Objective This study aimed to determine whether individuals living in socioeconomically disadvantaged areas were at higher risk for adverse post-operative outcomes including complications, mortality, and hospital re-admission after gynecologic cancer surgery. Methods Using the California Patient Discharge Data, we identified individuals aged 18 years and older undergoing gynecologic cancer surgery between 2008 and 2020. We included patients if they had a hospitalization where a gynecologic cancer was listed as the primary diagnosis code (International Classification of Diseases, Ninth and Tenth Revision) and an International Classification of Diseases, Ninth and Tenth Revision code(s) that corresponded to surgical treatment specific to that cancer. Individuals were excluded if record linkage number identifiers were missing, date of surgery was missing, or residential zip code was not listed. The social deprivation index was used as an aggregate measure of community socioeconomic characteristics. Higher social deprivation index values correspond to higher levels of socioeconomic disadvantage. Our primary outcome was the incidence of post-operative complications within 30 days of surgery; secondary outcomes included in-hospital post-operative mortality, severe post-operative complications, and post-operative re-admissions. The χ2 tests and Kruskal-Wallis tests were used to test for differences in the distribution of patient and hospital characteristics by the incidence of any post-surgical complication. Multi-variable marginal logistic regression models were used to assess the associations between patient and hospital characteristics and outcomes of interest. Results There were 57,823 patients who were included in our study, and 6616 patients (11.4%) who experienced at least 1 post-operative complication. The median social deprivation index score of patients experiencing a complication was higher than those who did not (62 [interquartile range; 36-84] vs. 60 [interquartile range; 34-83], p < .001). An individual living in social deprivation index quintile 5 (ie, area with highest socioeconomic disadvantage) had higher odds of experiencing a post-operative complication (adjusted odds ratio vs. quintile 1, 1.15 [95% confidence interval [CI] 1.04 to 1.27]). The adjusted predicted probability that they would experience a post-operative complication was 1.3 percentage points higher (0.4-2.3, p = .006) than an individual in quintile 1. Individuals living in quintile 5 faced higher odds of in-hospital post-operative mortality (adjusted odds ratio vs quintile 1, 1.64 [95% CI 1.11 to 2.43]). Conclusions Individuals living in socioeconomically disadvantaged areas face a higher probability for post-operative complications and in-hospital post-operative mortality after gynecologic cancer surgery. Although the magnitude of the effect is small, the impact of an individual’s socioeconomic background on post-operative outcomes can be observed independently of frequently associated co-variates such as race, ethnicity, and health insurance status.

Advanced endometrial cancer is associated with poor outcomes and few treatment options exist. Recently, the US Federal Drug Administration approved pembrolizumab for the treatment of endometrial cancers that are deficient in mismatch repair and have high microsatellite instability (MSI). Lynch syndrome is an autosomal dominant disease that causes MSI-high endometrial cancer. We report a case of a 46-year-old woman with Lynch syndrome and advanced endometrial cancer who experienced progressive disease after treatment with chemotherapy with carboplatin and paclitaxel. She was then treated with single-agent pembrolizumab and had an exceptional response. She was noted to have a significant decrease in the size of a large uterine mass extending into the vagina and vulva, as well as decrease in the size of lymphadenopathy. Data are limited at this time for patients with Lynch syndrome treated with single-agent pembrolizumab. Our case report seeks to add to the body of literature that suggests that this patient population may particularly benefit from this novel therapy.

ObjectiveAltmetric Attention Score (AAS) is an alternative metric for estimating the impact of academic publications. We studied the association of using podcasting to highlight publications about gynecological cancer with AAS and citation scores. MethodsArticles that were featured in the International Journal of Gynecological Cancer (IJGC) podcast series January 2019 to September 2022 were matched 1:1 to control articles by the journal in which the article was published, study topic and design, single/multicenter data, and year of publication. Podcast articles were compared with matched-controls by citation metrics and altmetric scores. ResultsA total of 99 podcasted articles published in 16 journals were matched. Median AAS was significantly higher in the podcast group than the matched-control group (22 (14-42) vs 5 (1-17), p<0.001). In a multivariable regression analysis, podcasting was the only factor associated with a high AAS (adjusted odds ratio (aOR) 8.6, 95% CI 3.8 to 19.7). In the podcast group, the median number of citations per year was higher than matched-control studies (5.5 (3.0-12.7) vs 4.5 (2.0-9.5), p=0.047). The only article characteristics that were independently associated with >= 12 citations per year were if the publication described a randomized controlled trial (aOR 4.7, 95% CI 1.6 to 13.6) or featured cervical carcinoma as the subject focus (aOR 2.9, 95% CI 1.3 to 6.5). Compared with all articles published in IJGC during the study period, articles that were featured in a podcast had higher median citations per year (5 (2-10) vs 1 (0-2.5), p<0.001). ConclusionWhen compared with matched-controls, podcasting an article is associated with a higher AAS but is not associated with generating a high (>= 12) number of citations per year. When compared with all articles published in the same journal during the same study period, articles that were featured in a podcast had higher median citations per year.

