 2.57; 95% CI, 1.88–3.53) neoplasms. NECE is a rare and aggressive uterine carcinoma. Compared to patients with poorly differentiated EC, patients with NECE present with later stage disease and have decreased survival. • Neuroendocrine carcinoma of the endometrium is a rare and aggressive uterine carcinoma. • Compared to patients with poorly differentiated endometrioid tumors, patients with neuroendocrine carcinomas present with later stage disease. • Survival for neuroendocrince carcinomas is inferior to that of high grade endometrioid carcinomas. [ABSTRACT FROM AUTHOR]

While women with stage III endometrial cancer are often treated with chemotherapy and external beam radiation, the optimal sequence of these modalities is unknown. We examined the association between the sequence of chemotherapy (CT) and external beam radiation therapy (RT) on survival for women with stage IIIC endometrial carcinoma. The National Cancer Database was used to identify women with stage IIIC endometrial carcinoma treated with adjuvant CT and RT from 2004 to 2015. Patients were stratified based on the sequence of therapy: RT before CT, CT before RT, or concurrent therapy. The association between treatment sequence and mortality was examined through a weighted propensity score analysis. A total of 6981 patients were identified, including 5116 (73.3%) who received CT before RT, 696 (10.0%) who received RT before CT, and 1169 (16.7%) who received concurrent therapy. The use of CT-RT increased from 39.9% in 2004 to 75.5% in 2015, while use of RT-CT decreased from 34.0% to 4.4% and concurrent therapy decreased from 26.1% to 20.2% over the same period (P < 0.001). Compared to CT-RT, there was no difference in risk of mortality with RT before CT (HR = 1.01; 95% CI, 0.86–1.19) while concurrent therapy was associated with a 47% increased risk of mortality (HR = 1.47; 95% CI, 1.31–1.66). In a sensitivity analysis combining the groups that received RT first (RT before CT or concurrent RT-CT), mortality was 25% higher (HR = 1.25; 95% CI, 1.13–1.39) compared to a strategy of CT followed by RT. Among women with stage IIIC endometrial carcinoma treated with combination chemotherapy and external beam radiation, a strategy employing chemotherapy first is associated with improved survival compared to concurrent therapy. • Use of chemotherapy before radiation is increasing for with stage IIIC endometrial carcinoma. • Among women with stage IIIC endometrial carcinoma treated with combination chemotherapy and external beam radiation. • A strategy employing chemotherapy first is associated with improved survival compared to concurrent therapy. • Prospective studies investigating optimal individualized sequences after initiation of chemotherapy are still needed. [ABSTRACT FROM AUTHOR]

Objective Patient reported outcomes (PRO) relating to treatment toxicities have been demonstrated to reliably evaluate adverse events in clinical trials. We assessed the user satisfaction of implementing a focused PRO questionnaire for patients with gynecologic cancers undergoing chemotherapy. Methods Patients with gynecologic cancers undergoing chemotherapy were prospectively identified after IRB approval from April 2017 to August 2017. We administered a 24-symptom questionnaire, adapted from the validated PRO version of the Common Terminology Criteria for Adverse Event, to enrolled participants at the beginning of two outpatient visits. Patient and provider satisfaction with use of PRO was assessed afterwards. Descriptive statistics were performed. Results A total of 44 patients were enrolled. Patients were racially diverse: 52% Caucasian, 18% African-American, 9% Asian, and 20% other; 27% were of Hispanic origin. The majority of patients had ovarian cancer (54%), followed by uterine (29%) and cervical cancer (15%). Ninety-five percent of patient and 97% of provider satisfaction survey responses indicated the PRO questionnaire addressed important symptoms. Nearly all patient and provider responses indicated the PRO questionnaire was easy to use. Sixty-nine percent of patient and 97% of provider responses indicated the questionnaire positively impacted clinical care; 85% of patients wished to use a similar questionnaire throughout treatment. Conclusions We have shown that incorporating a focused patient-reported symptom questionnaire into routine outpatient care of gynecological oncology patients undergoing chemotherapy was met with a high degree of patient and provider satisfaction regarding questionnaire content, feasibility, and perception of care improvement. [ABSTRACT FROM AUTHOR]

