Adolescent caesarean delivery in the US military health care system

ObjectivesDetermine cesarean delivery (CD) rates and associated demographics among military dependent teenagers.MethodsUnited States military health care claims records of live births from 2003-2006 to 13- through 19-year-old dependent children were analyzed using logistic regression.ResultsThe CD rate rose from 17% in 2003 to 20% in 2006. Rates were significantly higher for ages 18 and 19, for African American sponsors' children, and those who gave birth in a civilian facility. Rates did not differ significantly by sponsor's military rank.ConclusionsTeenagers in the military health care system have increasing rates of CD. Independent demographic risk factors for teenage CD include age > 17 years, sponsor's race African American, and delivery at a civilian facility.     

Surgical complications in patients treated for invasive cervical cancer

OBJECTIVES: The aim of this study was to analyse, retrospectively, complications of therapy of 898 patients suffered from invasive cervical carcinoma. All patients have undergone radical surgical treatment in Gynaecological Department of Medical University of Gdańsk between 1972 and 2000. MATERIALS AND METHODS: Patients were divided into four groups according to clinical examination (FIGO staging from 1985). Group Ia consisted of 27 (3%) patients; Ib consisted of 711 (79%) patients; IIa consisted of 133 (15%) patients and IIb consisted of 27 (3%) patients. 85 (9.5%) patients ware older than 60. In all cases radical abdominal hysterectomy and pelvic lymph nodes dissection was applied. RESULTS: Intraoperative complications ware observed in 66 (7.3%) patients. Among them 2 (0.2%) patients ware died, 29 (3.2%) patients had massive hemorrhage and 37 (4.1%) patients had local organs damage as bladder, rectum or ureter wall. During the postoperative period 11 (1.2%) patients ware died. There ware observed ureterovaginal fistula in 25 (2.7%) cases and vesicovaginal fistula in 9 (1.0%) cases. CONCLUSION: Radical surgical treatment of invasive cervical carcinoma performed in our department is relatively safe procedure. Results showed above are similar to the results from leading oncology centers.     

Sexual health in women treated for cervical cancer: characteristics and correlates

OBJECTIVE: A large proportion of women with a history of cervical cancer experience sexual problems as a result of treatment. The present study examined whether differences in sexual health between cervical cancer survivors and women with no history of cervical cancer could be explained by selected demographic, clinical, and psychosocial and physical factors. METHODS: Women treated between 1 and 5 years previously for stage 0 to II cervical cancer and age- and education-matched women with no history of cancer undergoing routine cervical cancer screening were recruited to participate. All participants had a partner with whom they had ever been sexually active. Women completed measures of sexual health, vaginal changes, partner relationship quality, perceived physical appearance, and sexual self-concept. RESULTS: Cervical cancer survivors reported significantly (p<.05) less sexual interest, more sexual dysfunction, and lower sexual satisfaction. The most consistent predictors of sexual health after treatment among survivors were time since diagnosis, receipt of radiotherapy, partner relations, and perceived physical appearance, as well as vaginal changes. These variables accounted for about 50% of the variance in sexual health outcomes. CONCLUSION: The findings suggest that efforts to improve sexual health in women with a history of cervical cancer must move beyond the direct effects of cancer treatment on vaginal anatomy and physiology. Sexual rehabilitation interventions should consider partner relationships, perceived physical appearance, and women's attitudes toward themselves as sexual beings, in addition to vaginal changes. Future research should use prospective longitudinal research designs incorporating appropriate comparison groups to further explore this issue.     

Costs of cervical cancer and precancerous lesions treatment in a publicly financed health care system

Purpose

Although cervical cancer is the most frequent cancer for women in Taiwan, no examination of its treatment costs has yet been undertaken. This study aimed to investigate the costs of cervical cancer and precancerous lesion treatment in Taiwan.

Methods

A total of 7,398 cases of cervical intraepithelial neoplasia (CIN) lesions were identified from the Taiwan Cervical Cancer Screening Registration System in 2003. A further 1,469 cases of invasive cervical cancer (ICC) were also identified from a survey on cervical cancer staging information conducted by the Taiwan Cancer Registration Task Force. Resource usage covering the first 6 months after CIN diagnosis and the 5 years after ICC diagnosis were extracted from the National Health Insurance claims database. The duration of each visit and the transportation costs were collected by means of personal interviews with CIN/ICC patients. The mean and standard deviation of the treatment and indirect costs were estimated.

Results

The average total costs for CIN patients were NT$4,201 for CIN1, NT$8,623 for CIN2 and NT$14,406 for CIN3, with the indirect costs accounting for 25–33% of the total. The total costs for ICC patients were NT$210,230 for Stage 1, NT$392,387 for Stage 2, NT$433,969 for Stage 3 and NT$464,701 for Stage 4, with the indirect costs accounting for about 14–17% of the total.