Objectives The Ovarian Cancer Comorbidity Index (OCCI) is an age-specific index developed and previously found to be more predictive of overall and cancer-specific survival than the Charlson Comorbidity Index (CCI). The objective was to perform secondary validation of the OCCI in a US population. Methods A cohort of ovarian cancer patients undergoing primary or interval cytoreductive surgery from January 2005 to January 2012 was identified in SEER-Medicare. OCCI scores were calculated with the regression coefficients determined from the original developmental cohort for five comorbidities. Cox regression analyses were used to calculate associations between the OCCI risk groups and 5-year overall survival and 5-year cancer-specific survival in comparison to the CCI. Results A total of 5052 patients were included. Median age was 74 (range 66–82) years. 47% (n=2375) had stage III and 24% (n=1197) had stage IV disease at diagnosis. 67% had a serous histology subtype (n=3403). All patients were categorized as moderate (48.4%) or high risk (51.6%). The prevalence of the five predictive comorbidities were: coronary artery disease 3.7%, hypertension 67.5%, chronic obstructive pulmonary disease 16.7%, diabetes 21.8%, and dementia 1.2%. Controlling for histology, grade, and age-stratification, worse overall survival was associated with both a higher OCCI (hazard ratio (HR) 1.57; 95% confidence interval (CI) 1.46 to 1.69) and CCI (HR 1.96; 95% CI 1.66 to 2.32). Cancer-specific survival was associated with the OCCI (HR 1.33; 95% CI 1.22 to 1.44) but was not associated with the CCI (HR 1.15; 95% CI 0.93 to 1.43). Conclusions This internationally developed comorbidity score for ovarian cancer patients is predictive for both overall and cancer-specific survival in a US population. CCI was not predictive for cancer-specific survival. This score may have research applications when utilizing large administrative datasets.

OBJECTIVE:Bibliometric literature in gynecologic oncology is limited. We aimed to study the association between the level of income of the country of authorship and citation metrics.METHODS:A retrospective study including all articles and reviews published during 1977-2022 in the International Journal of Gynecological Cancer (IJGC) and Gynecologic Oncology journals. Country of origin was defined as the corresponding author's address. We classified articles into groups by level of income of the country of origin, as defined by the World Bank. The primary outcome measure was the median number of citations per year.RESULTS:A total of 9835 articles were included in the analysis (IJGC n=3786 (38.5%), Gynecologic Oncology n=6049 (61.5%)). There were 8587 (87.3%) publications from high income countries, 1134 (11.5%) from upper-middle income countries, and 114 (1.2%) from lower-middle income countries. There were no publications from countries of low income. Most publications originated in the United States with 4089 (41.6%), followed by China (n=730, 7.4%), Italy (n=533, 5.4%), Canada (n=467, 4.7%), and Japan (n=461, 4.7%). Over the most recent 5 years there was a decrease in the representation of upper-middle income countries and lower-middle income countries; 16.3% (91/557) in 2018 versus 9.1% (38/417) in 2022 (p=0.005). In a multivariable regression analysis that included year of publication, open access publication model, study being supported by funding, publishing journal, review article, and level of income, all factors were associated with high citation per year score except the income classification of the article's country of origin (adjusted OR 1.59-1.72, 95% CI 0.61 to 4.30).CONCLUSION:High income countries have a disproportionate representation in gynecologic oncology publications. After adjusting for confounders, the country's level of income was not independently associated with a high citation per year score. This implies that the number of citations per year is not compromised by the country's level of income.