Objective Although racial disparities in treatment and outcome for endometrial cancer are well recognized, little work has explored disparities in young women. We performed a population-based analysis to compare survival between black and white women with endometrial cancer at < 50 years of age. Methods We used the National Cancer Data Base to identify women < 50 years of age with endometrial cancer from 1998 to 2012. Clinical and demographic characteristics were compared between black and white women and survival by race analyzed using Kaplan-Meier curves and multivariable Cox proportional hazards models. Results We identified a total of 35,850 women < 50 years of age including 31,947 (89.1%) white and 3903 (10.9%) black patients. Black women were more likely to have advanced stage, poorly differentiated, and non-endometrioid histology neoplasms ( P < 0.05 for all). In a multivariable model, survival was 19% worse for black patients than white patients (HR = 1.19; 95% CI, 1.08–1.32). A similar effect was seen when limited to women with early-stage tumors (HR = 1.24; 95% CI, 1.04–1.49), while among patients with advanced stage tumors, no association between race and survival was seen (HR = 1.12; 95% CI, 0.89–1.41). Five-year survival rates were 90.6% (95% CI, 88.6–92.3%) for white and 81.5% (95% CI, 73.0–87.5%) for black women with stage IB tumors, and 75.1% (95% CI, 72.5–77.5%) and 63.3% (95% CI, 54.1–71.2%) for white and black women with stage III tumors, respectively. Conclusions Young black women are more likely to present with pathologically aggressive, advanced stage tumors. Even after adjusting for these pathologic differences, young black women with endometrial cancer have higher mortality than white women. [ABSTRACT FROM AUTHOR]

Objective Treatment selection for recurrent ovarian cancer is typically based on the duration of time between the completion of adjuvant, platinum-based therapy and the time of recurrence, the platinum free interval (PFI). We examined the use of, and outcomes associated with platinum-based chemotherapy based on the PFI in women with recurrent ovarian cancer. Methods The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged > 65 years with epithelial ovarian cancer who underwent surgery and platinum-based chemotherapy and who developed a recurrence > 3 months after the completion of adjuvant therapy. Patients were stratified by PFI into 3 groups: PFI < 6 months, PFI 7–12 months, and PFI > 12 months. Multivariable models were used to examine predictors of use of platinum-based therapy and survival for each group. Results A total of 2369 patients were identified. In women with a PFI of ≤ 6 months, treatment consisted of platinum-based combination therapy in 28.2%, single agent platinum in 5.2% and non-platinum therapy in 66.6%. Corresponding rates of these treatments among women with a PFI of 7–12 months were 39.7%, 12.4% and 47.9%, respectively; the rates were 57.6%, 13.2% and 29.3% in those with a PFI of > 12 months, respectively. Median survival was 13, 18, and 27 months for patients with a PFI of ≤ 6 months, 7–12 months, and > 12 months, respectively ( P < 0.0001). For all three groups, platinum combination therapy was associated with decreased risk of death compared to non‑platinum based therapy. Conclusion Platinum free interval is a strong predictor of survival in elderly women with recurrent ovarian cancer. There is widespread variation in treatment selection for women with recurrent ovarian cancer with many women receiving non-guideline based regimens. [ABSTRACT FROM AUTHOR]

Objective To explore the presentation, management and outcomes of adult women diagnosed with immature ovarian teratoma. Methods The National Cancer Database (NCDB) was used to identify women ≥ 18 years of age diagnosed with an immature teratoma from 1998 to 2012. We analyzed demographic, clinical and tumor characteristics, and treatment trends. Multivariable models were employed to examine predictors of adjuvant chemotherapy use and survival. Results We identified a total of 1045 adult women with immature teratoma. The median age of diagnosis was 27 years and most were diagnosed between ages 18 and 39 (88.9%). The majority presented with early-stage (I/II) disease (76.0%), underwent unilateral salpingo-oophorectomy (52.5%) and received adjuvant chemotherapy (56.8%). The probability of receiving chemotherapy increased with stage, grade, and treatment at academic compared to community based centers (P < 0.05.). Older age, advanced stage, and grade III histology were associated with worse survival (P < 0.05). Five-year survival rates were: 98.3% (95% CI 96.8–99.1), 93.2% (95% CI 82.8–97.4), 82.7% (95% CI 74.3–88.5), and 72.0% (95% CI 50.1–85.5) for stages I, II, III, and IV disease, respectively. Conclusions The incidence of immature teratoma is highest in young adults aged 18 to 39. Most patients present with early-stage disease, are managed with fertility sparing surgery and chemotherapy and have an excellent prognosis. Later age at diagnosis, advanced stage, and high-grade histology confer a worse prognosis. [ABSTRACT FROM AUTHOR]

