Reducing readmissions after robotic surgical management of endometrial cancer:A potential for improved quality care

Objective

To describe readmission patterns after robotic surgery for endometrial cancer and identify risk factors for readmission within 90 days of discharge.

Methods

Patients with endometrial cancer who underwent robotic surgical management at an academic institution from 2006 to 2010 were identified. Patient characteristics, intraoperative data, and postoperative complications were analyzed. Student's t-test and Fisher's exact test were used to compare patients readmitted within 90 days to those who were not.

Results

Three hundred ninety-five patients were included. Thirty (7.6%) were readmitted within 90 days of surgical discharge. Length of stay greater than one day (40.0% vs. 23.0%, p = 0.04) and postoperative complication (63.3% vs. 13.4%, p < 0.01) were associated with readmission. The median interval to readmission was 9.5 days and median duration of subsequent hospitalization was 2.5 days. Fever (31.3%) and workup for vaginal drainage (25.0%) were the most common reasons for readmission. Only 2 of the 10 patients readmitted with fever had culture-proven infection, and no patients readmitted for vaginal drainage had a confirmed urinary tract injury. Of the 30 patients readmitted, 5 required a second operation — 3 for vaginal cuff dehiscence and 2 for port site hernia.

Conclusions

Robotic surgery for endometrial cancer was associated with a 7.6% readmission rate. The most common reasons for readmission, fever and evaluation for urinary tract injury, were frequently not associated with severe illness. This supports additional education to consider raising the threshold for readmission by using more widespread outpatient evaluation for the potential complications of robotic endometrial cancer surgery.     

The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy

Objective

To determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use.

Methods

This is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA + transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared.

Results

The analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p = 0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p = 0.014; day 1: p < 0.0001; day 2: p = 0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p = 0.046; day 2: p = 0.008).

Conclusions

The use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.     

Overall survival after pelvic exenteration for gynecologic malignancy

Background

Five-Year survival after pelvic exenteration for gynecologic malignancies has been reported as high as 60%. The objective of this study was to determine overall survival (OS) after pelvic exenteration and evaluate factors impacting outcome.

Methods

A retrospective review of all women who underwent pelvic exenteration at our institution between February 1993 and December 2010 was performed. OS was defined as time from exenteration to date of death or last contact. Survival analysis was performed using the Kaplan Meyer method. Multivariate analysis was performed to determine the impact of clinical and pathologic factors on survival outcomes.

Results

One hundred sixty patients with gynecologic malignancy underwent pelvic exenteration. Five-year recurrence free survival (RFS) was 33% (95%CI 0.25–0.40). Factors which negatively impacted RFS included shorter treatment-free interval (p = .050), vulvar primary (p = .032), positive margins (p < .001), lymphovascular space invasion (LVSI, p < .001), positive lymph nodes (p < .001) and perineural invasion (p = 0.030). In multivariate analysis, positive margins (p = .040), positive nodes (p < .001) and lymphovascular space invasion (LVSI, p = .003) retained a significant impact on RFS.Five-year OS was 40% (95% CI 0.32–0.48). Factors which negatively impacted OS included vulvar primary (p = .04), positive margins (p < .001), LVSI (p < .001), positive lymph nodes (p < .001) and perineural invasion (p = .008). In multivariate analysis, positive nodes (p = .001) and LVSI (p = .001) retained a significant impact on OS.

Conclusion

Five-year OS after pelvic exenteration was 40%. Survival outcomes have not significantly improved despite improvements in technique and patient selection. Multiple non-modifiable factors at the time of exenteration are associated with poor survival.     

Development and pilot of an advance care planning website for women with ovarian cancer: A randomized controlled trial

Objective

Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer.

Methods

Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation.

Results

At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p = 0.220) or palliative care consultation (p = 0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p = 0.054) and quality (p = 0.119) of information and when they accessed the website, used it longer (p = 0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers.

Conclusions

A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research.     

Pelvic exenteration: Impact of age on surgical and oncologic outcomes

Objective

To evaluate whether preoperative age impacts surgical outcomes, complication rates, and/or recurrence in women undergoing pelvic exenteration.

