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▪ ▪ ▪ • The report includes endometrial and ovarian cancer rating and subspecialty rankings. • Procedure and condition ratings for gyn cancer are more reflective of quality of care. • Endometrial cancer methodology can improve by including MIS. • Ovarian cancer methodology can improve by including controls for complex surgery. [ABSTRACT FROM AUTHOR]

Transportation is an underrecognized, but modifiable barrier to accessing cancer care, especially for clinical trials. Clinicians, insurers, and health systems can screen patients for transportation needs and link them to transportation. Direct transportation services (i.e., ride-sharing, insurance-provided transportation) have high rates of patient satisfaction and visit completion. Patient financial reimbursements provide necessary funds to counteract the effects of transportation barriers, which can lead to higher trial enrollment, especially for low socioeconomic status and racially and ethnically diverse patients. Expanding transportation interventions to more cancer patients, and addressing knowledge, service, and system gaps, can help more patients access needed cancer care. [ABSTRACT FROM AUTHOR]

We examined the association of gynecologic oncology (GYO) versus medical oncology (MEDONC) based care with survival, health care utilization and spending outcomes in women undergoing chemotherapy for advanced gynecologic cancers. Women with newly diagnosed stage III-IV uterine, ovarian, and cervical cancers from 2000 to 2015 were identified in SEER-Medicare. We assessed the association of provider specialty with overall survival, emergency department utilization, admissions, and spending. Outcomes were assessed using unadjusted and Inverse Treatment Probability Weighted propensity-score applied, multi-variable cox modeling, Poisson regression, and generalized models of log-transformed data. We identified 7930 gynecologic cancer patients (4360 ovarian, 2934 uterine, 643 cervix). 37% were treated by GYO and 63% by MEDONC. For ovarian patients, GYO care was associated with improved OS (median OS 3.3 v. 2.9 years; HR 0.85, 95%CI 0.80, 0.91, p <.0001) and similar mean spending per month ($4015 v. $4316, mean ratio 0.97 (95% CI 0.93, 1.02), p =.19), compared to MEDONC in adjusted analyses. For uterine patients, GYO care was associated with similar OS, but decreased spending ($3573 v. $4081, mean ratio 0.87 (95% CI.81, 0.93), p <.0001), and decreased ED utilization (RR 0.76, 95% CI 0.69, 0.85, p <.0001). For cervical patients, GYO care was associated with similar OS, and similar spending. Admissions were more likely in ovarian (RR 1.23, 95%CI 1.11, 1.37, p =.0001) and cervical patients (RR 1.26, 95% CI 1.05, 1.51, p =.015) treated by GYO, in adjusted analyses. GYO based care was associated with improved OS and equal spending for patients with advanced stage ovarian cancer. Uterine and cervix patients had similar OS, and less or equal spending respectively, when treated by GYO compared to MEDONC. • 2/3 of advanced gyn-cancer patients receive chemotherapy from medical-oncologists versus 1/3 from gynecologic-oncologists. • Gynecologic-oncology chemotherapy-based care in ovarian cancer is associated with improved OS and equivalent spending. • Patients receiving chemotherapy from gynecologic-oncologists were treated by higher volume providers and had less delays. [ABSTRACT FROM AUTHOR]

We sought to determine if past surgical history is associated with perioperative outcomes for patients undergoing hysterectomy. A retrospective cohort study was conducted at a single, tertiary, academic health system of women who underwent hysterectomy from May 2016 – May 2017. Past surgical history (PSH) involving any abdominal or pelvic surgery, baseline demographics and perioperative outcomes were collected. For purposes of analyses, PSH was defined using three algorithms: 1) any prior abdominopelvic surgery, 2) having had abdominopelvic surgeries likely to cause adhesive disease, 3) anatomic location of prior PSH (none; pelvic; abdominal; or abdominal+pelvic). Descriptive, bivariable and multivariable analyses were performed. 1256 patients underwent hysterectomy. In adjusted analyses, PSH defined by any prior abdominopelvic surgery was associated with length of stay (LOS) (2.1 days (95%CI 1.9, 2.2) vs. 1.8 (95%CI 1.6, 2.0), (p =0.02)). PSH of procedures likely to cause adhesive disease was associated with greater estimated blood loss (EBL) (243.2 mL (95%CI 208.1, 278.3) vs. 189.0 (95%CI 1734, 204.7), (p =0.01)), longer LOS (2.5 days (95%CI 2.2, 2.8) vs. 1.9 (95%CI 1.7, 2.0), (p <0.01)), and more readmissions (OR 2.4, 95%CI 1.3, 4.5) (p<0.01). PSH defined by anatomic location revealed a trend (p =0.07) towards greater EBL in those with prior pelvic or abdominal+pelvic surgery compared to none or abdominal only, whereas LOS, readmissions and operative times did not differ. Increased total number of prior open surgeries was associated with operative time (p <0.0001), EBL (p<0.0001), hospital LOS (p<0.0001) and readmission (p =0.026). Prior abdominopelvic surgery is associated with worse perioperative outcome measures in women undergoing hysterectomy. • Past surgical history is associated with perioperative outcomes following hysterectomy. • Different definitions of PSH are variably associated with hysterectomy-based outcomes such as blood loss and readmission. • PSH should be included in risk adjustment strategies when developing value-based care models for hysterectomy. [ABSTRACT FROM AUTHOR]

To determine the impact on overall survival (OS) of different modalities of adjuvant therapy for the treatment of stage III endometrial cancer (EC), by histology. Stage 3 endometrioid (EAC), serous (SER), clear cell (CC), and carcinosarcoma (CS) patients who underwent primary surgical staging from 2000 to 2013 were identified in SEER-Medicare. Adjuvant therapy was defined by a 4-arm comparator grouping (none; RT only; CT only; combination RT), as well as by an 8-arm comparator grouping (none; RT only; CT only; concurrent CT-RT; concurrent CT-RT then CT; Serial CT-RT; serial RT-CT; sandwich). Modality of RT and CT were analyzed using Kaplan-Meier estimates, log rank tests, and multivariable cox modeling. Of 2870 cases identified (1798 EAC, 606 SER, 118 CC, 348 CS), 31.5% received no adjuvant therapy. The remainder received RT or CT alone, concurrent RT-CT, serial or sandwich modalities. OS differed by adjuvant therapy in adjusted and unadjusted models, when combining all histologies, and when stratifying by histology using both the 4-arm, and 8-arm comparator analyses (log rank p <.05, all). By histology, in adjusted analyses, sandwich modality had the greatest improvement in OS for endometrioid, but pairwise comparisons did not identify a superior chemotherapy-based regimen. For serous and clear cell, the greatest improvement in OS was seen with concurrent RT-CT, and for carcinosarcoma, CT alone. OS for advanced EC significantly differs by histology and mode of adjuvant therapy. Future studies should evaluate the efficacy of combination-based adjuvant therapy versus chemotherapy alone, by histologic subtype and molecular signature. • OS amongst stage III endometrial cancers receiving adjuvant therapy differ by histology. • Amongst histologic subtypes of stage III endometrial cancer, chemotherapy-based adjuvant therapy is associated with OS. • Sandwich, concurrent chemoradiotherapy and chemotherapy alone were differently associated with OS by histology. [ABSTRACT FROM AUTHOR]

To investigate the patterns of use and impact of lymphadenectomy (LND) on overall survival (OS) of patients with apparent early stage malignant ovarian germ cell tumors (MOGCTs). Patients with apparent stage I MOGCT diagnosed between 2004 and 2015 were drawn from the National Cancer Database. The performance of LND was assessed from the pathology report. OS was evaluated using Kaplan-Meier curves, and compared with the log-rank test. A multivariate Cox analysis was performed to control for confounders. A total of 2774 patients were identified; 1426 (51.4%) underwent LND. The median number of lymph nodes (LN) removed was 9 (range 1–81); 48.3% of patients had at least 10 lymph nodes removed. The rate of regional lymph node metastasis was 10.3% (147 patients). There was no difference in OS, between patients who did (n = 1287) and did not (n = 1210) undergo LND, p = 0.81; 5-yr OS rates were 96.5% and 97.6% respectively. After controlling for patient age, insurance status, histology, presence of medical comorbidities, and receipt of chemotherapy, the performance of LND was not associated with better survival (HR: 1.33, 95% CI: 0.82, 2.14). While LN metastasis is common in apparent early stage MOGCTs, the performance of LND was not associated with a survival benefit. • In a cohort of 2774 patients with apparent early stage MOGCT approximately half underwent LND. • Rate of LN metastasis was 10.3%. • LND was not associated with better survival. [ABSTRACT FROM AUTHOR]

Health care in the United States is in the midst of a significant transformation from a “fee for service” to a “fee for value” based model. The Medicare Access and CHIP Reauthorization Act of 2015 has only accelerated this transition. Anticipating these reforms, the Society of Gynecologic Oncology developed the Future of Physician Payment Reform Task Force (PPRTF) in 2015 to develop strategies to ensure fair value based reimbursement policies for gynecologic cancer care. The PPRTF elected as a first task to develop an Alternative Payment Model for thesurgical management of low risk endometrial cancer. The history, rationale, and conceptual framework for the development of an Endometrial Cancer Alternative Payment Model are described in this white paper, as well as directions forfuture efforts. [ABSTRACT FROM AUTHOR]