Conclusions

CIN and ICC treatment resulted in considerable costs to the healthcare system in Taiwan. Indirect costs associated with such treatment were also substantial and cannot be ignored.     

The effect of ten years of regionalized perinatal health care in Iowa, U.S.A

In 1973, Iowa, a rural, midwestern state in the U.S.A., established a Statewide Perinatal Care Program. A major objective was to develop and maintain a regionalized system of care. Such a system has been developed but differed from traditional systems by using regional level II centers. Iowa's low population density necessitated this modification. The development and maintenance of Iowa's system is described. Evaluation is provided by analysis of commonly available birth and mortality data. Improved birth-weight-specific neonatal and fetal mortality rates suggest an overall improvement in care. A more favorable birth weight distribution and evidence of screening and selective referral of high-risk patients provide evidence of improvements in prenatal care. Data are presented to show that a stratified system of care is evidence in the state. Level I hospitals currently manage low-risk patients and report very low mortality rates. Level II facilities receive high-risk referrals, but selective referral occurs since the tertiary center accounts for a disproportionate number of fetal and neonatal deaths, and births weighting less than 1500 g. Other regions may benefit from similar approaches to development of regionalized systems of care and evaluation of the same.     

Patterns of research. Oral contraceptives and cervical cancer

Original papers on the oral contraceptive use-cervical cancer relationship are analysed. The purpose of this study was to ascertain the biases of the original articles collected in relation to various characteristics of any investigation. Papers were located by using MEDLINE, reviewing the references of each article identified by MEDLINE, and then reviewing the contents of those journals in which an original could be published. Fifty-five publications (from 49 original studies) were graded as to quality and classified as biased or unbiased. Nineteen studies were considered unbiased. The most common biases identified were confounding, detection bias, and misclassification bias. The pattern of research/publication has changed since the association began to be analysed: articles shift from gynecological to cancer and epidemiological journals; the number of studies performed by gynecologists alone and pathologists alone decreases, while studies performed by epidemiologists alone or in collaboration with gynecologists increase. This collaboration produced studies with fewer biases. It is suggested that the above mentioned collaboration should be increased to improve access to, and then the application of the results obtained in the original studies on oral contraceptives and cervical cancer.     

Post-treatment follow-up procedures in cervical cancer patients previously treated with radiotherapy

Purpose

We investigated the role of physical examination, CT scan, chest X-ray, and Pap smear in the routine follow-up program for cervical cancer patients previously treated with radiotherapy.

Methods

The records of women who had developed recurrent cervical cancer after radiotherapy were retrospectively reviewed. The optimal procedure for the detection of recurrence was evaluated according to the disease-free interval (DFI). Survival analysis was performed based on the Kaplan?CMeier method and comparisons between groups were made using the log-rank test.

Results

A total of 146 recurrent cervical cancer patients were included in our database. The majority of recurrences were diagnosed either by symptoms, physical examination, or CT scan. The patients whose recurrent disease was detected by Pap smear, physical examination, or CT scan had a significantly longer survival than those detected by symptoms. When analyzed according to DFI, physical examination, and CT scan led to the detection of recurrence in patients with a DFI of 1?C5?years. In contrast, chest X-ray and Pap smear only had a clinical impact on the diagnosis of recurrence in patients with a DFI of 1?C2?years.

Conclusions

Chest X-ray and Pap smear can be routinely performed for the first 2?years after radiotherapy, but can be omitted or used sparingly thereafter.     

Hormonal activity of transposed ovaries in young women treated for cervical cancer.

The purpose of this study was to assess the hormonal function of transposed ovaries in young women treated for cervical cancer. Between 1992 and 1998, in the Silesian Medical Academy in Bytom, 101 women underwent radical hysterectomy with ovarian transposition by the Wertheim-Meigs method. Concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, estradiol and testosterone in blood serum and cytologic indices (maturation index, karyopyknotic index and maturation value) were assessed before surgery and on the ninth day after surgery. Patients were subsequently requested to return in July 1999 to have the hormonal activity of their ovaries assessed from the perspective of a few years after the operation, and the effect of supplementary radiotherapy soon after surgery. There was a statistically significant difference between those who had radiotherapy and those who did not with respect to climacteric complaints and hormonal parameters. A correlation was found between serum estradiol levels and maturation value. Proper ovarian hormonal function was still present in 69.8% of patients, even 60 months after surgery, but a lower bone mineral density was also observed. Ovarian transposition is a procedure that allows ovarian function to be preserved in young women treated for cervical cancer; it also helps to obviate the necessity for long-term hormone-replacement therapy. However attention must be paid to the concomitant possibility that women with cervical cancer may have a lower bone mineral density, and routine follow-up measurement of FSH levels or cytologic indices is advocated.     