Methods

All women who underwent a pelvic exenteration for any gynecologic indication at our institution from 1993 to 2010 were included. Women were stratified into groups based on age in years (young: ≤ 50, middle: 51–64, and senior: ≥ 65). Baseline characteristics, surgical outcomes, early (< 60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were ascertained. Fisher's exact test or Kruskal–Wallis test was performed. Kaplan–Meier survival curves were compared.

Results

161 patients were included (58 young, 62 in the middle, and 41 senior). Women in the young group predominately had a diagnosis of cervical cancer (82.8%) while women in the senior group primarily had a diagnosis of vulvar or vaginal cancer (70.7%). Senior women were also more likely to have hypertension (p < 0.0001) and pulmonary disease (p = 0.040). Operative time was significantly shorter for women in the senior group (8.5 h) compared with the middle (9.5 h) and young group (10.1 h) (p = 0.0089). There were no significant differences in early or late complications when stratified by age. The overall survival did not differ between age groups (p = 0.3760).

Conclusion

Although hypertension and pulmonary disease were more frequent in the senior age group, duration of surgery, blood loss, length of hospital stay and complication rates did not increase with age. Advanced chronological age should not be considered a contraindication to a potentially curative surgical procedure.     

Concentraciones de interleucina-16 en pacientes con preeclampsia y gestantes normotensas sanas

Objective

To compare interleukin-16 concentrations in patients with preeclampsia and healthy normotensive pregnant women.

Method

A total of 100 patients were selected. Fifty patients with preeclampsia were selected as the study group (group A) and 50 healthy normotensive pregnant women with the same age and body mass index as the study group were selected as controls (group B). Blood samples were extracted from all patients before labor and immediately after diagnosis in group B to determine interleukin-16 concentrations.

Results

There was statistically significant difference in interleukin-16 concentrations between group A (211.9 ± 78.7 pg/ml) and group B (83.6 ± 9.9 pg/ml; p < 0.05). There was a strong, positive and significant correlation with systolic blood pressure values (r = 0.282; p < 0.05) and with diastolic blood pressure values (r = 0.320; p < 0.05). A cutoff value of 180 pg/ml had an area under the curve of 0.95, sensitivity of 94.0%, specificity of 70.0%, a positive predictive value of 75.8% and a negative predictive value of 92.1%, with a diagnostic accuracy of 75.0%.

Conclusions

Interleukin-16 concentrations were significantly higher in patients with preeclampsia than in healthy normotensive pregnant women.     

Introduction of staging laparoscopy in the management of advanced epithelial ovarian,tubal and peritoneal cancer: Impact on prognosis in a single institution experience

Objective

To evaluate the prognostic impact of routinely use of staging laparoscopy (S-LPS) in patients with primary advanced epithelial ovarian cancer (AEOC).

Methods

All women were submitted to S-LPS before receiving primary debulking surgery (PDS) or neoadjuvant treatment (NACT). The surgical and survival outcome were evaluated by univariate and multivariate analysis.

Results

Among 300 consecutive patients submitted to S-LPS no complications related to the surgical procedure were registered. The laparoscopic evaluation showed that almost half of the patients (46.3%) had a high tumor load. One-hundred forty-eight (49.3%) women were considered suitable for PDS and the remaining 152 (50.7%) were submitted to NACT. The percentages of complete (residual tumor, RT = 0) and optimal (RT < 1 cm) cytoreduction of PDS and interval debulking surgery (IDS) were 62.1% and 57.5%, 22.5% and 27.7%, respectively, p = 0.07. The post-operative complications of NACT/IDS group were lower than PDS group (p = 0.01). The median progression free survival in women with RT = 0 at PDS was 25 months (95% CI, 15.1–34.8), which was statistically significant longer than in all other patients, irrespective of the type of treatment they received (p = 0.0001). At multivariate analysis, residual disease (p = 0.011) and performance status (p = 0.016) maintained an independent association with the PFS.

Conclusions

Including S-LPS in a tertiary referral center for the management AEOC does not appear to have a negative impact in terms of survival and it may be helpful to individualize the treatment avoiding unnecessary laparotomies and surgical complications.     

Concentraciones de interleucina-15 en preeclámpticas y embarazadas normotensas sanas

Objective

To compare interleukin-15 concentrations in preeclamptic patients and healthy normotensive pregnant women.