Investigate the incidence of homologous recombination DNA damage response (HR-DDR) genomic alterations among patients with uterine sarcoma. The American Association for Cancer Research GENIE v13.0 database was accessed and patients with uterine leiomyosarcoma, adenosarcoma, undifferentiated uterine sarcoma, high-grade endometrial stromal sarcoma, low-grade endometrial stromal sarcoma, and endometrial stromal sarcoma not otherwise specified were identified. We determined the incidence of pathogenic alterations in the following genes involved in HR-DDR: ATM, ARID1A, ATRX, BAP1, BARD1, BLM, BRCA2, BRCA1, BRIP1, CHEK2, CHEK1, FANCA, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCL, MRE11, NBN, PALB2, RAD50, RAD51, RAD51B, RAD51C, RAD51D, WRN. Data from the OncoKB database, as provided by cBioPortal, was utilized to determine the presence of pathogenic genomic alterations. A total of 509 patients contributing with 525 samples were identified. Median patient age at sample collection was 56 years while the majority were White (80.7%). The most common histologic subtype was leiomyosarcoma (63.8%) followed by adenosarcoma (12.3%). The overall incidence of HR-DDR genomic alterations was 28.2%. The most commonly altered genes were ATRX (18.2%), BRCA2 (4%), and RAD51B (2.6%). The highest incidence of HR-DDR genomic alterations was observed among patients with leiomyosarcoma (35.4%), adenosarcoma (27%) and undifferentiated uterine sarcoma (30%), while those with low-grade endometrial stromal sarcoma had the lowest (2.9%) incidence. Approximately 1 in 3 patients with uterine sarcoma harbor a pathogenic alteration in HR-DDR genes. Incidence is high among patients with uterine leiomyosarcoma and adenosarcoma. • Uterine sarcomas have an overall poor prognosis. • 28.2% of patients with uterine sarcomas harbor a pathogenic alteration in homologous recombination DNA damage response genes. • Incidence is highest among patients with uterine leiomyosarcoma and adenosarcoma. [ABSTRACT FROM AUTHOR]

Investigate outcomes for advanced stage epithelial ovarian cancer (EOC) patients based on facility-level utilization of neoadjuvant chemotherapy (NACT). Stage III-IV EOC patients diagnosed between 2010 and 2016 were identified in the National Cancer Database. Percentage of patients managed with NACT was calculated for facilities, reporting ≥120 patients. Facilities with lowest and highest quartile of NACT rate comprised the low and high-utilizing groups. Clinico-pathological characteristics were collected, and appropriate statistical analysis performed. High- and low-utilizing facilities managed on average 54.1% and 25.4% of patients with NACT respectively. Patients managed at high-utilizing facilities were significantly more likely to be >65 (p = 0.029), have stage IV disease (p < 0.001) and comorbidities (p < 0.001). Patients managed with primary debulking surgery (PDS) at low-utilizing facilities were significantly more likely to be >65, have stage IV disease, and have comorbidities (all, p < 0.001). Patients undergoing PDS at low-utilizing facilities were significantly less likely to achieve complete gross resection (p < 0.001), and were significantly more likely to experience 90-day mortality (p < 0.001), and unplanned 30-day readmission (p < 0.001). After controlling for age, comorbidities, race, insurance status, stage, grade and histology, high-utilizing facilities trended towards better overall survival (OS) (HR: 0.92, 95% CI: 0.85–0.99). Overall, patients undergoing PDS had better OS compared to those who had NACT (median 42 vs 27 months, p < 0.001). Despite treating an EOC population with more advanced disease and comorbidities, high-utilizing facilities have lower surgical morbidity and mortality with no detrimental impact on long-term survival. Careful patient selection to minimize the morbidity and mortality associated with PDS is pivotal. • Adoption of neoadjuvant chemotherapy among high-volume facilities varies. • Patients managed at low-adopting facilities experience higher surgical morbidity. • Inappropriate selection of patients for primary cytoreductive surgery is associated with worse oncologic outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background: We examined the distribution of obesity, diabetes, and race in Type I and Type II endometrial cancers (EC) and their associations with clinical outcomes. Methods: A multi-institutional retrospective analysis of Type I and II EC cases from January 2005 to December 2010 was conducted. Type I (endometrioid), Type II (serous and clear cell), low grade (LG) (grade 1 and 2 endometrioid), and high grade (HG) (grade 3 endometrioid, serous, clear cell) cohorts were compared. Univariate and multivariate analyses were used to determine time-to-recurrence (TTR), recurrence-free survival (RFS), and overall survival (OS). Results: Type I EC patients were more frequently obese than Type II (66% versus 51%, p<0.0001) and had similar rates of diabetes (25% versus 23%, p=0.69). African-Americans (AA) had higher median BMI than Caucasians in both Type I (p<0.001) and II (p<0.001) ECs, and were twice as likely to have diabetes (p<0.001). In Type I EC, DM was associated with worse RFS and OS in unadjusted and adjusted models (RFS HR 1.38, 95%CI 1.01–1.89; OS HR 1.86, 95%CI 1.30–2.67), but not with TTR. BMI was associated with improved TTR in the adjusted analysis for Type I EC (HR 0.98, 95%CI 0.95–1.0), but not with RFS or OS. There was no association between DM or BMI and outcomes in Type II or HG EC. AA race was not associated with RFS or OS on adjusted analyses in any group. Conclusions: Obesity and diabetes are highly prevalent in Type I and II ECs, especially in AA. DM was associated with worse RFS and OS in Type I EC. Neither DM nor BMI was associated with outcomes in Type II or HG EC. [Copyright &y& Elsevier]

Abstract: Objective: Preclinical evidence suggests that metformin exhibits anti-tumorigenic effects in endometrial cancer. We sought to investigate the association of metformin on endometrial cancer outcomes. Methods: A multi-institutional IRB-approved retrospective cohort analysis was conducted comparing endometrial cancer patients with diabetes mellitus who used metformin (based on medication review at the time of diagnosis) to those who did not use metformin from 2005 to 2010. Metformin use on treatment related outcomes (TTR: time to recurrence; RFS: recurrence free survival; OS: overall survival) were evaluated using univariate and multivariate modeling. Results: 24% (363/1495) endometrial cancer patients were diabetic, of whom 54% used metformin. Metformin users were younger and heavier than non-users, though nearly all were postmenopausal and obese. 75% of both groups had endometrioid histology. Stage, grade, and adjuvant therapy distributions were similar. Metformin users had improved RFS and OS. Non-metformin users had 1.8 times worse RFS (95% CI: 1.1–2.9, p=0.02) and 2.3 times worse OS (95% CI: 1.3–4.2, p=0.005) after adjusting for age, stage, grade, histology and adjuvant treatment. Metformin use was not associated with TTR. Conclusion: Metformin use was associated with improved RFS and OS but not TTR, most likely due to improving all-cause mortality. Its role in modifying cancer recurrence remains unclear. Prospective studies that capture metformin exposure prior to, during and post endometrial cancer treatment may help define the role of metformin upon cancer specific and overall health outcomes. [Copyright &y& Elsevier]

Abstract: Introduction: Studies have shown that body composition, age, gender, changes in monocyte count and repeated dosing alter pharmacokinetic properties of PEGylated liposomal doxorubicin (PLD). However, limited information exists regarding the clinical risk factors of ovarian cancer patients who develop palmar plantar erythrodysesthesia (PPE) while receiving PLD for cancer recurrence. Methods: We conducted a retrospective cohort analysis of consecutive patients with recurrent ovarian and primary peritoneal cancer who were treated with PLD from 2005 to 2009. Clinical and pathologic data were abstracted from electronic medical records. Statistical analyses were performed using univariate and bivariate analyses, logistic regression, and log rank-tests. Results: Twenty-three percent (31/133) of patients developed PPE. Age, body mass index (BMI), race, stage, and histology did not significantly differ between PPE and non-PPE patients. There was a possible trend for decreasing PPE with increasing body mass index (BMI) (24.5% of normal weight, 27.5% of overweight; 23.8% of obese class I; 13.3% of obese class II; and 0% of obese class III), though not statistically significant. The number of chemotherapy regimens prior to PLD, and the mean cycles of PLD received did not differ between patients with and without PPE. 77.4% of PPE cases occurred within the first 3 infusion cycles. PPE was not associated with time to progression. Conclusion: Nearly one-quarter of ovarian cancer patients receiving PLD will develop PPE. Further investigation of factors such as BMI associated with PPE may aid in patient selection for PLD, and future development of other nanoparticle and liposomal agents. [Copyright &y& Elsevier]