Costs and effectiveness of alternative strategies for cervical cancer screening in military beneficiaries

OBJECTIVE: To estimate the potential effects, on costs and outcomes, of changes in sensitivity and specificity associated with new screening methods for cervical cancer in the military. METHODS: A Markov model of the natural history of cervical cancer was created to simulate a cohort of 100,000 military beneficiaries aged 18-85. Probability estimates for various outcomes and the accuracy of screening tests were obtained from the literature. Cost estimates were obtained from military sources where available; otherwise, civilian costs were used. The outcomes and costs of conventional cytology, liquid-based cytology, and liquid-based cytology with human papillomavirus (HPV) triage were compared at 1-, 2-, and 3-year screening frequencies. RESULTS: Marginal reductions in the incidence of cervical cancer from increasing screening sensitivity are greater than reductions in cancer mortality at every screening interval. Incremental improvements in both cancer incidence and mortality are higher at less frequent screening intervals. Increases in the ratio of low- to high-grade lesions result from increasing the sensitivity of the screening test or shortening the screening interval. Both liquid-based cytology and liquid-based cytology with HPV testing are cost effective (less than $50,000 per life-year saved) when performed at 3-year screening intervals. However, neither strategy is cost-effective when performed more frequently than every 3 years. CONCLUSION: Use of a more sensitive cervical cancer screening test increases costs. However, a more sensitive test performed less frequently may be more effective and less expensive than conventional cytology done annually. In the military setting, this has significant implications for both expense reduction and readiness enhancement.     

Pregnancy outcome in patients treated with cervical conization for cervical intraepithelial neoplasia

Objective

To examine the causal contribution of conization to premature delivery.

Methods

This was a retrospective, case-control, multicenter study of women who underwent conization in 5 hospitals in the Basque Country (Spain) from 1998 to 2007. Three study groups were established: group A, post-conization infant deliveries; control group B, pre-conization infant deliveries; and control group C, infant deliveries without conization.

Results

Comparing group A with group C, there was a higher rate of preterm delivery before 35 weeks (5.3% versus 1.6%), a lower mean birth weight (3156.2 g versus 3328.5 g), and a greater prevalence of infants under 2500 g (10.6% versus 3.7%). There were no significant differences between group A and group B: preterm delivery before 35 weeks (5.3% versus 4.8%), mean birth weight (3156.2 g versus 3119.4 g), and prevalence of infants under 2500 g (10.6% versus 10.6%).

Conclusion

Pregnancy in women post-conization was associated with a risk of preterm delivery. However, there were no significant differences between women who underwent conization before and those who underwent conization after delivery. Cervical conization does not necessarily increase the risk of preterm delivery in subsequent pregnancy. Conization should be considered an indicator of such risk because it is associated with pregnancy complications arising from socio-epidemiologic factors present in women requiring conization that are also present in women who have premature delivery.     

Clinical case mix adjustment of cesarean delivery rates in U.S. military hospitals, 2002

OBJECTIVE: To assess whether significant variations in observed cesarean rates in U.S. military hospitals may be attributed to differences in clinical case mix. METHODS: Hospital discharge records for births in U.S. military hospitals in 2002 were grouped into mutually exclusive clinical strata to calculate predicted cesarean rates for subgroups defined by maternal race, health plan, hospital location, delivery volume, teaching status, and neonatal intensive care unit (NICU) status. The 95% confidence interval (CI) around each standardized ratio (SR) of the observed-to-predicted cesarean rate was used to assess statistical significance. RESULTS: Observed cesarean rates were significantly higher than predicted rates for small hospitals (23.1% and 20.4%, respectively, SR 1.13, 95% CI 1.08-1.19), teaching hospitals (23.7% and 22.5%, respectively, SR 1.05, 95% CI 1.02-1.08), black women (25.1% and 22.8%, respectively, SR 1.10, 95% CI 1.05-1.14), and other minorities (22.7%, and 21.6%, respectively, SR 1.05, 95% CI 1.01-1.09). No significant differences between observed and predicted cesarean rates were found across hospital locations or NICU status. Significant differences found for non-managed care beneficiaries were attributed to teaching status of the hospitals in which they delivered. CONCLUSION: Clinical case mix does not adequately account for the relatively high rates of cesarean delivery observed for small hospitals and teaching hospitals and among black women in the study population. Further study is recommended to identify additional clinical and nonclinical factors that should be considered when comparing performance across institutions, health plans, or individual providers.     