Objective Extended-duration thromboprophylaxis for 4 weeks after discharge has been demonstrated to reduce venous thromboembolic events (VTE) in cancer patients undergoing abdominopelvic surgery and is recommended in national guidelines. We examined the utilization and effectiveness of extended-duration low molecular weight heparin prophylaxis in high-risk cancer patients. Methods We analyzed patients with colon, ovarian, and uterine cancer who underwent surgery from 2009 to 2013 and who were recorded in the MarketScan database. Multivariable models and propensity score analysis with inverse probability of treatment weight were developed to examine uptake and predictors of use of post-discharge low molecular weight heparin (LMWH), as well as associated adverse events (transfusion, and hemorrhage). Results A total of 63,280 patients were identified. Use of extended-duration prophylaxis increased from 2009 to 2013 from 1.4% to 1.7% ( P = 0.67) for colectomy, 5.9% to 18.3% for ovarian cancer surgery ( P < 0.001), and 6.3% to 12.2% ( P < 0.001) for hysterectomy for endometrial cancer. There was no association between use of extended-duration prophylaxis and reductions in VTE for any of the procedures: colectomy (2.4% with extended-duration prophylaxis vs. 2.9% without prophylaxis, OR = 0.84; 95% CI, 0.54–1.31), ovarian cancer-directed surgery (3.7% vs. 3.6%, OR = 1.01; 95% CI, 0.76–1.33), hysterectomy (2.1% vs. 2.1%; OR = 0.96; 95% CI, 0.67–1.38). Extended-duration prophylaxis was associated with an increased risk of adverse postoperative events: 2.20 (95% CI, 1.51–3.19) after colectomy, 1.24 (95% CI, 0.92–1.68) following ovarian cancer-directed surgery and 0.99 (95% CI, 0.66–1.48) for hysterectomy for endometrial cancer. Conclusion Use of extended-duration thromboprophylaxis is low among high-risk cancer patients undergoing surgery. [ABSTRACT FROM AUTHOR]

Objective Procedural volume is associated with outcomes for many surgical interventions. Little is known about the association between volume and outcomes of radiation. We examined the association between treatment center and hospital volume and outcomes for women with locally advanced cervical cancer treated with radiation. Methods Women with stage IIB–IVA cervical cancer treated with primary radiation from 1998 to 2011 and recorded in the National Cancer Database were examined. Hospital volume was estimated as the mean annualized volume, while center-specific effects on care were examined using a hospital-specific random effect. Multivariable regression models adjusted for metrics of treatment quality were used to estimate survival. Results 20,766 patients treated at 1115 hospitals were identified. The median follow-up was 24.2 months while 5-year survival was 36.5% (95% CI, 35.6–37.4%). Higher hospital volume was associated with receipt of brachytherapy (P < 0.05), but had no effect on use of chemotherapy. In a multivariable model accounting for clinical and demographic factors as well as quality of care, hospital volume was not associated with survival (P = 0.25). The specific hospital in which patients received care was the strongest predictor of survival (P < 0.0001) followed by stage, year of diagnosis and treatment quality (P < 0.0001 for all). The hospital-specific effect on mortality expressed as a hazard ratio, ranged from 0.66 to 1.53 across hospitals. Conclusion For locally advanced cervical cancer, hospital volume has a minimal impact on outcome; however, the specific center in which care is delivered is strongly associated with survival. [ABSTRACT FROM AUTHOR]

