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Association between hospital surgical volume and perioperative outcomes of fertility-sparing trachelectomy for cervical cancer: A national study in the United States.

ABSTRACT: OBJECTIVE:To examine the association between hospital surgical volume and perioperative outcomes for fertility-sparing trachelectomy performed for cervical cancer. METHODS:This is a population-based retrospective observational study utilizing the Nationwide Inpatient Sample from 2001 to 2011. Women aged ≤45 years with cervical cancer who underwent trachelectomy were included. Annualized hospital surgical volume was defined as the average number of trachelectomies a hospital performed per year in which at least one case was performed. Perioperative outcomes were assessed based on hospital surgical volume in a weighted model, specifically comparing the top-decile centers to the lower volume centers. RESULTS:There were a total of 815 trachelectomies performed at 89 centers, and 76.4% of the trachelectomy-performing centers had a minimum surgical volume of one trachelectomy per year. The top-decile group had a higher rate of lymphadenectomy performance compared to the lower volume group (96.4% versus 82.4%, odds ratio [OR] 5.65, 95% confidence interval [CI] 2.81-11.4, P < 0.001). There was a significant inverse linear association between annualized surgical volume and the number of perioperative complications (P = 0.020). The top-decile group also had a lower rate of perioperative complications (9.7% versus 21.0%, P < 0.001) and prolonged hospital stay ≥7 days (2.0% versus 6.5%, P = 0.006) compared to the lower volume group. In a multivariable analysis, the top-decile group had a 65% relative decrease in perioperative complication risk compared to the lower volume group (adjusted-OR 0.35, 95%CI 0.20-0.59, P < 0.001). CONCLUSION:Fertility-sparing trachelectomy for young women with cervical cancer is a rare surgical procedure; <90 centers performed this procedure from 2001 to 2011 and most hospitals perform a small number of cases annually. Higher hospital surgical volume for trachelectomy may be associated with reduced perioperative morbidity.

SUBMITTER: Matsuo K

PROVIDER: S-EPMC7526700 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveTo propose an ideal patient candidate with early-stage cervical cancer for undergoing fertility-sparing trachelectomy.MethodsThis nationwide, multicenter, retrospective study was conducted by the Japan Society of Obstetrics and Gynecology involving women aged <45 years with clinical stage I-II cervical cancer who had planned fertility-sparing trachelectomy and pelvic lymphadenectomy between 2009 and 2013 (n = 393). Ideal candidates were defined to have a tumor size of ≤2 cm, no lymph node metastasis, no deep stromal invasion, and no high-risk histology (n = 284, 69.6%). Less-ideal candidates were defined to have any one of these four characteristics (n = 109, 30.4%). Propensity score inverse probability of treatment weighting was used to assess survival outcomes.ResultsLess-ideal candidates were more likely to undergo hysterectomy conversion (22.9% versus 3.2%), receive postoperative radiotherapy (11.9% versus 0.4%), or chemotherapy (32.1% versus 3.2%) compared with ideal candidates (all, P < 0.05). The weighted model revealed that among those who underwent trachelectomy (ideal candidates, n = 275 and less-ideal candidates, n = 84), less-ideal candidates had significantly decreased disease-free survival (5-year rates: 85.5% versus 95.5%; HR 3.93, 95% CI 1.99-7.74; P < 0.001) and cause-specific survival (92.5% versus 98.6%; HR 5.47, 95% CI 1.68-17.8, P = 0.001) compared with ideal candidates. Similarly, less-ideal candidates were significantly associated with decreased disease-free survival compared with ideal candidates among those who were young age, had small tumors or squamous histology, and underwent surgery alone (all, P < 0.05).ConclusionLess-ideal candidates had approximately four-fold higher recurrence risk and cancer mortality compared with ideal candidates. Ideal candidates for fertility-sparing trachelectomy for early-stage cervical cancer proposed in our study may be useful as the future framework for developing guidelines for fertility-sparing trachelectomy in Japan.