Method

A total of 100 patients were selected. Fifty preeclamptic patients were selected as cases (group A) and 50 normotensive pregnant women with a similar age and body mass index to the study group were selected as controls (group B). Blood samples were collected before labor in all patients and immediately after diagnosis in group B to determine interleukin-15 concentrations.

Results

There were no significant differences in maternal age, gestational age or body mass index at sample extraction (p = ns). Interleukin-15 concentrations were significantly higher in patients in the study group (group A; 3.21 ± 0.79 pg/ml) than in those in the control group (group B; 2.26 ± 0.24 pg/ml; p < 0.05). There was a moderate, positive and significant correlation with systolic blood pressure values (r = 0.584; p < 0.05) and diastolic blood pressure values (r = 0.589; p < 0.05).

Conclusions

Interleukin-15 concentrations were significantly higher in preeclamptic patients than in healthy normotensive pregnant women.     

Concentraciones de interleucina-17 en pacientes preeclámpticas y embarazadas normotensas sanas

Objective

To compare concentrations of interleukin-17 in preeclamptic and healthy normotensive pregnant women.

Method

A total of 100 patients were selected. Fifty preeclamptic patients were selected as the study group (group A) and 50 healthy normotensive pregnant women, with a similar age and body mass index as the study group, were selected as controls (group B). To determine interleukin-17 concentrations, blood samples were collected in all patients before labor and immediately after diagnosis in group A.

Results

There were no significant differences in relation to maternal age, gestational age or body mass index at sample extraction (p = ns). Statistically significant differences were found in interleukin-17 concentrations between patients in the study group (group A; 6.0 +/- 0.9 pg/ml) and patients in the control group (group B; 3.9 +/- 1.0 pg/ml; p < 0.05). There was a significant correlation with values of systolic blood pressure (r = 0.232; p < 0.05) and diastolic blood pressure (r = 0.181; p < 0.05) in group A.

Conclusions

Interleukin-17 values were significantly higher in preeclamptic patients than in healthy normotensive pregnant women.     

Ensayo clínico,aleatorizado y controlado para evaluar la eficacia y la seguridad de la administración de 25 μg de misoprostol vaginal frente a 50 μg de misoprostol sublingual para la inducción del trabajo del parto

Objectives

To compare the safety and efficacy of 25 μg of vaginal misoprostol versus 50 μg of sublingual misoprostol for induction of labor.

Patients and methods

Four hundred fifty women were randomly assigned to receive 25 μg of vaginal misoprostol or 50 μg of sublingual misoprostol every 4 h for up to four doses. The main outcome assessed was the number of vaginal deliveries in 24 h.

Results

A total of 155/225 (68.9%) patients in the sublingual group and 154/225 (68.4%) women in the vaginal group delivered vaginally (p = 0.920; RR = 1.021; 95% CI for RR, 0.685-1.521). The mean time (± standard deviation) for starting labor was 2.75 ± 2.20 h in the sublingual group and 3.8 ± 2.77 h in the vaginal group (p < 0.001). The mean number (± standard deviation) of doses was 1.9 ± 0.8 in the vaginal group and 1.6 ± 0.8 in the sublingual group (p = 0.010). Indications for cesarean section and the frequency of tachysystole were similar in both groups. There was a greater need for oxytocin in the vaginal group (22.7%) than in the sublingual group (14.7%) (p = 0.020).

Conclusions

No statistically significant differences were found between the 2 treatment groups in the main variable: the number of vaginal deliveries in 24 h.     

Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers

Objectives

To evaluate some health indicators in women with advanced breast or gynecological cancers (ABGCs) after discontinuation of active cancer treatment in function of the model of care received.

Methods

This prospective study included patients who were discontinuing anticancer treatment to be followed up only with palliative care (PC). Patients who had been evaluated at least once in PC were categorized as the integrated care model (ICM); those who had not been consulted by the PC team before, as the traditional care model (TCM). Data were analyzed using chi-square, Mann–Whitney, Kaplan–Meier, and Cox regression model.

Results

Among the 87 patients included in the study, 37 (42.5%) had been previously evaluated by the PC team (ICM). Patients who were followed up under an ICM exhibited better QoL (global health, p = 0.02; emotional functioning, p = 0.03; social functioning, p = 0.01; insomnia, p = 0.02) and less depression (p = 0.01). The communication process had no issues in 73% of cases from the ICM group compared with 42% of cases from the TCM group (p = 0.004). Patients who were not previously evaluated in PC received more chemotherapy in the last 6 weeks of life compared to those who had already been evaluated (40% versus 5.9%, p = 0.001). Early evaluation in PC was one of the independent prognostic factors of overall survival.