Abstract: Objective: To assess the practice of adjuvant radiation (RT) for endometrial cancer in the United States following the publication of the Post Operative Radiation Therapy in Endometrial Carcinoma (PORTEC1), and Gynecologic Oncology Group-Adjuvant Radiation for Intermediate Risk Endometrial Cancers (GOG99). Methods: A retrospective cohort study using the NCI SEER database compared the use of RT pre and post publication of PORTEC1 (1996–99 v 2000–03) and GOG 99 (2000–03 v 2004–07). Criteria for intermediate (IR) and high-intermediate (HIR) risk categories as defined by PORTEC1 and GOG99 were applied. Chi-squared statistics and adjusted multivariable Poisson models were used. Results: RT did not increase for HIR (RR 1.05, 95%CI 0.99, 1.11) or IR groups (RR 1.0, 95% CI 0.95, 1.05) following GOG99 publication, or for HIR (RR 1.01, 95% CI 0.86, 1.19) or IR groups (RR 0.88, 95% CI 0.77–1.00) following PORTEC1 publication. Radiation rates changed heterogeneously across the country without a discernible pattern of cause. Among radiated patients, brachytherapy use increased, whereas external beam use decreased after GOG99 publication. Conclusions: As the debate regarding the utility of adjuvant radiation in early stage endometrial cancer continues, we found that overall, clinicians had not adopted GOG99 or PORTEC1 results into their clinical practice in the years immediately after publication. However, we did identify significant variation in practice by geographic location. Given that barely half the women deemed highest risk for recurrence received radiation, these findings illustrate that clinical practice reflects the continued controversy surrounding adjuvant radiation in the treatment of endometrial cancer. [Copyright &y& Elsevier]

Abstract: Objectives: There is limited data regarding physical strain and minimally invasive gynecologic surgery (MIS). We sought to evaluate ergonomic strain among gynecologic oncologists. Methods: An online survey was sent to all physician members of the Society of Gynecologic Oncology in North America in 2010. The survey contained 42 questions and data was analyzed using univariate and bivariate analyses with summary statistics, t-tests, and chi-squared test. Results: There were 260 respondents (31.2%) to the survey. Case mix was 26% benign and 64% oncologic surgery. Over 52% of respondents had been in practice for greater than 11years and 52% practice in an academic setting. Physical discomfort related to MIS was reported in 88% (216/244) of surgeons with 52% reporting persistent pain. Increased pain symptoms were associated with surgeon''s height, glove size, age and female gender. Patient body mass index (BMI) was associated with pain symptoms in surgeons performing conventional laparoscopic surgery, but not robotic surgery. To decrease pain, surgeons changed positions (78%), limited the number of cases per day (14%), spread cases throughout the week (6%), or limited the total number of cases (3%). Only 29% had received treatment at any time for pain symptoms. Treatment included physical therapy (59%), medical management (28%), surgery (13%), and time off (1%). Only 16% of those with pain symptoms had received formal ergonomic training. Conclusion: Physical strain rates of 88% are far greater than previously reported. Such prevalent occupational strain presents a growing problem in the face of increasing demand for MIS. [Copyright &y& Elsevier]

Abstract: Objective: To compare the short-term surgical outcome of patients undergoing robotic radical hysterectomy (RRH) versus open radical hysterectomy (ORH) for the treatment of early stage cervical cancer. Methods: IRB approval was obtained for a retrospective chart review of all radical hysterectomies (RHs) for Stage I and II cervical cancer performed at Brigham and Women''s Hospital between August 1, 2004 and August 1, 2007. Prior to August 1, 2006 all procedures were ORHs. After this date, all procedures were RRHs. Demographic data, operative data and short-term outcomes were compared. Statistical analysis using t-tests and Fisher''s Exact test were performed with SAS software. Results: A total of 48 RHs were identified, including 16 RRHs and 32 ORHs. The groups did not differ significantly in age, body mass index, stage, or histology. Mean operative time was significantly longer for RRH than ORH (4:50 vs 3:39 h, p =0.0002). The mean estimated blood loss was significantly less for RRH than ORH (81.9 vs 665.6 mL, p <0.0001). The mean number of lymph nodes resected did not differ between RRHs and ORHs (15.6 vs 17.1, p =0.532). There were no intra-operative complications in the RRH group and one ureteral transection in the ORH group. Three RRH patients (18.8%) suffered post-operative complications which included a vaginal cuff infected hematoma, a transient ureterovaginal fistula, and a pelvic lymphocele, in comparison to seven in the ORH group (21.9%) which included 3 wound infections, two patients with pulmonary emboli, a partial small bowel obstruction with a mesenteric abscess, and a post-operative ileus (p =0.999). Mean length of stay was significantly shorter for the RRH group (1.7 vs. 4.9 days, p <0.0001). Conclusion: RRH results in lower blood loss and shorter length of stay, compared to ORH. Intra-operative and post-operative complication rates are comparable. RRH is a promising new surgical technique that deserves further study. [Copyright &y& Elsevier]

Histaminergic neurons of the tuberomammillary nucleus (TMN) are hypothesized to promote wakefulness, but little is known about the activity of these cells during spontaneous behavior. We measured histaminergic neuron activity in the dorsomedial, ventrolateral, and caudal TMN at four different times using Fos and adenosine deaminase immunohistochemistry and recordings of sleep/wake behavior. Because circadian factors could influence neuronal activity, we then assessed TMN neuron activity in predominantly sleeping or awake animals, all killed at the same time of day. In both experiments, Fos expression in histaminergic neurons of all three TMN subnuclei was higher during periods of wakefulness. These results demonstrate that histaminergic neurons throughout the TMN are wake-active, and this activity is largely independent of the time of day. [Copyright &y& Elsevier]

The administration of adjuvant chemotherapy within 42 days from surgery is one of the proposed quality measures for patients with epithelial ovarian cancer (EOC). The aim of the present study was to evaluate the impact of chemotherapy delay in the survival of patients with stage I EOC. The National Cancer Database was accessed, and patients diagnosed between 2004 and 2015 with FIGO stage I EOC who received multi-agent chemotherapy were identified. Overall survival (OS) was compared between patients who received chemotherapy <6 weeks and 6–12 weeks from surgery with the log-rank test following generation of Kaplan-Meier curves. Cox model was constructed to control for a priori selected confounders. A total of 8549 patients who received adjuvant chemotherapy at a median 35 days from surgery (interquartile range 19) were identified; 67.7% received adjuvant chemotherapy <6 weeks from surgery while 32.3% experienced a delay. Patients who experienced a delay were more likely to have comorbidities (18.4% vs 14.9%, p < 0.001), and be managed in non-academic facilities (57.1% vs 53.2%, p = 0.001). Patients who experienced a delay had worse OS compared to those who did not, p < 0.001; 5-year OS rates 85.7% and 89.7%, respectively. For patients with high-grade serous tumors, those who experienced a delay had a 5-yr OS of 81.9% compared to 88.6% for those who did not, p < 0.001. After controlling for age, race, presence of comorbidities, insurance status, tumor histology and grade, performance of lymphadenectomy and substage, chemotherapy delay was associated with worse survival (HR: 1.25, 95% CI: 1.10, 1.42). For patients with early stage EOC administration of adjuvant chemotherapy within 6 weeks from surgery was associated with better overall survival, especially for those with stage IC disease. • 1 in 3 patients with stage I EOC experience a delay in adjuvant chemotherapy administration following staging surgery. • Delay in adjuvant chemotherapy has a negative impact on overall survival. • Detrimental impact is more pronounced for patients with stage IC or high-grade serous histology. [ABSTRACT FROM AUTHOR]

To examine patient barriers and facilitators to PARP inhibitor (PARP-I) maintenance therapy in ovarian cancer. PARP-I improves survival in ovarian cancer, but these multi-year therapies cost around $100,000 annually and are under-prescribed. We recruited patients with ovarian cancer treated with PARP-I maintenance therapy at an academic health system for a semi-structured interview. Patient demographics, including genetics and PARP-I cost, were self-reported. We assessed patient experiences with barriers and facilitators of PARP-I usage. Two team members used a thematic approach to analyze and identify key themes. In May 2022, we interviewed 10 patients (mean age = 65 years; 80% White; 60% with a germline genetic mutation). Patients paid on average $227.50 monthly for PARP-I, straining resources for some participants. While sampled patients were insured, all patients identified having no or inadequate insurance as a major barrier to PARP-I. At the same time, all participants prioritized clinical effectiveness over costs of care. Patients identified PARP-I delivery from specialty pharmacies, separate and different from other medications, as a potential barrier, but each had been able to navigate delivery. Patients expressed significant initial side effects of PARP-I as a potential barrier yet reported clinician communication and prompt dose reduction as facilitating continuation. Patients identified cost, restrictive pharmacy benefits, and initial side effects as barriers to PARP-I usage. Having insurance and a supportive care team were identified as facilitators. Enhancing communication about PARP-I cost and side effects could improve patient experience and receipt of evidence-based maintenance therapy in ovarian cancer. • Patients with ovarian cancer identified having insurance and financial assistance as facilitators of PARP inhibitor usage. • Patients identified cost, restrictive pharmacy benefits, and initial side effects as barriers to PARP inhibitor usage. • Clinician communication and prompt dose reduction for side effects facilitated PARP inhibitor continuation. [ABSTRACT FROM AUTHOR]

