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OBJECTIVE: To examine the prognostic performance of the revised 2018 International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging schema. METHODS: We used the National Cancer Database to identify women with cervical cancer diagnosed from 2004 to 2015. Using clinical and pathologic data, each patient's stage was classified using three staging schemas: American Joint Committee on Cancer 7th edition, FIGO 2009 and FIGO 2018. The FIGO 2018 revised staging classifies stage IB tumors into three substages based on tumor size (IB1–IB3) and classifies patients with positive lymph nodes (pathologically or clinically detected) as stage IIIC1 (positive pelvic nodes) or IIIC2 (positive para-aortic nodes). Five-year survival rates were estimated for each stage grouping. We sought to determine whether the 2018 FIGO staging system was able to offer improved 5-year survival rate differentiation compared with older staging schemas. RESULTS: A total of 62,212 women were identified. The classification of stage IB tumors into three substages improved discriminatory ability. Five-year survival in the FIGO 2018 schema was 91.6% (95% CI 90.4–92.6%) for stage IB1 tumors, 83.3% (95% CI 81.8–84.8%) for stage IB2 neoplasms, and 76.1% (95% CI 74.3–77.8%) for IB3 lesions. In contrast, for women with stage III tumors, higher FIGO staging was not consistently associated with worse 5-year survival rates: stage IIIA (40.7%, 95 CI 37.1–44.3%), stage IIIB (41.4%; 95% CI 39.9–42.9%), stage IIIC1 (positive pelvic nodes) was 60.8% (95% CI 58.7–62.8%) and stage IIIC2 37.5% (95% CI 33.3–41.7%). CONCLUSION: The FIGO 2018 staging schema provides improved discriminatory ability for women with stage IB tumors; however, classification of all women with positive lymph nodes into a single stage results in a very heterogeneous group of patients with highly variable survival rates.
Purpose To characterize treatment patterns and oncologic outcomes in patients with low-volume lymph node metastasis (isolated tumor cells [ITCs] and micrometastasis [MM]) discovered during sentinel node (SLN) mapping for endometrial carcinoma. Methods We identified endometrial cancer cases treated surgically from 9/2005-4/2013 in which SLN mapping was performed. MM was defined as tumor within a lymph node measuring >0.2mm but <2.0mm. ITCs were those measuring ≤0.2mm. Results Eight hundred forty-four patients met inclusion criteria. Median age was 61 (range, 30-90). Histology was as follows: endometrioid, 724 (85.8%); serous, 104 (12.3%); and clear cell, 16 (1.9%). Median number of lymph nodes resected was 6 (range, 0-60); median number of SLNs was 2 (range, 0-15). Seven hundred fifty-three patients (89.2%) were node negative, 23 (2.7%) had ITCs only, 21 (2.5%) had MM only, and 47 (5.6%) had macrometastasis. Adjuvant chemotherapy was given to 106 (14%) of 753 node-negative patients, 19 (83%) of 23 patients with ITCs, 17 (81%) of 21 patients with MM, and 42 (89%) of 47 with macrometastasis. Median follow-up was 26 months (range, 0-108). Three-year recurrence-free survival was as follows: node-negative patients, 90% (± 1.5); ITCs only, 86% (± 9.4); MM only, 86% (± 9.7); and macrometastasis, 71% (± 7.2), (p<0.001). Conclusion Patients with ITCs and MM frequently received adjuvant chemotherapy, and had improved oncologic outcomes in comparison to those with macrometastasis to the lymph nodes. Further prospective study is needed to determine optimal post-resection management in patients with ITCs or MM alone.
OBJECTIVE: To examine the rate of opioid use for gynecologic surgical procedures and to investigate persistent opioid use among those women who received an initial opioid prescription. METHODS: A retrospective cohort study using the MarketScan database was performed. MarketScan is a claims-based data source that captures claims from more than 50 million privately insured patients and 6 million Medicaid enrollees from 12 states. We identified women who underwent major and minor gynecologic surgery from 2009 to 2016. Among women who received an opioid prescription, new persistent opioid use was defined as receipt of one or more opioid prescriptions from 90 to 180 days after surgery with no intervening additional procedures or anesthesia. Multivariable models were used to examine associations between clinical characteristics and any use and new persistent use of opioids. RESULTS: A total of 729,625 patients were identified. Overall, 60.0% of patients received a perioperative opioid prescription. Receipt of an opioid prescription ranged from 36.7% in those who underwent dilation and curettage to 79.5% of patients who underwent minimally invasive hysterectomy. Among patients who received a perioperative opioid prescription, the rate of new persistent opioid use overall was 6.8%. The rate of new persistent opioid use was 4.8% for myomectomy, 6.6% for minimally invasive hysterectomy, 6.7% for abdominal hysterectomy, 6.3% for endometrial ablation, 7.0% for tubal ligation, and 7.2% for dilation and curettage (P<.001). In a multivariable model, patients who underwent dilation and curettage and endometrial ablation were at highest risk for new persistent opioid use. Younger patients, Medicaid recipients, and patients with depression, anxiety, and substance use disorder more commonly had new persistent opioid use (P<.001 for all). Among women who received an opioid prescription, the rate of new persistent opioid use decreased over time from 7.0% in 2010 to 5.5% in 2016 (P<.001). CONCLUSION: The rate of new persistent opioid use after major and minor gynecologic procedures is substantial.
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