Post-treatment surveillance for ovarian carcinoma patients: the effect of health maintenance organization penetration rate

Post-treatment surveillance for ovarian carcinoma patients: the effect of health maintenance organization penetration rate

OBSTETRICS & GYNECOLOGY Surgical site infection after primary debulking surgery for epithelial ovarian cancer: predictors and impact on survival Chris...

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OBSTETRICS & GYNECOLOGY Surgical site infection after primary debulking surgery for epithelial ovarian cancer: predictors and impact on survival Christine Tran, Michaela E McGree, BS, Amy L Weaver, MS, Janice R Martin, Maureen A Lemens, RN, William A Cliby, MD, FACS, Sean C Dowdy, MD, FACS, Jamie N Bakkum-Gamez, MD Mayo Clinic, Rochester, MN

for ascites, diffuse peritoneal thickening (DPT), omental cake, lymphadenopathy (LP), and splenic or hepatic involvement. Preoperative factors included age, BMI, ECOG performance status (PS), ASA score, albumin, CA-125, and thrombocytosis. Two prediction models were constructed to estimate the probability of complete and suboptimal resection (residual disease (RD) >1 cm) using multivariable logistic analysis. Discrimination (c-index) was assessed using 300 bootstrap resamples.

INTRODUCTION: Surgical site infection (SSI) following epithelial ovarian cancer (EOC) primary debulking surgery (PDS) occurs in 10-15% of patients. Perioperative factors associated with SSI and the impact of SSI on EOC survival were determined.

RESULTS: 296 patients met inclusion criteria: 155 complete resection, 27 suboptimal debulking, 114 measurable RD 1 cm. On multivariable analysis, absence of ascites, omental cake, and splenic involvement on CT imaging predicted complete resection (c-index 0.748). Predictors of suboptimal resection were DPT and LP on CT imaging, and ECOG PS (c-index 0.664).

METHODS: EOC cases that underwent PDS between 1/1/03 and 12/31/11 were retrospectively reviewed. SSIs were defined according to the American College of Surgeons National Surgical Quality Improvement Program guidelines. Bowel leaks were considered organ/space SSIs. Logistic regression models were fit to identify factors associated with SSI. Cox proportional hazards models were utilized to evaluate the association of patient and perioperative characteristics with overall survival (OS) and disease-free survival (DFS). RESULTS: Among 888 cases, 96 (10.8%) developed an SSI: 32 superficial, 2 deep, and 62 organ/space. Factors independently associated with superficial SSI were increasing Body Mass Index (BMI) (odds ratio 1.41 [95% CI, 1.12, 1.76] per 5 kg/m2), increasing operative time (1.24 [1.02, 1.50] per hour), and advanced stage (III/IV) (10.22 [1.37, 76.20]). Factors independently associated with organ/space SSI were history of GERD (2.13 [1.23, 3.71]), surgical complexity (intermediate 3.11 [1.02, 9.49]; high 8.07 [2.60, 25.09]), and residual disease (measureable 1cm 1.77 [0.96, 3.27]; >1cm (3.36 [1.48, 7.61]). Superficial (HR 1.69 [1.12, 2.57]) or organ/space (HR 1.46 [1.07, 2.00]) SSIs were independently associated with worse OS. SSI occurrence did not independently influence DFS. CONCLUSIONS: Development of SSI after PDS worsens OS. Most risk factors for SSI are not modifiable. Alternative measures to lower rates of SSI are needed since reducing SSI may improve OS. Preoperative identification of SSI risk factors may assist in risk assessment and operative decision making. Preoperative prediction of complete and suboptimal cytoreduction in advanced stage ovarian cancer Jo Marie Tran Janco, MD, Gretchen E Glaser, MD, Bohyun Kim, MD, PhD, Michaela E McGree, BS, Amy L Weaver, MS, William A Cliby, MD, FACS, Sean C Dowdy, MD, FACS, Jamie N Bakkum-Gamez, MD Mayo Clinic, Rochester, MN and Carilion Clinic, Roanoke, VA

CONCLUSIONS: Multiple factors are important in predicting complete or suboptimal cytoreduction; these models are useful prediction tools for improved counseling and selection for primary surgery. Post-treatment surveillance for ovarian carcinoma patients: the effect of health maintenance organization penetration rate Varun Singla, Robert J Avino, BA, Randall K Gibb, MD, David G Mutch, MD, Feng Gao, PhD, Katherine S Virgo, PhD, Frank R Johnson, MD, FACS Billings Clinic, Billings, MT and American Cancer Society, Atlanta, GA and Washington University and Saint Louis University, Saint Louis, MO INTRODUCTION: In the US, over 21,000 women are diagnosed with ovarian cancer each year. Most receive curative-intent treatment and post-treatment surveillance. We recently carried out a survey of the Society of Gynecologic Oncologists (SGO), which documented that the intensity of surveillance varies markedly. Consensus-based surveillance guidelines exist, but high-quality evidence is not available. Since it is commonly felt that health maintenance organizations (HMOs) restrict test utilization, we sought to determine the effect of HMO penetration rate on the variation in surveillance intensity. METHODS: 943 SGO members and candidate members were surveyed to determine their surveillance practices. The survey offered 4 idealized clinical vignettes and a menu of 11 testing modalities. Responses were stratified by the HMO penetration rate (0-29%, 3040%, >40%) in each gynecologist’s practice location. Repeatedmeasures analysis of variance (ANOVA) were employed for analysis.

INTRODUCTION: A tool using computed tomography (CT) imaging and preoperative clinical variables to predict successful primary cytoreduction in women with advanced stage epithelial ovarian cancer (EOC) would be helpful for preoperative counseling and patient selection.

RESULTS: 323 of those surveyed responded; 283 were evaluable. There was statistically significant variation (p<0.05) in the three most frequently recommended modalities: office visit, serum CA-125 level, and pelvic exam. For example, physicians in the 0-29% penetration rate cohort recommended 4.4  1.6 office visits in year 1, while those in the 30-40% cohort recommended 4.2  1.2 visits in year 1.

METHODS: Women who underwent primary cytoreductive surgery for stage III/IV EOC and had preoperative CT images of the abdomen/pelvis available for review were included. Images were reviewed

CONCLUSIONS: The variability in utilization of office visits is statistically significant but, surprisingly, our data indicate that HMO penetration rate contributes minimally to that variability.

ª 2014 by the American College of Surgeons Published by Elsevier Inc.

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http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.710 ISSN 1072-7515/14