Simple Summary: The impact of a prior cervical excisional procedure on the oncologic outcomes of patients with early-stage cervical cancer undergoing radical hysterectomy is not established. Smaller retrospective studies suggest that conization prior to the performance of radical hysterectomy may be associated with lower risk of tumor relapse, especially for patients undergoing minimally invasive hysterectomy. We utilized a large hospital-based database and identified patients with FIGO 2009 stage IB1 disease who had primary surgical treatment. Approximately one in three patients had a prior excisional procedure performed within 3 months of radical surgery. We demonstrated that the performance of an excisional procedure prior to radical hysterectomy may be associated with better overall survival. For patients who had a prior excisional procedure, minimally invasive surgery was not associated with worse overall survival compared to laparotomy even after controlling for confounders. Objective: To investigate the impact of a prior cervical excisional procedure on the oncologic outcomes of patients with apparent early-stage cervical carcinoma undergoing radical hysterectomy. Methods: The National Cancer Database (2004–2015) was accessed, and patients with FIGO 2009 stage IB1 cervical cancer who had a radical hysterectomy with at least 10 lymph nodes (LNs) removed and a known surgical approach were identified. Patients who did and did not undergo a prior cervical excisional procedure (within 3 months of hysterectomy) were selected for further analysis. Overall survival (OS) was evaluated following the generation of Kaplan–Meier curves and compared with the log-rank test. A Cox model was constructed to control a priori-selected confounders. Results: A total of 3159 patients were identified; 37.1% (n = 1171) had a prior excisional procedure. These patients had lower rates of lymphovascular invasion (29.2% vs. 34.9%, p = 0.014), positive LNs (6.7% vs. 12.7%, p < 0.001), and a tumor size >2 cm (25.7% vs. 56%, p < 0.001). Following stratification by tumor size, the performance of an excisional procedure prior to radical hysterectomy was associated with better OS even after controlling for confounders (aHR: 0.45, 95% CI: 0.30, 0.66). The rate of minimally invasive surgery was higher among patients who had a prior excisional procedure (61.5% vs. 53.2%, p < 0.001). For these patients, performance of minimally invasive radical hysterectomy was not associated with worse OS (aHR: 1.37, 95% CI: 0.66, 2.82). Conclusions: For patients undergoing radical hysterectomy, preoperative cervical excision may be associated with a survival benefit. For patients who had a prior excisional procedure, minimally invasive radical hysterectomy was not associated with worse overall survival. [ABSTRACT FROM AUTHOR]

Telemedicine rapidly increased with the COVID-19 pandemic and could reduce cancer care disparities. Our objective was to evaluate sociodemographic (race, insurance), patient, health system, and cancer factors associated with telemedicine use in gynecologic cancers. We conducted a retrospective cohort study of patients with endometrial cancer and epithelial ovarian cancer with at least one visit from March 2020 to October 2021, using a real-world electronic health record-derived database, representing approximately 800 sites in US academic (14%) and community practices (86%). We used multivariable Poisson regression modeling to analyze the association of ever using telemedicine with patient, sociodemographic, health system, and cancer factors. Of 3950 patients with ovarian cancer, 1119 (28.3%) had at least one telemedicine visit. Of 2510 patients with endometrial cancer, 720 (28.7%) had at least one telemedicine visit. At community cancer practices, patients who identified as Black were less likely to have a telemedicine visit than patients who identified as white in both ovarian and endometrial cancer (Ovarian: RR 0.62, 95% CI 0.42–0.9; Endometrial: RR 0.56, 95% CI 0.38–0.83). Patients in the Southeast, Midwest, West, and Puerto Rico were less likely to have telemedicine visits than patients in the Northeast. Uninsured patients were less likely, and patients with Medicare were more likely, to have one or more telemedicine visit than patients with private insurance. In this national cohort study, <30% of patients ever used telemedicine, and significant racial and regional disparities existed in utilization. Telemedicine expansion efforts should include programs to improve equity in access to telemedicine. • Among 6460 patients with patients with endometrial or ovarian cancer, 28% used telemedicine at least once since March 2020. • Patients with Medicare were more likely to use telemedicine, and there were regional differences in telemedicine usage. • In community cancer practices, patients who identified as Black were less likely to use telemedicine than white patients. [ABSTRACT FROM AUTHOR]

Investigate the overall survival of patients with FIGO stage I endometrioid endometrial carcinoma who underwent sentinel lymph node biopsy (SLNBx). Patients diagnosed between 2012 and 2015 with pathological stage I endometrioid endometrial carcinoma who underwent minimally invasive hysterectomy and had at least one month of follow-up were identified in the National Cancer Database (NCDB). Patients who underwent SLNBx or systematic lymphadenectomy (LND) (defined as at least 20 lymph nodes removed) were selected. Overall survival (OS) was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders. A total of 13,010 patients with endometrioid endometrial carcinoma who met the inclusion criteria were identified; 9861 (75.8%) and 3149 (24.2%) patients had systematic LND and SLNBx, respectively. Patients who had LND were more likely to receive radiation therapy (27.4% vs 19.3%, p < 0.001) and chemotherapy (13% vs 8.7%, p < 0.001) compared to those who had SLNBx. After controlling for patient age, race, insurance status, depth of myometrial invasion, tumor grade, tumor size, presence of lymph-vascular invasion and receipt of radiation therapy, the performance of SLNBx was not associated with worse survival (HR: 0.99, 95% CI: 0.80, 1.21). For high-intermediate risk patients (based on GOG-99 criteria) after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.07, 95% CI: 0.80, 1.44). For intermediate risk patients who did not receive external beam radiation therapy or chemotherapy after controlling for confounders, performance of SLNBx was not associated with worse survival (HR: 1.58, 95% CI: 0.94, 2.65). SLNBx had no negative impact on the survival of patients with FIGO stage I endometrioid endometrial carcinoma who undergo hysterectomy. • A rapid implementation of SLNBx for endometrioid endometrial cancer has occurred. • Overall survival is comparable to comprehensive LND. • No detrimental impact was found for intermediate or high-intermediate risk patients. [ABSTRACT FROM AUTHOR]

The mutational spectra of low-grade serous carcinomas (LGSCs) and serous borderline tumors (SBTs) of the ovary are poorly characterized. We present 17 cases of advanced or recurrent LGSC/SBT patients who underwent molecular profiling. Thirteen LGSCs and four SBTs underwent targeted gene panel testing by massively parallel sequencing. Microsatellite stability and tumor mutation burdens (TMBs) were determined based on panel sequencing data. The mean TMB was 5.2 mutations/megabase (range 3–10) in 14 cases. Twelve of twelve (12/12) cases were microsatellite stable. Clear driver mutations were identified in 11 cases, namely KRAS (5/17), BRAF (2/17), NRAS (2/17) and ERBB2 (2/17). Five cases harbored BRCA2 alterations (allele fractions: 44–51%), including two classified as likely benign/benign variants, and three classified as variants of uncertain significance (VUSs), with two variants being confirmed to be germline. The three BRCA2 VUSs were missense variants that were assessed to be of unlikely clinical significance, based on family cancer history and expected impact on protein function. Two patients received PARP inhibitors during their disease course, with neither of the patients demonstrating appreciable response. The mutational spectra in 17 clinically aggressive SBT/LGSC cases demonstrate genomically stable tumors, frequently driven by the RTK/RAS/MAPK pathway. While BRCA2 variants were identified, our data demonstrate BRCA2 gene variants are at most VUSs and of dubious clinical significance, in contrast to disease-associated BRCA1/2 variants that may be identified in high-grade serous carcinoma. Germline testing and PARP inhibitors are thus expected to provide limited benefit to patients with LGSC/SBTs. • 17 cases of FIGO stage III low-grade serous carcinoma/serous borderline tumors underwent molecular profiling. • Tumor mutational burdens were generally low (range 3–10 mutations/Mb in 14 cases assessed). • Microsatellites were assessed to be stable in 12/12 cases. • The majority of tumors (11/17) harbored a clear driver mutation in forms of RTK/RAS/MAPK pathway gene mutations. • While BRCA2 variants were seen in 5/17 cases, further analyses suggest they are unlikely to be clinically significant. [ABSTRACT FROM AUTHOR]