Conclusion

When followed up concurrently by a PC and clinical oncology team, patients reported better QoL and less depression, received less chemotherapy within the last 6 weeks of life and survived longer than those followed up under a TCM.     

Physician pain and discomfort during minimally invasive gynecologic cancer surgery

Objective

Despite increasing awareness of physical strain to surgeons associated with minimally invasive surgery (MIS), its use continues to expand. We sought to gather information from gynecologic oncologists regarding physical discomfort due to MIS.

Methods

Anonymous surveys were e-mailed to 1279 Society of Gynecologic Oncology (SGO) members. Physical symptoms (numbness, pain, stiffness, and fatigue) and surgical and demographic factors were assessed. Univariate and multivariate analyses were performed to determine risk factors for physical symptoms.

Results

We analyzed responses of 350 SGO members who completed the survey and currently performed > 50% of procedures robotically (n = 122), laparoscopically (n = 67), or abdominally (n = 61). Sixty-one percent of members reported physical symptoms related to MIS. The rate of symptoms was higher in the robotic group (72%) than the laparoscopic (57%) or abdominal groups (49%) (p = 0.0052). Stiffness (p = 0.0373) and fatigue (p = 0.0125) were more common in the robotic group. Female sex (p < 0.0001), higher caseload (p = 0.0007), and academic practice (p = 0.0186) were associated with increased symptoms. On multivariate analysis, robotic surgery (odds ratio [OR] 2.38, 95% CI 1.20–4.69) and female sex (OR 4.20, 95% CI 2.13–8.29) were significant predictors of symptoms. There was no correlation between seeking treatment and surgical modality (laparotomy 11%, robotic 20%, laparoscopy 25%, p = 0.12).

Conclusions

Gynecologic oncologists report physical symptoms due to MIS at an alarming rate. Robotic surgery and female sex appear to be risk factors for physical discomfort. As we strive to improve patient outcomes and decrease patient morbidity with MIS, we must also work to improve the ergonomics of MIS for surgeons.     

Velocimetría Doppler del flujo sanguíneo de la arteria uterina y riesgo de muerte perinatal en preeclámpsicas

Objective

To determine the association between Doppler velocimetry values of uterine artery blood flow with the risk of perinatal death in preeclamptic patients.

Materials and method

We selected 80 patients with a diagnosis of preeclampsia. Preeclamptic patients were divided into those with perinatal deaths and those without. The variables analyzed were the pulsatility index, the resistance index, and the systolic/diastolic flow ratio of the uterine arteries.

Results

There were no differences in maternal age, height or weight between preeclamptic patients with or without perinatal deaths (p = ns), or between gestational age at the time of Doppler ultrasound and systolic and diastolic blood pressure (p = ns). The pulsatility index (1.206 ± 0.140) and resistance index (0.684 ± 0.098) of the uterine arteries were significantly higher in women with perinatal deaths than in those without (1.113 ± 0.109 and 0.605 ± 0.116, respectively; P<.05). No significant differences were found in mean values of the systolic/diastolic flow ratio of the uterine arteries (p = ns).

Conclusion

A high value of the pulsatility index and resistance index of the uterine arteries on Doppler velocimetry in preeclamptic patients is associated with an increased risk of perinatal death.     

Diffusion of Enhanced Recovery principles in gynecologic oncology surgery: Is active implementation still necessary?

Objective

Spontaneous diffusion of the evidence-based Enhanced Recovery After Surgery (ERAS) program from an early adopter department (colorectal surgery) to other closely related departments (gynecologic surgery) within the same hospital could be expected. Given this diffusion hypothesis, this quality improvement study examines the value of active implementation of ERAS in addition to spontaneous diffusion.

Methods

A nonrandomized, pre-post intervention study was conducted at a tertiary referral hospital. Prospective data of consecutive patients who underwent abdominal surgery between March, 2010 and March, 2011 for gynecologic malignancies were collected and compared with those of a historical cohort of patients treated before the structured implementation of ERAS by an expert team. Outcomes were length of hospital stay, length of functional recovery, and compliance to protocol care elements.