Pattern of invasion is of prognostic value in surgically treated cervical cancer patients

OBJECTIVES: Different patterns of invasion (representing different grades of tumor cell dissociation) are associated with prognostic outcome in cancer. We evaluated the prognostic value of different patterns of invasion (PI) in cervical carcinomas (CX). METHODS: Six hundred eleven surgically treated CX (FIGO IB to IIB) were re-evaluated histologically regarding the PI, using a three-level scoring system. Closed PI was defined as cohesive growth with well-delineated (pushing) borders. In finger-like PI the tumor grows in solid cords/trabecles. Highly dissociative growth in small groups or single cells was defined as spray-like PI. Types of PI were correlated to tumor stage, histo-morphologic factors and prognostic outcome. RESULTS: Sixty percent of the tumors showed a spray-like PI, 30% a finger-like PI and only 7.4% were of the closed type. Spray-like PI showed a significant correlation with advanced stage disease, lymphovascular space involvement, poorly differentiated tumors and pelvic lymph node metastases. Spray-like PI was accompanied by a reduced 5-year overall survival when compared to the finger-like and closed PI (68.7% vs. 80.9% vs. 88.5%; P=0.0004). The prognostic impact of the PI disappeared in node-positive patients (P=0.06) but persisted in patients without pelvic lymph node disease (P=0.03). In multivariate analysis, using COX regression model, the PI represented as independent prognostic factor. CONCLUSIONS: Spray-like PI (i.e., highest degree of tumor cell dissociation) is associated with advanced tumor stages, increased rate of recurrency and a reduced overall survival. In separate analysis of patients with and without lymph node metastases, the impact of PI persisted only in node-negative cases as a prognostic factor.     

Immunomodulating capacity of the monocyte-macrophage system in patients with uterine cervical cancer

The authors recently measured the Interleukin-1 (IL-1) and Prostaglandin E (PGE) activity of the monocyte-macrophage system (M phi) in vitro. The results indicated that immunodeficiency in cancer patients is closely associated with reduced IL-1 activity and increased PGE activity of M phi. Immunosuppressive factors in the serum of cancer patients seem to play some role in the mechanism of such change. Therefore, when potentiating M phi in nonspecific immunotherapy, it seems important to suppress secretion of PGE (a suppressor factor of M phi origin which is secreted simultaneously) to make this therapy more effective in advanced cancer cases. Based on these results, an animal experiment was carried out in which tumor-bearing mice were treated with OK-432 and Indomethacin (Ind.) (a PG inhibitor). The results of this experiment suggested that this combination therapy reinforces the M phi-mediated immunopotentiation, resulting in a stronger antitumor effect of OK-432. When we used this combination therapy in advanced cancer cases, the changes observed in immunological parameters also indicated an immunopotentiating effect, i.e., an antitumor effect. These results indicate that the optimum application of BRM therapy should be decided on the basis of an understanding of the immunological factors in the patient.     

Thromboembolic events in patients treated with definitive chemotherapy and radiation therapy for invasive cervical cancer

OBJECTIVES: Determine the incidence of and risk factors for thromboembolic events (TE) in patients treated with definitive chemoradiation for cervical cancer at our institution. METHODS: A retrospective chart review was performed of all patients with a diagnosis of invasive carcinoma of the cervix (FIGO Stage IB-IVA) treated with definitive chemoradiation at University of Iowa Hospitals and Clinics (UIHC) from July 2002 to December 2003. Forty-eight patients met these criteria. All but one patient received 45 Gy to the pelvis followed by brachytherapy, IMRT, or conformal boost. One patient received 39.6 Gy to the pelvis. Cisplatin chemotherapy, 40 mg/m squared, was given weekly for 6 weeks. Data were collected for FIGO stage, age, body mass index (BMI), and smoking history. TE were confirmed by Doppler ultrasound or pulmonary imaging. Log-rank tests were used to examine the association between time to TE and the variables FIGO stage and smoking status. The association between time to TE and the continuous variables age and BMI was examined with Cox proportional hazards regression. All tests were two-sided and carried out to the 5% level of significance using the SAS statistical software package. RESULTS: Minimum follow-up was 8 months. Eight patients (16.7%) developed a TE. The associations were not statistically significant for stage (P = 0.72), smoking status (P = 0.72), age (P = 0.63) or BMI (P = 0.86). Risk factors were similar in both groups. Data review suggests that the entire group had risk factors for TE. CONCLUSIONS: We noted a high incidence of TE (16.7%) in patients treated at UIHC with chemoradiation for invasive cervical cancer. We did not find a statistical association between age, stage, smoking history, or BMI and risk of TE in this group. Patients with and without TE had multiple risk factors for TE.