Investigate the prevalence of ERBB2/HER2 gene amplification among patients with gynecologic malignancies. The American Association of Cancer Research (AACR) Genomics Evidence of Neoplasia Information Exchange (GENIE) (version 13.1) database was accessed and patients with endometrial, ovarian, and cervical cancer were identified. Patients with available data on the presence of copy-number gene alterations were selected for further analysis. Incidence of ERBB2 amplification following stratification by tumor site and histology was evaluated. Data from the OncoKB database, as provided by cBioPortal, was utilized to determine presence of pathogenic genomic alterations. A total of 6961 patients who met the inclusion criteria were identified: 49.1% with ovarian cancer, 45.2% with endometrial cancer and 5.7% with cervical cancer respectively. Overall incidence of ERBB2 amplification was 3.8%. Highest incidence of ERBB2 amplification was observed among patients with mucinous ovarian (14.4%), uterine serous (13.2%), uterine clear cell (9.4%), and uterine carcinosarcoma (7.9%). ERBB2 amplification was rare among patients with TP53 wild-type endometrioid endometrial cancer (0.4%). High incidence of mutations in genes of the PI3K pathway was observed among patients with ERBB2 amplified tumors. ERBB2 amplification is frequently encountered among patients with uterine serous carcinoma, and mucinous ovarian carcinoma. In addition, a high incidence was also observed among those with uterine clear cell carcinoma, and uterine carcinosarcoma. For patients with endometrioid endometrial carcinoma, incidence of ERBB2 amplification is low, especially in the absence of TP53 mutations. • Overall incidence of ERBB2/HER2 amplification was 3.8%. • Highest incidence observed in mucinous ovarian cancer, uterine serous, clear cell and carcinosarcoma. • ERBB2 amplified tumors are characterized by high incidence of mutation in PI3K pathway. • Multiple novel strategies to target ERBB2/HER2 amplification are in development. [ABSTRACT FROM AUTHOR]

To evaluate the role of radical hysterectomy in the management of patients with stage II endometrial carcinoma. Patients diagnosed between 2004 and 2015, with stage II (based on the revised FIGO staging) endometrial carcinoma who had hysterectomy and regional lymph node surgery were identified in the National Cancer Database. Those who had radical or modified radical (RH), or total hysterectomy (TH) were selected. Overall survival (OS) was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to evaluate survival after controlling for confounders. A total of 7552 patients who met the inclusion criteria were identified. Rate of RH was 10.5%. Those who underwent RH had longer hospital stay (median 3 vs 2 days, p < 0.001) and a higher 90-day (1.6% vs 0.8%, p = 0.05) mortality. There was no difference in OS between patients who had RH (n = 712) and SH (n = 5955) (p = 0.62); 5-year survival rates were 77.4% and 76.9%, respectively. After controlling for patient age (<65, ≥65 years), race (white, black, other/unknown), insurance status, presence of comorbidities, tumor size (<5, ≥5 cm, unknown), histology (endometrioid, non-endometrioid), performance of adequate lymphadenectomy, and receipt of adjuvant chemotherapy and radiation therapy, performance of radical hysterectomy was not associated with better survival (HR: 1.01, 95% CI: 0.85, 1.21). Radical hysterectomy was not associated with a survival benefit in a cohort of patients with stage II endometrial carcinoma. • Rate of radical hysterectomy for patients with stage II endometrial cancer was 10.5%. • Patients who underwent radical hysterectomy had longer hospital stay and higher 90-day mortality. • Radical hysterectomy did not confer a survival benefit in this cohort. [ABSTRACT FROM AUTHOR]

Objective: To evaluate factors associated with survival of patients with advanced stage mucinous ovarian carcinoma (MOC) using a large multi-institutional database.Methods: Patients diagnosed between 2004 and 2014 with advanced stage (III-IV) MOC were identified within the National Cancer Database. Those without a personal history of another primary tumor who received cancer-directed surgery with a curative intent were selected for further analysis. Overall survival (OS) was evaluated with Kaplan-Meier curves, and compared with the log-rank test. Multivariate Cox analysis was performed to identify independent predictors of survival.Results: A total of 1509 patients with a median age of 59 years (IQR 20) met the inclusion criteria: stage III (n = 1045, 69.3%) and stage IV disease (n = 464, 30.7%). Patients who received chemotherapy (n = 1065, 70.6%) had better OS compared to those who did not (n = 385, 25.5%), (median OS 15.44 vs 5.06 months, p < 0.001). The type of reporting facility (p = 0.65) and the year of diagnosis (p = 0.27) were not associated with OS. Presence of residual disease was strongly associated with OS (p < 0.001). After controlling for confounders, the administration of chemotherapy (HR 0.63, 95% CI 0.55, 0.72) was associated with better survival.Conclusion: Advanced stage MOC has an extremely poor prognosis. Patients who received chemotherapy had a small improvement in survival. Every effort to achieve complete gross resection should be performed. Given no improvement in survival outcomes over time, there is an eminent need for novel treatment options. [ABSTRACT FROM AUTHOR]

To evaluate the clinicopathological characteristics, management and prognosis of patients with vulvar extramammary Paget disease of the vulva (EMPD). The U.S National Cancer Database was accessed and patients diagnosed between 2004 and 2015 with microscopically confirmed vulvar EMPD were selected. Overall survival (OS) was calculated for patients diagnosed between 2004 and 2014, who had at least one month of follow-up. Five year OS rates were calculated following generation of Kaplan-Meier curves while comparisons were made with the log-rank test. A total of 2602 patients were identified. Median age at diagnosis was 72 years (range 31–90 years) and the majority were of White race (92%), without any co-morbidities (80.9%). Personal history of another tumor was present in 36.9% of patients. In situ EMPD was diagnosed in 994 cases (38.2%) and the majority (95.1%) were managed with local excision or vulvectomy. Five-year OS was 85.8%, while presence of positive margins was not associated with worse OS (p = 0.38). Invasive EMPD was diagnosed in 1608 (61.8%) patients. Staging information was available for 1172 patients, 75.3% had early stage disease. Most patients underwent surgical treatment (91.6%); 53.6% had positive margins. Performance of lymphadenectomy was infrequent (6.8%). Moreover, immunotherapy (4.5%), chemotherapy (1.5%) and radiation therapy (2.2%) were rarely employed in the management of invasive EMPD. Patients with early stage disease (n = 766) had better OS compared to those with advanced stage (n = 278) (5-yr OS rates were 84.3% and 73.6% respectively, p = 0.015) while presence of positive margins was not associated with worse OS (p = 0.35). Extramammary Paget disease is a rare vulvar tumor. Surgical excision is the main treatment option while other modalities are rarely employed. Overall survival rates are encouraging. • Approximately 95.% of patients with invasive vulvarl EMPD had excision. • Only 6.8% had lympadenectomy • Presence of positive margins was not associated with overall survival. [ABSTRACT FROM AUTHOR]

Prior to the COVID-19 pandemic, telehealth visits and remote clinical trial operations (such as local collection of laboratory tests or imaging studies) were underutilized in gynecologic oncology clinical trials. Current literature on these operational changes provides anecdotal experience and expert opinion with few studies describing patient-level safety data. We aimed to evaluate the safety and feasibility of telehealth and remote clinical trial operations during the COVID-19 Pandemic. Gynecologic oncology patients enrolled and actively receiving treatment on a clinical trial at a single, academic institution during the designated pre-Telehealth and Telehealth periods were identified. Patients with at least 1 provider or research coordinator telehealth visit were included. Patient demographics, health system encounters, adverse events, and protocol deviations were collected. Pairwise comparisons were performed between the pre-Telehealth and Telehealth period with each patient serving as their own control. Thirty-one patients met inclusion criteria. Virtual provider visits and off-site laboratory testing increased during the Telehealth period. Delays in provider visits, imaging, and laboratory testing did not differ between time periods. Total and minor protocol deviations increased in incidence during the Telehealth period and were due to documentation of telehealth and deferment of non-therapeutic testing. Major protocol deviations, emergency department visits, admissions, and severe adverse events were of low incidence and did not differ between time periods. Telehealth and remote clinical trial operations appeared safe and did not compromise clinical trial protocols in a small, single institutional study. Larger scale evaluations of such trial adaptations should be performed to determine continued utility following the Pandemic. • Utilization of Telehealth and remote laboratory and imaging within clinical trials increased during the Covid pandemic. • No difference in adverse patient outcomes, such as emergency department visits, were observed with telehealth use. • Telehealth and remote testing in clinical trials appear safe and feasible. • Incorporation of telehealth and remote testing should be considered in future gynecologic oncology clinical trial protocols. [ABSTRACT FROM AUTHOR]