Results

Seventy-seven patients treated after structured implementation of ERAS were compared with 38 patients included in the historical cohort. Most women had surgery for ovarian or endometrial cancer (48% and 37% respectively). Postoperative care mostly lacked ERAS elements and needed to be actively implemented. With structured implementation, a reduced time to functional recovery (median 3 versus 6 days, p < 0.001) and a shorter length of hospital stay (5 versus 7 days, p < 0.001) were achieved.

Conclusions

After several years of practicing ERAS in colorectal surgery, spontaneous spread of ERAS principles to gynecologic oncology surgery occurred partially. The results of this study underscore the need for a structured and supported pro-active process to implement the ERAS program in a complete and successful way.     

Racial disparities and patterns of ovarian cancer surgical care in California

Objective

To investigate disparities in the frequency of ovarian cancer-related surgical procedures and access to high-volume surgical providers among women undergoing initial surgery for ovarian cancer according to race.

Methods

The California Office of Statewide Health Planning and Development database was accessed for women undergoing a surgical procedure that included oophorectomy for a malignant ovarian neoplasm between 1/1/06 and 12/31/10. Multivariate logistic regression analyses were used to evaluate differences in the odds of selected surgical procedures and access to high-volume centers (hospitals ≥ 20 cases/year) according to racial classification.

Results

A total of 7933 patients were identified: White = 5095 (64.2%), Black = 290 (3.7%), Hispanic/Latino =1400 (17.7%), Asian/Pacific Islander = 836 (10.5%) and other = 312 (3.9%). White patients served as reference for all comparisons. All minority groups were significantly younger (Black mean age 57.7 years, Hispanic 53.2 years, Asian 54.5 years vs. 61.1 years, p < 0.01). Hispanic patients had lower odds of obtaining care at a high-volume center (adjusted OR (adj. OR) = 0.72, 95% CI = 0.64–0.82, p < 0.01) and a lower likelihood of lymphadenectomy (adj. OR = 0.80, 95% CI = 0.70–0.91, p < 0.01), bowel resection (adj. OR = 0.80, 95% CI = 0.71–0.91, p < 0.01), and peritoneal biopsy/omentectomy (adj. OR = 0.69, 95% CI = 0.58–0.82, p < 0.01). Black racial classification was associated with a lower likelihood of lymphadenectomy (adj. OR = 0.76, 95% CI = 0.59–0.97, p = 0.03).

Conclusions

Among women undergoing initial surgery for ovarian cancer, Hispanic patients are significantly less likely to be operated on at a high-volume center, and both Black and Hispanic patients are significantly less likely to undergo important ovarian cancer-specific surgical procedures compared to White patients.     

Minimally invasive surgery for endometrial cancer: Does operative start time impact surgical and oncologic outcomes?

Objective

Recent literature in ovarian cancer suggests differences in surgical outcomes depending on operative start time. We sought to examine the effects of operative start time on surgical outcomes for patients undergoing minimally invasive surgery for endometrial cancer.

Methods

A retrospective review was conducted of patients undergoing minimally invasive surgery for endometrial cancer at a single institution between 2000 and 2011. Surgical and oncologic outcomes were compared between patients with an operative start time before noon and those with a surgical start time after noon.

Results

A total of 380 patients were included in the study (245 with start times before noon and 135 with start times after noon). There was no difference in age (p = 0.57), number of prior surgeries (p = 0.28), medical comorbidities (p = 0.19), or surgical complexity of the case (p = 0.43). Patients with surgery starting before noon had lower median BMI than those beginning after noon, 31.2 vs. 35.3 respectively (p = 0.01). No significant differences were observed for intraoperative complications (4.4% of patients after noon vs. 3.7% of patients before noon, p = 0.79), estimated blood loss (median 100 cc vs. 100 cc, p = 0.75), blood transfusion rates (7.4% vs. 8.2%, p = 0.85), and conversion to laparotomy (12.6% vs. 7.4%, p = 0.10). There was no difference in operative times between the two groups (198 min vs. 216.5 min, p = 0.10). There was no association between operative start time and postoperative non-infectious complications (11.9% vs. 11.0%, p = 0.87), or postoperative infections (17.8% vs. 12.3%, p = 0.78). Length of hospital stay was longer for surgeries starting after noon (median 2 days vs. 1 day, p = 0.005). No differences were observed in rates of cancer recurrence (12.6% vs. 8.8%, p = 0.39), recurrence-free survival (p = 0.97), or overall survival (p = 0.94).