Project description:BACKGROUND:Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ?2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease. FINDINGS:Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors???2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions???2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation. CONCLUSION:Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

Project description:ObjectiveTo examine trends and associated characteristics and outcomes of minimally invasive surgery (MIS) for women with early-stage ovarian cancer.MethodsThe National Inpatient Sample was queried to examine early-stage ovarian cancer treated with MIS from 2001 to 2011. Annualized hospital surgical volume was defined in the unweighted model as the average number of procedures performed per year in which at least one case was performed. Trends, characteristics, and outcomes related to MIS use were assessed in the weighted model.ResultsAmong 73,707 oophorectomy cases, there were 4822 (6.5%) MIS cases. Utilization of MIS increased from 3.9% to 13.5% from 2001 to 2011 (3.5-fold increase, P < 0.001), and the number of MIS-offering centers also increased from 10.6% to 36.2% (3.4-fold increase, P < 0.001). MIS was associated with a decreased complication rate (20.3% versus 35.4%) and shorter hospital stay (median, 2 versus 4 days) compared to laparotomy (both, P < 0.001). Of the 472 hospitals at which MIS was performed, the majority were minimum-volume with one MIS oophorectomy per year (340 [72.0%], n = 1929 [40.0%]), followed by mid-volume (85 [18.0%], n = 1272 [26.4%]) and topdecile-volume (47 [10.0%] hospitals, n = 1621 [33.6%]). The topdecile-volume group had the highest rate of lymphadenectomy compared to other groups (62.2% versus 39.2-55.1%, P < 0.05). On multivariable analysis, a one increment increase in annualized hospital surgical volume was associated with an 11% decrease in multiple complications (adjusted-odds ratio 0.89, 95% confidence interval 0.82-0.97, P = 0.006).ConclusionUtilization of MIS for early-stage ovarian cancer has significantly increased in the United States in 2000s. In 2011, one in eight surgeries performed for early ovarian cancer were performed via MIS. MIS procedures performed at hospitals with a higher surgical volume may be associated with improved short-term perioperative outcomes.

Project description:BACKGROUND:Textural features extracted from MRI potentially provide prognostic information additional to volume for influencing surgical management of cervical cancer. PURPOSE:To identify textural features that differ between cervical tumors above and below the volume threshold of eligibility for trachelectomy and determine their value in predicting recurrence in patients with low-volume tumors. METHODS:Of 378 patients with Stage1-2 cervical cancer imaged prospectively (3T, endovaginal coil), 125 had well-defined, histologically-confirmed squamous or adenocarcinomas with >100 voxels (>0.07 cm3) suitable for radiomic analysis. Regions-of-interest outlined the whole tumor on T2-W images and apparent diffusion coefficient (ADC) maps. Textural features based on grey-level co-occurrence matrices were compared (Mann-Whitney test with Bonferroni correction) between tumors greater (n = 46) or less (n = 79) than 4.19 cm3. Clustering eliminated correlated variables. Significantly different features were used to predict recurrence (regression modelling) in surgically-treated patients with low-volume tumors and compared with a model using clinico-pathological features. RESULTS:Textural features (Dissimilarity, Energy, ClusterProminence, ClusterShade, InverseVariance, Autocorrelation) in 6 of 10 clusters from T2-W and ADC data differed between high-volume (mean ± SD 15.3 ± 11.7 cm3) and low-volume (mean ± SD 1.3 ± 1.2 cm3) tumors. (p < 0.02). In low-volume tumors, predicting recurrence was indicated by: Dissimilarity, Energy (ADC-radiomics, AUC = 0.864); Dissimilarity, ClusterProminence, InverseVariance (T2-W-radiomics, AUC = 0.808); Volume, Depth of Invasion, LymphoVascular Space Invasion (clinico-pathological features, AUC = 0.794). Combining ADC-radiomic (but not T2-radiomic) and clinico-pathological features improved prediction of recurrence compared to the clinico-pathological model (AUC = 0.916, p = 0.006). Findings were supported by bootstrap re-sampling (n = 1000). CONCLUSION:Textural features from ADC maps and T2-W images differ between high- and low-volume tumors and potentially predict recurrence in low-volume tumors.

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Association between hospital surgical volume and perioperative outcomes of fertility-sparing trachelectomy for cervical cancer: A national study in the United States.

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