Significant disparities exist in clinical trial participation in non-gynecologic cancers, but little is known about disparities in ovarian cancer trial participation. Our objective was to examine patient, sociodemographic (race/ethnicity, insurance), cancer, and health system factors associated with clinical trial participation in ovarian cancer. We conducted a retrospective cohort study of patients with epithelial ovarian cancer diagnosed from 2011 to 2021, using a real-world electronic health record derived database, representing around 800 sites of care in US academic and community practices. We used multivariable Poisson regression modeling to analyze the association of ever participating in an ovarian cancer clinical drug trial with patient, sociodemographic, health system, and cancer factors. Of the 7540 patients with ovarian cancer, 5.0% (95% CI 4.5–5.5) ever participated in a clinical drug trial. Patients of Hispanic or Latino ethnicity were 71% less likely to participate in clinical trials (RR 0.29, 95% CI 0.13–0.61) than non-Hispanic patients, and patients whose race was unknown or other than Black or White were 40% less likely to participate in clinical trials (RR 0.68, 95% CI 0.52–0.89). Patients who had Medicaid insurance were 51% less likely (RR 0.49, 95% CI 0.28–0.87) and those with Medicare were 32% (RR 0.48–0.97) less likely to participate in clinical trials than privately-insured patients. In this national cohort study, only 5% of patients with ovarian cancer participated in clinical drug trials. Interventions are needed to decrease race, ethnicity, and insurance disparities in clinical trial participation. • In a national cohort of 7540 patients with ovarian cancer, only 5.0% ever participated in a clinical drug trial. • Hispanic or Latino patients were 71% less likely to participate in ovarian cancer clinical trials. • Patients with Medicaid were 51% less likely and patients with Medicare 32% less likely to participate in clinical trials than privately-insured patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the prevalence of regional lymph node (LN) metastasis in patients with non-clear cell epithelial ovarian cancer apparently confined to the ovary, stratified by tumor grade.Methods: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was accessed (1988-2014). We identified patients with epithelial ovarian carcinoma of serous, endometrioid and mucinous histology apparently confined to the ovary who underwent extensive lymphadenectomy (defined as at least 20 lymph nodes removed). Demographics, tumor histology, grade and lymph node status were collected. Comparisons were made with Chi square and Mann-Whitney U tests.Results: A total of 1242 women met the inclusion criteria. Endometrioid adenocarcinoma was the most common histology (564 patients (45.4%)) while 443 (35.7%) and 235 (18.9%) patients had serous, and mucinous adenocarcinoma, respectively. The rate of LN metastasis in low-grade serous was 9.0% (6/67) vs. 14.4% (54/376) in high-grade serous histology (OR, 1.71, 95% CI 0.70, 4.14, p = 0.24). In patients with low-grade endometrioid tumors, the rate of LN metastasis was 1.7% (7/407) vs. 5.1% (8/157) observed in those with high-grade tumors (OR: 3.07, 95% CI 1.09, 8.61, p = 0.033). Lastly, the rate of LN metastasis in mucinous histology was 1.7% (3/177) in low-grade vs. 8.6% (5/58) in high-grade tumors (OR: 5.47, 95% CI 1.27, 23.66, p = 0.024).Conclusions: Regional LN metastasis in apparent stage I low-grade mucinous and endometrioid ovarian tumors is infrequent. [ABSTRACT FROM AUTHOR]

Prior authorization was designed to minimize unnecessary care and reduce spending but has been associated with delays in necessary care. Our objective was to estimate the occurrence of prior authorization, and impact on cancer care, in gynecologic oncology. We performed a retrospective cross-sectional study of patients seen in University of Pennsylvania gynecologic oncology practices (January–March 2021). Using electronic medical records, we measured the incidence of prior authorization during the 3-month period and prior experience of prior authorization for cancer care overall and by type of order (chemotherapy, imaging, surgery, prescription drugs). We assessed the impact of prior authorization occurrence on clinical outcomes (time to service, changes in care). Of the 2112 clinic visits of 1406 unique patients, 5% experienced prior authorization during the 3-month study period. An additional 20% faced prior authorization requests earlier in cancer care. Of the 83 prior authorization requests, imaging accounted for the majority (54%) followed by supportive medications (29%) and chemotherapy (17%). After appeal, 79% of cases were approved. For patients whose prior authorizations were approved, there was a mean of 16 days from order placement to care delivery (95% CI 11–20, range 0–98 days). Of the 17 denials, 3 (18%) led to a substantial change in care (i.e., not receiving planned treatment). 25% of gynecologic oncology patients experienced prior authorization during their cancer care. While 80% of claims were ultimately approved, patients experienced over a 2-week delay in care when prior authorization occurred. Reform is needed to reduce the burden of prior authorization in oncology. • 1 in 4 patients experience prior authorization during gynecologic oncology care. • Imaging accounted for 54% of prior authorization followed by supportive medications (29%) and chemotherapy (17%). • 79% of prior authorizations were approved with a 2-week care delay on average. [ABSTRACT FROM AUTHOR]

Purpose To identify prevalence, correlates and survival implications of non-surgically managed epithelial ovarian cancer (EOC). Methods The National Cancer Database (NCDB) was queried for EOC cases between 2003 and 2011. Type of treatment, survival data, reasons for non-surgical treatment, clinicopathologic and process-based factors were collected. Logistic regression identified independent predictors of surgical treatment; Cox proportional hazards regression modeled association between time to death and receipt of surgery. Results 172,687 of 210,667 patients (82%) received surgical treatment for EOC. 95% of patients treated non-surgically had stage III, stage IV or unknown stage disease. The reason for non-surgical treatment was unclear in 80% of cases. Black race and uninsurance were significantly associated with non-surgical treatment. Median survival time was 57.4 months (95% CI: 56.8–57.9) for surgery with or without systemic treatment compared to 11.9 months (95% CI: 11.6–12.2) for systemic treatment alone and 1.4 months (95% CI: 1.3–1.4) for no treatment. Relative to surgical treatment, the adjusted hazard ratio for death associated with systemic treatment alone was 1.9 (p < 0.001); hazard ratio for untreated patients was 4.7 (p < 0.001). Among 29,921 patients older than 75 with Stage III/IV disease, 21.5% received only systemic treatment; 22.8% were entirely untreated. Conclusion 18% of EOC patients in the NCDB did not receive surgical treatment. These patients experienced significantly worsened survival. Prospective investigation is needed to determine how often apparent deviation from best-practices guidelines is clinically appropriate. Non-surgically treated patients may be at risk for poor access to gynecologic oncology care and deserve further study. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study is to report recurrence-free and overall survival for women with endometrial adenocarcinoma who were surgically staged using robotic-assisted laparoscopy. Methods: A retrospective chart review was performed for all consecutive endometrial adenocarcinoma patients surgically staged with robotic-assisted laparoscopy at the University of North Carolina Hospital from 2005 to 2010. Demographic data, 5-year survival, and recurrence-free intervals were analyzed. Statistical analysis using Chi-square, t-test, and Kaplan–Meier curves were performed with SAS software. Study results were compared to endometrial cancer statistics from the Surveillance Epidemiology and End Results database from the National Cancer Institute. Results: A total of 499 patients were identified and included in the study. Recurrence-free intervals after robotic-assisted surgical staging were 85.2% for stage IA, 80.2% for stage IB, 69.8% for stage II, and 69% for stage III. Projected 5-year survival was 88.7% for all patients included in the study. Nearly 82% of cases were endometrioid adenocarcinoma, with papillary serous, clear cell or mixed histology comprising 17.4% of cases. Median follow up time was 23months, with a range of 0 to 80months. Among stage IA, IB, II, and III patients, projected overall survival was 94.2%, 85.9%, 77.4%, and 68.6%, respectively. Conclusions: The results from this study demonstrate that robotic-assisted surgical staging for endometrial cancer does not adversely affect rates of recurrence or survival. These findings provide further evidence that robotic-assisted laparoscopic surgical staging is not associated with inferior results when compared to laparotomy or traditional laparoscopy. [Copyright &y& Elsevier]

In patients undergoing surgery for early stage endometrial cancer, we sought to evaluate the effect of lymphadenectomy (LND), as well as surgical route, on the risk of postoperative venous thromboembolism (VTE). The Surveillance, Epidemiology, and End Results cancer registries (2000−2013) linked to Medicare claims follow up from 1999 to 2014 was accessed to identify those with stage I-II endometrioid endometrial cancer who underwent hysterectomy. Performance of LND, 90-day incidence of postoperative VTE, open vs minimally invasive surgery (MIS), demographics, comorbidities, grade, and stage were collected. A washout period of 12 months with no prior VTE was required. t- test, Chi square test, univariate and multivariable Poisson regression with robust variance estimator were used. A total of 15,101 patients had hysterectomy for early stage endometrial cancer. LND was performed in 9004 (60%) patients. VTE was found in 486 patients. There were 346 VTEs (3.8%) in the LND group vs 140 (2.3%) in those without LND (RR = 1.67, p < 0.0001). Adjusting for age, stage, grade, comorbidities and surgical approach, LND remained a significant risk for VTE (RR = 1.7, p < 0.001). In those who underwent MIS, LND was associated with a two-fold increase in the risk of VTE (p = 0.0008) (adjusted RR = 1.99, p = 0.0014) and had a statistically comparable rate of VTE when compared to the open surgical approach (p = 0.054). LND is associated with an increased 90-day risk of postoperative VTE in patients undergoing surgery for early stage endometrial cancer. The need for extended postoperative VTE prophylaxis in patients undergoing LND via MIS needs further exploration. • Lymphadenectomy is associated with an increased risk of postoperative VTE in early stage endometrial cancer. • At the time of hysterectomy, minimally invasive lymphadenectomy has a comparable rate of VTE to the open approach. • Extended postoperative VTE prophylaxis in patients undergoing minimally lymphadenectomy may be considered. [ABSTRACT FROM AUTHOR]