Conclusion

Our results indicate equivalent surgical outcomes and no increased risk of postoperative complications regardless of operative start time in minimally invasive endometrial cancer staging, despite longer length of hospital stay for surgeries beginning after noon.     

Perioperative and clinical outcomes in the management of epithelial ovarian cancer using a robotic or abdominal approach

Objective

To evaluate the feasibility and efficacy of robotic-assisted management of epithelial ovarian cancer.

Methods

Retrospective review of robotic-assisted or abdominal ovarian cancer cases presenting with pelvic mass, initial staging, or debulking after neoadjuvant chemotherapy performed by a single surgeon (2008–2012). Patient characteristics and outcomes were compared using chi-squared or Student's t-tests.

Results

There were 63 robotic and 26 abdominal cases. Patient characteristics were similar for age, uterine weight, and BMI, with prior abdominal surgery more common in the abdominal group (p = 0.0257). Robotic operative time was longer (p < 0.0001), while blood loss (p < 0.0001) and hospital stay (p = 0.0009) were reduced. Major complication rates (16% vs. 23%, p = 0.4209) and lymphadenectomy yields (13 vs. 11 nodes, p = 0.2310) were similar. Neoadjuvant chemotherapy was more common in the robotic group (52% vs. 15%, p = 0.0013). Residual disease rates for all cases (73% vs. 50%, p = 0.880) and for Stage II–IV cases (61% vs. 40%, p = 0.929) were equivalent. Follow-up was longer for the abdominal group; however, an equivalent percentage of patients had at least 1 year of follow-up (57% vs. 77%, p = 0.0789). At 1 year, survival and no evidence of disease (NED) rates were equivalent for all cases (survival: 97% vs. 90%, p = 0.2501; NED: 81% vs. 85%, p = 0.6773) and for Stage II–IV cases (survival: 96% vs. 88%, p = 0.3080; NED: 76% vs. 81%, p = 0.6920).

Conclusions

A robotic approach for the management of epithelial ovarian cancer, including patients treated with neoadjuvant chemotherapy, is feasible and effective. Debulking, recurrence, and survival rates were similar to laparotomy at 1 year.     

The role and timing of palliative medicine consultation for women with gynecologic malignancies: Association with end of life interventions and direct hospital costs

Objective

Aggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies.

Methods

A retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥ 30 days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission < 3 days. Inpatient direct hospital costs were calculated for the last 30 days of life from accounting records. Data were analyzed using Fisher's Exact, Mann–Whitney U, Kaplan–Meier, and Student's T testing.

Results

49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0–3) versus 2 (range 0–6) p = 0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30 days of life were lower for patients with timely consultation, $0 (range 0–28,019) versus untimely, $7729 (0–52,720), p = 0.01.

Conclusions

Timely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.     

Integrating a complementary medicine consultation for women undergoing chemotherapy

Objective

To explore oncology healthcare providers’ (HCPs’) patterns of referral of women undergoing chemotherapy to a complementary medicine (CM) consultation integrated within a conventional oncology service.

Methods

Oncology HCPs used a structured referral system for referral to an integrative physician (IP) for CM consultation. Referral goals were in accordance with a specified list of quality-of-life (QOL) outcomes.

Results

In total, the study HCPs referred 282 female patients, of whom 238 (84.4%) underwent CM consultation by the study IP: 59 (24.8%) with gynecologic cancer and 179 (75.2%) with non-gynecologic cancer. Use of CM for cancer-related outcomes was significantly higher among referred patients with gynecologic cancer than those with non-gynecologic cancer (69.5% vs 46.9%; P = 0.003). Oncologists initiated most of the referrals in the gynecologic oncology group, whereas oncologic nurses referred most patients in the non-gynecologic oncology group. Among patients with gynecologic cancer, the correlation between HCP indication and patient expectation was high for gastrointestinal concerns (κ 0.41).

Conclusion

The integration of a structured and informed process of referral to CM consultation may enhance patient-centered care and QOL during chemotherapy.