Background Therapeutic options are limited for uterine serous carcinoma (USC). TP53 , PIK3CA , FBXW7 , and ERBB mutations, as well as HER2 and EGFR overexpression have been reported. We aim to evaluate patterns of molecular, genomic and protein changes in 628USC tumors. Methods 628 consecutive cases of USC submitted to Caris Life Sciences from Mar, 2011 to July, 2014 were reviewed. These were analyzed using the Illumina TruSeq Amplcon Cancer panel to search for sequenced variants in 47 genes commonly implicated in carcinomatosis. In situ hybridization and immunohistochemistry were also used to assess copy number and protein expression, respectively, of selected genes. Results 31 out of 47 genes of interest harbored mutations, including TP53 (76%), PIK3CA (29%), FBXW7 (12%) and KRAS (9.3%). BRCA1 and BRCA2 were mutated in 9.1% and 6.3%, respectively. ERCC1 and MGMT were absent in 81% and 46% of tumors analyzed, respectively, suggesting potential benefit from platinum and alkylating agents. While not traditionally considered hormone-dependent, our cohort showed high ERα (60%), PR (32%), and AR (27%) expression. HER2 overexpression was 10% via IHC, amplification was 17% via CISH/FISH and mutation was 2% via NGS. While low in PTEN mutation frequency (7%), 45% of USC showed PTEN loss on IHC, and 29% harbored PIK3A mutation, suggesting deregulation of P13K/AKT pathway in a subset of patients. 11% expressed PDL1 and 67% expressed PD1. Conclusions Our findings suggest hormonal receptors, as well as genes implicated in DNA repair, cell proliferation and cell cycle pathways are of interest in USC. [ABSTRACT FROM AUTHOR]

Objective Cytoreduction for ovarian cancer is associated with substantial morbidity. We examined the outcome of patients undergoing surgery for ovarian cancer to determine if there are sub-groups of patients who may benefit from alternative treatments. Methods The National Surgical Quality Improvement Program database was used to identify women who underwent surgery for ovarian cancer from 2005-2012. Multivariable logistic regression models were used to examine the effect of age, race, functional status, ASA class, preoperative albumin and performance of extended cytoreductive procedures on morbidity, mortality and resource utilization. Results A total of 2870 women were identified. The perioperative complication rate increased from 9.5% in women < 50 years, to 13.4% in those age 60-69 years, and 14.6% in women ≥ 70 years (P < 0.0001). Similarly, complications rose from 7.3% in those who did not require any extended procedures to 12.9% after 1 procedure, 28.4% for those who had 2, and 30.0% in women who underwent ≥ 3 extended procedures (P < 0.0001). In a series of multivariable models, the number of extended cytoreductive procedures performed and preoperative albumin were the factors most consistently associated with morbidity. Using a series of model fit statistics, compared to chance alone, the ability to predict any complication increased by 27.4% when procedure score was analyzed, 22.0% with preoperative albumin, 11% with age, and 4% with functional status. Conclusions While preoperative clinical and demographic factors may help predict the risk of adverse outcomes for women undergoing surgery for ovarian cancer, performance of extended cytoreductive procedures is the strongest risk factor for complications. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The study objective was to determine the prognostic significance of serum CA-125 levels in patients with grade 1 serous ovarian carcinoma (SOC) enrolled in a Phase III study. Methods: An ancillary analysis of a phase III study of women with advanced epithelial ovarian cancer treated with carboplatin/paclitaxel versus triplet or sequential doublet regimens. Grade 1 SOC was used as a surrogate for low-grade serous carcinoma. Results: Among 3686 enrolled patients, 184 (5%) had grade 1 disease and CA-125 levels available. For those with grade 1 SOC, the median patient age was 56.5; 87.3% had Stage III disease. Median follow-up was 102months and there was no difference in pre-chemotherapy CA-125 by treatment arm (P =0.91). Median pretreatment CA-125 for those with grade 1 SOC was lower (119.1) than for patients with grade 2–3 SOC (246.7; P <0.001). In those with grade 1, pretreatment CA-125 was not prognostic of outcome. However, patients with CA-125 levels that normalized after cycle 1, 2 or 3 were 60–64% less likely to experience disease progression as compared to those who never normalized or normalized after 4cycles (P ≤0.024). Normalization of CA-125 levels before the second cycle was negatively associated with death, with a HR of 0.45 (P =0.025). Conclusions: Pretreatment CA-125 level was significantly lower in women with grade 1 SOC compared to those with high-grade SOC. While pretreatment CA-125 was not associated with survival, serial CA-125 measurements during chemotherapy treatment were prognostic, with normalization before the second chemotherapy cycle associated with a decreased risk of death. [Copyright &y& Elsevier]