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time. This is a retrospective repeated cross-sectional study using the 2015–2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO. Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly. Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown. • There was no significant change in the number of GOs from 2015 to 2019. • The number of practice sites per gynecologic oncologist increased from 2015 to 2019. • Gynecologic oncologists' practice site dispersion increased from 2015 to 2019. • Geographic regions containing gynecologic oncologists increased from 2015 to 2019. [ABSTRACT FROM AUTHOR]

To assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes. Retrospective cohort study of the National Cancer Database, selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression. Among 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; OR ITT = 0.53; 95%CI 0.39–0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; OR PP = 0.49; 95%CI 0.32–0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; OR ITT = 0.51; 95%CI 0.40–0.64; OR PP = 0.39; 95%CI 0.28–0.55), and unplanned readmission (overall rate 2.3%; OR PP = 0.52; 95%CI 0.33–0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND. We identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes. • Sentinel lymph node biopsy in minimally invasive staging of endometrial cancer grew from 3% in 2012, to 16% in 2016. • Sentinel lymph node biopsy was less likely in Black, Hispanic, uninsured, rural, and low-income patients. • Compared with full lymph node dissection, sentinel lymph node biopsy had reduced conversion to open surgery from ~3% to ~1%. • No perioperative deaths occurred with sentinel lymph node biopsy alone (versus 0.4% after upfront lymph node dissection) • Reductions in certain perioperative complications were robust to propensity matching and varying cohort specifications. [ABSTRACT FROM AUTHOR]

• Rapid increase in the use of SLNBx for high grade endometrial cancer has occured. • Overall survival was comparable to patients undergoing systematic LND. • Incidence of positive lymph nodes was comparable in the SLNBx and LND groups. [ABSTRACT FROM AUTHOR]

• The OCM and other Alternative Payment Models are likely to increase in the future. • Several aspects of the OCM may not adequately incentivize higher value care. • Advocacy specific to the care of gynecologic cancer patients is needed for the next generation APMs. [ABSTRACT FROM AUTHOR]

To determine knowledge regarding endometrial cancer (EC) risk factors in a general gynecologic patient population. A questionnaire survey regarding health behaviors and knowledge of risk factors of EC was administered to patients presenting for routine gynecologic care at two general gynecologic practices affiliated with a tertiary-care center between August and October 2014. Patient demographics, lifestyle information, and knowledge regarding EC risk factors were assessed. Data were analyzed using univariable and bivariable analyses, Χ2 tests, Fischer's exact tests, and t -tests. 231 women responded. Median age was 56 years old (IQR 25–64), and 87% were Caucasian. Median BMI was 24.9 (IQR 22.3–29.2). 24.7% were overweight and 24.3% obese. The majority (69.4%) of patients received a college or graduate degree. Over half of the women (52.1%) did not know that obesity was associated with increased risk of EC. When dichotomized based on obese vs non obese, there was no difference in patients' knowledge of the association between obesity and EC (47% vs 48%, respectively, p =.93). 91% of all respondents reported that their gynecologist or primary care physician had never discussed the risks of EC with them. Regardless of education level, age or obesity status, the majority of women did not know the common risks of EC. Increased efforts towards educating women regarding obesity and other risk factors of EC are necessary in order to reduce the rising incidence of EC, a predominantly obesity-driven disease. Interventions must include general obstetrician-gynecologists and primary care providers. • The key finding of this study was the lack of knowledge of the common risk factors associated with endometrial cancer (EC). • 91% of respondents reported that their physician never had a discussion about the risks of EC. • This study adds evidence to show that increased education about EC is needed within the general gynecology population. [ABSTRACT FROM AUTHOR]

Investigate the prevalence of bilateral salpingo-oophorectomy (BSO) for women ≤50 years with early stage low-grade endometrial stromal sarcoma (LGESS) and its impact on overall survival (OS). Women ≤50 years, diagnosed with stage I LGESS and managed with hysterectomy between 2004 and 2015 were identified from the National Cancer Database. Patient demographics were recorded and compared with the chi-square test. OS for patients diagnosed between 2004 and 2014 with at least one month of follow-up was assessed using Kaplan-Meier curves, and compared with the log-rank test. A total 743 patients with a median age of 44 years met the inclusion criteria. Use of radiatiotherapy (9%), chemotherapy (0.8%) and hormonal therapy (11%) was infrequent. BSO was performed in 541 (72.8%) patients. Patients who had ovarian preservation (OP) were younger (median age 43 vs 45 years, p < 0.001), less likely to have comorbidities (6.9% vs 12.4%, p = 0.034), or undergo LND (30.7% vs 44.4%, p = 0.001). There were no differences between the two groups in terms of substage or patient race. Five year OS rates for patients who did (n = 490) and did not (n = 191) undergo BSO were 96.2% and 97.1% and there was no difference in OS, p = 0.50. Even after controlling for presence of comorbidities performance of BSO was not associated with better survival (HR: 1.28, 95% CI: 0.51, 3.19). Ovarian function was preserved in approximately one third of women ≤50 years with stage I LGESS with no clear detriment to overall survival. As BSO is associated with long term health effects in this patient population OP could be considered in selected women with stage I LGESS. In a cohort of premenopausal patients with stage I LG-ESS rate of BSO was 72.8%. OS in the present cohort was excellent. There was no difference in OS between the ovarian preservation and BSO groups. [ABSTRACT FROM AUTHOR]

Objective: To investigate the safety of uterine preservation in patients with high-grade epithelial ovarian carcinoma (EOC).Study Design: The Surveillance, Epidemiology, and End Results database was accessed (1988-2014) and patients aged < = 45 years, diagnosed with an unilateral high-grade non-clear cell EOC confined to the ovary were selected. Based on surgery codes we determined whether hysterectomy was performed. Overall (OS) and cancer-specific survival (CSS) was estimated calculated following generation of Kaplan-Meier curves and compared using the log-rank test. Cox hazard model was constructed to control for possible confounders.Results: A total of 1039 patients with a median follow-up of 119 months were identified. Rate of uterine preservation was 31.8 %. Patients who had hysterectomy were older (median 41 vs 32 yrs, p < 0.001). Patients with mucinous tumors were less likely to undergo hysterectomy (58.9 %) compared to those with endometrioid (73.9 %) and serous (75.9 %) carcinoma, p < 0.001. There was no difference in CSS between patients who did and did not have hysterectomy, p = 0.70 (5-yr rates were 93.9 % vs 92.2 %, respectively). After controlling for year of diagnosis, tumor histology (serous vs non-serous), disease stage, performance of lymph node dissection (LND) and tumor grade, uterine preservation was not associated with a worse cancer-specific (HR: 1.08, 95 % CI:0.69,1.71) and overall (HR:0.88, 95 % CI: 0.59, 1.32) mortality.Conclusion: In this retrospective cohort of patients with unilateral high-grade non-clear cell EOC confined to the ovary, uterine preservation was not associated with a worse prognosis. [ABSTRACT FROM AUTHOR]

To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes. Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22–40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests. A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: −2.15, 95% CI: −3.4, −0.9) and hysterectomy (AAPC: −3.31, 95% CI: −6.1, −0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: −0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II–IV), (p > 0.05). Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival. • Pediatric patients with MOGCTs are less likely to undergo extensive staging procedures. • A trend towards less extensive surgical procedures over time was noted. • No apparent impact on cancer specific survival was found. [ABSTRACT FROM AUTHOR]

• Gynecologic oncologists are experimenting with a variety of different alternative payment models (APMs). • There are many challenges associated with developing new APMs in gynecologic oncology. • Implementation challenges include stakeholder engagement, attribution, risk adjustment, and quality measurement. [ABSTRACT FROM AUTHOR]

The benefit of adjuvant chemotherapy for Stage IC grade 1 and stage IA/IB grade 2 endometrioid ovarian adenocarcinoma (EOOC) remains unclear as the NCCN guidelines recommend either observation only or adjuvant chemotherapy. Therefore, we sought to determine whether patients with stage I EOOC had improved overall survival (OS) following receipt of adjuvant chemotherapy. Patients with pathological stage I ovarian endometrioid adenocarcinoma diagnosed between 2004 and 2014 were identified from the National Cancer Database. Demographics, pathologic factors including tumor grade, and treatment information including receipt of adjuvant chemotherapy were collected. The impact of chemotherapy on OS was evaluated with Kaplan-Meier curves, and compared with log-rank tests. Multivariate Cox analysis was performed to control for confounders. A total of 4538 patients were identified and the median age was 55 years The rate of adjuvant chemotherapy use was 50.9%. Higher rates were noted among patients with stage IC and grade 3 tumors. Following stratification by tumor grade, substage and extent of lymphadenectomy, adjuvant chemotherapy was associated with a survival benefit for patients with grade 2 tumors who did not undergo (stage IA/IB: 95.7% vs 83%, p = 0.038; stage IC: 84.5% vs 84.8%, p = 0.39) or had limited lymphadenectomy (stage IA/IB: 96% vs 89.5%, p = 0.03; stage IC: 97.2% vs 83.9%, p = 0.001). A survival difference was also seen for patients with grade 3 tumors who did not undergo lymphadenectomy but did not reach statistical significance. Adjuvant chemotherapy was associated with an overall survival benefit for patients with inadequately-staged, grade 2 stage I ovarian endometrioid adenocarcinoma. A possible benefit for inadequately-staged patients with grade 3 tumors cannot be excluded. • Rate of adjuvant chemotherapy use for patients with stage I endometrioid ovarian cancer was 50.9%. • Higher rates were noted among patients with stage IC and grade 3 tumors. • A survival benefit was noted for inadequately staged patients with grade 2 tumors. [ABSTRACT FROM AUTHOR]