OBJECTIVE: This study aimed to assess trends in the rate of bilateral salpingectomy and bilateral tubal ligation procedures in the United States between 2019 and 2020. STUDY DESIGN: A population-based, retrospective, cross-sectional study was conducted using discharge data from the National Inpatient Sample (NIS), an all-payer administrative claims database covering 98% of the United States.1 All hospitalizations reporting ICD-10-PCS (International Classification of Diseases, 10th Revision-Procedure Coding System) procedure codes for bilateral salpingectomy or bilateral tubal ligation between January 1, 2019 and December 31, 2020 were included (Supplemental Table 1).2 Admissions with newborn delivery were determined by the ICD-10-CM (ICD-10 Clinical Modification) Delivery Indicator reported in the NIS, and concurrently performed procedures were determined by ICD-10-PCS codes and associated procedure days.1 Analyses were done on data weighted to obtain national estimates, with variance estimates derived from the NIS sampling methodology. Linear segmented regression was used to assess monthly percentage change (MPC) in hospitalizations using the National Cancer Institute's Joinpoint Regression Program.3 Briefly, this program fits trend data with linear segments using a minimum number of statistically significant joinpoints, with individual joinpoints serving as the start and end of 2 trend segments. A maximum of 4 joinpoints, 1 gridpoint between observed values, and minimum meaningful MPC difference of 5% were prespecified. Demographic characteristics for admissions during the period of steep decline (February-April 2020) were compared with characteristics for admissions in the same months in 2019 with chi-square tests. Analyses were conducted using IBM SPSS Statistics, Version 29.0 (IBM Corp, Armonk, NY). This study consulted the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies4 and was determined to be Not Human Subjects Research by the Mass General Brigham Institutional Review Board. RESULTS: Bilateral salpingectomy and bilateral tubal ligation procedures were performed during 352,270 admissions in 2019 (95% confidence interval [CI], 337,125-367,415) and 304,200 admissions in 2020 (95% CI, 291,016-317,384) (P<.001). Across the study period CONCLUSION: Permanent contraception is a critical women's health service, the access to which was threatened by the COVID-19 pandemic. We found that inpatient salpingectomy and tubal ligation procedures decreased in 2020 compared with 2019, with the sharpest decline during the first wave of the COVID-19 pandemic. This pattern was similar to trends reported for hysterectomy procedural volume.5 Salpingectomy and tubal ligation procedures during admissions with newborn delivery had a shallow decline but were relatively protected from the sharp decline observed in overall procedure volume. We did not find evidence that the decrease in procedure volume disproportionately affected specific economic, racial, or regional subsets of the population. -

Lay Summary The most common type of ovarian cancer likely begins in the fallopian tubes. Surgically removing the fallopian tubes decreases a person’s risk of ovarian cancer. ‘Opportunistic salpingectomy’ refers to the removal of the fallopian tubes during surgery that is done for other reasons. Opportunistic salpingectomy is commonly done during hysterectomy. The types of other surgery performed together with opportunistic salpingectomy in the USA were analysed in the present study. Opportunistic salpingectomy was found to be done at the time of bariatric surgery, bowel surgery, hernia repair, gallbladder surgery, and breast surgery. Offering opportunistic salpingectomy to all women who are scheduled for those types of surgeries could lead to between 3600 and 5800 fewer deaths from ovarian cancer in the USA per year.

ObjectiveTo evaluate whether a citation advantage exists for open access (OA) publications in gynecologic oncology. MethodA cross-sectional study of research and review articles published in the International Journal of Gynecological Cancer (IJGC) and in Gynecologic Oncology during 1980-2022. Bibliometric measures were compared between OA publications and non-OA publications. The role of authors in low/middle-income countries was assessed. We analyzed article characteristics associated with a high citations per year (CPY) score. ResultsOverall, 18 515 articles were included, of which 2398 (13.0%) articles were published OA. The rate of OA has increased since 2007. During 2018-2022, the average proportion of articles published OA was 34.0% (range 28.5%-41.4%). OA articles had higher CPY (median (IQR), 3.0 (1.5-5.3) vs 1.3 (0.6-2.7), p<0.001). There was a strong positive correlation between OA proportion and impact factor; IJGC - r(23)=0.90, p<0.001, Gynecologic Oncology - r(23)=0.89, p<0.001. Articles by authors from low/middle-income countries were less common among OA articles than among non-OA articles (5.5% vs 10.7%, p<0.001). Articles by authors from low/middle-income countries were less common in the high CPY group than for articles without a high CPY score (8.0% vs 10.2%, p=0.003). The following article characteristics were found to be independently associated with a high CPY: publication after 2007, (adjusted odds ratio (aOR)=4.9, 95% CI 4.3 to 5.7), research funding reported (aOR=1.6, 95% CI 1.4 to 1.8), and being published OA (aOR=1.5, 95% CI 1.3-1.7). Articles written by authors in Central/South America or Asia had lower odds of having high CPY (Central/South America, aOR=0.5, 95% CI 0.3 to 0.8; Asia, aOR=0.6, 95% CI 0.5 to 0.7). ConclusionOA articles have a higher CPY, with a strong positive correlation between OA proportion and impact factor. OA publishing has increased since 2007, but articles written by authors in low/middle-income countries are under-represented among OA publications.