Objective: To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations.Data Sources: MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of "gestational trophoblastic disease," "molar pregnancy," and "human chorionic gonadotropin" themes.Methods Of Study Selection: Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up.Tabulation, Integration, and Results: Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%).Conclusion: Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization.Systematic Review Registration: PROSPERO, CRD42019116414. [ABSTRACT FROM AUTHOR]

Objective: To estimate whether targeted educational interventions can increase human papillomavirus (HPV) vaccine acceptability and knowledge among young women.Methods: An exploratory phase of the study was conducted to determine baseline acceptance of the prophylactic HPV vaccine and barriers to acceptance. Based on the results of that phase of the study, a randomized controlled trial of women aged 12-26 at a single institution was completed. A sample size of at least 84 women in each of three study arms (control, educational handout, or educational video) was planned to detect a 20% difference in vaccine acceptability among arms. All participants completed a survey collecting data on demographics, HPV vaccine preferences, and HPV vaccine knowledge after completion of their randomization assignments. The primary outcome was HPV vaccine acceptability. The secondary outcome was HPV vaccine knowledge.Results: From March 2017 through August 2017, 256 women were randomized to one of three study arms: control (n=85), educational handout (n=84), or educational video (n=87). Demographics were similar between study arms. Overall, 51.7% of participants in the educational video arm reported willingness to accept the HPV vaccine compared with 33.3% and 28.2% of participants in the educational handout and control arms, respectively (P<.01). Those in the educational video and handout arms had higher median HPV vaccine knowledge scores than those in the control arm (6 and 5 vs 3, P<.01). Both interventions were reported as helpful in learning (97.7% vs 92.9%, P=.15), but the educational video arm was more likely to be helpful in deciding on vaccination (86.2% vs 70.2%, P<.01).Conclusion: Targeted educational interventions increase HPV vaccine acceptability and knowledge among young women. Follow up studies are needed to determine whether these interventions also increase rates of vaccine uptake and series completion.Clinical Trial Registration: Clinicaltrials.gov, NCT03337269. [ABSTRACT FROM AUTHOR]

PURPOSE: Seventeen percent of patients with cancer visit the emergency department (ED) annually, often with nonemergent complaints. We sought to describe the burden of treat-and-release ED utilization by patients with gynecologic cancers and to identify opportunities for improved triage. MATERIALS AND METHODS: Patients with gynecologic cancer diagnoses who were treated and released were identified within the Nationwide Emergency Department Sample, a stratified sample of US hospital-based ED visits, from 2009 to 2013. Sample weights were applied to generate national estimates. Associations with visit charges were assessed with weighted multivariable linear regression. RESULTS: Between 2009 and 2013, there were an estimated 174,092 annual treat-and-release ED visits by patients with gynecologic cancer (95% CI, 163,480 to 184,703 visits), which corresponded to $736 million in annual charges with an average visit charge of $4,232 (95% CI, $4,099 to $4,366). Annual visits and total charges increased significantly over the 5 years under study. Visits were more frequent for patients with cervical cancer (44.1%) versus ovarian (27.8%) and uterine (24.6%) cancer. These patients were younger and more likely to be from low socioeconomic status areas. The most common primary diagnoses were similar across cancers, including abdominal pain (10.5%), chest pain (6.1%), and urinary tract infection (5.2%). The most frequent diagnostics were culture/smear, computed tomography scan, and x-ray, and the most frequent therapeutic procedures included wound care, transfusion, and paracentesis. CONCLUSION: Patients with gynecologic cancers, and cervical cancer in particular, are frequently seen in the ED with issues that could be less expensively managed in an outpatient clinic or urgent care setting. Visit frequency, but not per-visit cost, is increasing over time. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to investigate the patterns of use and outcomes of adjuvant chemotherapy for patients diagnosed with FIGO stage I ovarian clear cell carcinoma (OCCC). Methods A cohort of patients diagnosed between 2004 and 2015 with OCCC was drawn from the National Cancer Database. Those with stage I disease who had primary surgery and underwent systematic lymphadenectomy (defined as at least 10 lymph nodes removed) were selected for further analysis. Factors associated with the administration of adjuvant chemotherapy were investigated with multivariate logistic regression. Overall survival (OS) was evaluated using Kaplan-Meier curves for patients diagnosed between 2004 and 2014, while comparisons were made with the log-rank test. Multivariate Cox analysis was performed to control for possible confounders. Results A total of 2325 patients met the inclusion criteria. Median age was 55 years. The majority were White (86.6%). Adjuvant chemotherapy was administered to 1839 (79.1%) patients. Hospital type and location, patient age, disease sub-stage, and year of diagnosis were independently associated with the administration of chemotherapy. Patients who received adjuvant chemotherapy (n = 1629) had better OS than those who did not (n = 443), (5-year OS rates 89.2% vs 82.6%, p < 0.001). After controlling for disease sub-stage, age, race, hospital type and medical comorbidities, adjuvant chemotherapy was associated with better overall survival (HR: 0.59, 95% CI: 0.45, 0.78). Conclusions Adjuvant chemotherapy could be associated with a survival benefit for patients with stage I OCCC. [ABSTRACT FROM AUTHOR]

Objective To design an endometrial cancer (EC) alternative payment (ECAP) model focused on surgical management of EC, as well as identify drivers of cost in order to develop opportunities for cost-savings while maintaining quality of care. Methods National practice patterns and reimbursements were compared between private payers (MarketScan data, years 2009–13) and public payers (Medicare, year 2014) of EC patients who underwent hysterectomy. An episode of care for EC included the hysterectomy, stratified by surgical approach (laparotomy versus robotic versus laparoscopy), and in- and outpatient reimbursements from 30 days preoperatively to 60 days postoperatively. Reimbursements were categorized into cost centers. A decision model informed modifiable components influencing overall reimbursements for EC surgical care. Variations in length of stay (LOS), emergency department (ED visits), and readmissions were analyzed to create an optimal care model. Results A total of MarketScan (n = 29,558) and Medicare (n = 377) patients were included. Mean total reimbursement for an episode of care was $19,183 (SD $10,844) for Medicare and $30,839 (SD $19,911) for MarketScan. Mean reimbursements were greatest for abdominal cases in Medicare ($25,553; SD $11,870) and MarketScan ($35,357; SD $21,670), followed by robotic and laparoscopic. Among MarketScan patients, 7.6% of women were readmitted within 60 days after surgery and 11.7% had an evaluation in the ED. The median reimbursement per patient for readmission was $14,474 (IQR $8584 to $26,149), and for ED visit was $6327 (IQR $1369 to $29,153). In an optimized care model, increasing the rate of minimally invasive surgery by 5% while reducing LOS by 10% and ED visits/readmissions by 10%, lowered the average case reimbursement by $903 (2.9%) for MarketScan and $1243 (5.9%) for Medicare. Conclusion An ECAP model demonstrates that reimbursements vary by public versus commercial payers in the U.S. for the surgical management of endometrial cancer patients, and that opportunities for cost savings exist. Nominal increases in the rate of minimally invasive surgery and reduction in the rate of ED visits/readmissions and length of stay can result in substantial savings for endometrial cancer care. [ABSTRACT FROM AUTHOR]

Objective: The causal link between obesity and endometrial cancer is well established; however obese women's knowledge of this relationship is unknown. Our objective was to explore patients' understanding of this relationship and assess the acceptability of a technology-based weight loss intervention. Methods/materials: Obese women with Type I endometrial cancer/hyperplasia were surveyed about their assessment of their body mass, knowledge of the relationship of obesity and endometrial cancer, and eating and activity habits. Interest in participation in an intervention also was assessed. Results: Eighty-one women with early stage (71.6% stage I) and grade (41.7% grade 1) disease completed the survey. The median BMI was 35.4 kg/m² (IQR 32.2-43.5 kg/m²) and the average age was 59.3 (SD 11.1) yr. 76.25% of women were unable to categorize their BMI correctly and 86.9% of those incorrectly underestimated their BMI category. One-third (35.9%) were unaware of any association between obesity and endometrial cancer and 33.3% responded that obesity decreased or did not significantly increase the risk of endometrial cancer. 59% expressed interest in a weight loss intervention. Conclusions: Endometrial cancer survivors with obesity underestimated their obesity and lacked knowledge regarding the link between obesity and endometrial cancer. However, the majority expressed interest in electronically delivered weight loss interventions. [ABSTRACT FROM AUTHOR]