BACKGROUND:Multiple studies have assessed post-operative readmissions in advanced ovarian cancer.OBJECTIVE:To evaluate all unplanned readmissions during the primary treatment period of advanced epithelial ovarian cancer, and the impact of readmission on progression-free survival.METHODS:This was a single institution retrospective study from January 2008 to October 2018. Χ2/Fisher's exact and t-test, or Kruskal-Wallis test were used. Multivariable Cox proportional hazard models were used to assess the effect of covariates in progression-free survival analysis.RESULTS:A total of 484 patients (279 primary cytoreductive surgery, 205 neoadjuvant chemotherapy) were analyzed. In total, 272 of 484 (56%; 37% primary cytoreductive surgery, 32% neoadjuvant chemotherapy, p=0.29) patients were readmitted during the primary treatment period. Overall, 42.3% of the readmissions were surgery related, 47.8% were chemotherapy related, and 59.6% were cancer related but not related to surgery or chemotherapy, and each readmission could qualify for more than one reason. Readmitted patients had a higher rate of chronic kidney disease (4.1% vs 1.0%, p=0.038). Post-operative, chemotherapy, and cancer-related readmissions were similar between the two groups. However, the percentage of inpatient treatment days due to unplanned readmission was twice as high for primary cytoreductive surgery at 2.2% vs 1.3% for neoadjuvant chemotherapy (p<0.001). Despite longer readmissions in the primary cytoreductive surgery group, Cox regression analysis demonstrated that readmissions did not affect progression-free survival (HR=1.22, 95% CI 0.98 to 1.51; p=0.08). Primary cytoreductive surgery, higher modified Frailty Index, grade 3 disease, and optimal cytoreduction were associated with longer progression-free survival.CONCLUSIONS:In this study, 35% of the women with advanced ovarian cancer had at least one unplanned readmission during the entire treatment time. Patients treated by primary cytoreductive surgery spent more days during readmission than those with neoadjuvant chemotherapy. Readmissions did not affect progression-free survival and may not be valuable as a quality metric.

Counseling regarding opportunistic salpingectomy (OS) at the time of benign gynecologic surgery is recommended due to the opportunity to reduce the risk of ovarian cancer for patients already undergoing surgery. Recently, OS has also been demonstrated as feasible during elective laparoscopic cholecystectomy. This study aimed to describe the prevalence of bilateral salpingectomy performed at the time of non-gynecologic surgery, types of concurrently performed procedures, and demographic characteristics of patients undergoing OS at the time of non-gynecology surgery in the United States at a population level.

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.

A 45-year-old woman was diagnosed with stage IB2 HPV-associated endocervical carcinoma. No evidence of locally advanced or metastatic disease was discovered during pre-operative workup. An abdominal radical hysterectomy, bilateral salpingectomy, and lymphatic mapping with sentinel lymph node

Objectives: Performed a cost-utility analysis comparing maintenance therapies for advanced epithelial ovarian cancer to surveillance based on genetic mutation. Methods: We developed Markov models of post-frontline treatment disease course until death for women diagnosed with stage III-IV epithelial ovarian cancer to compare niraparib, olaparib, bevacizumab, and olaparib+bevacizumab with active surveillance. Four subgroups were analyzed: (1) all-comers, (2) BRCA, (3) non-BRCA homologous recombination deficiency (HRD), and (4) homologous recombination proficient (HR proficient). Transition probabilities for progression-free survival and adverse events were derived from randomized controlled trials, for all-cause mortality from US life tables, and for disease-specific mortality after recurrence from SEER. Utilities for maintenance treatment, grade 3-4 adverse events, disease-free off treatment, recurrence, and death were derived from ovarian cancer-specific time trade-off studies. Costs of treatment, adverse events, recurrence, and death were obtained from Centers for Medicare & Medicaid Services (CMS) fee schedules and published studies. Analysis was conducted from CMS’s perspective. We considered a 3-month cycle length, a lifetime time horizon and applied a 3% annual discount rate. The primary outcome of interest was the incremental cost-effectiveness ratio (ICER), defined as the ratio of incremental cost to incremental quality-adjusted life-year (QALY). Uncertainty was evaluated using deterministic and probabilistic sensitivity analyses and represented by cost-effectiveness at willingness-to-pay (WTP) thresholds up to $200K/QALY. Results: For all-comers, surveillance and olaparib+bevacizumab were undominated (more effective and less costly), and the ICER of olaparib+bevacizumab in reference to surveillance was $182,823/ QALY. The probability of cost-effectiveness of olaparib+bevacizumab at a WTP threshold of $100K/QALY was 20%. For BRCA patients, surveillance and olaparib were nominated, and the ICER of olaparib was $49,896/QALY. The probability of olaparib being cost-effective at a WTP threshold of $100K/QALY was 71%. For non-BRCA HRD patients, surveillance and olaparib+bevacizumab were both undominated, and the ICER of olaparib+bevacizumab was $98,685/QALY. At a WTP threshold of $100,000/QALY, olaparib+bevacizumab had a higher probability of being cost-effective (48%) than niraparib (6%) or bevacizumab alone (4%). For HR proficient patients, surveillance was undominated and had the highest probability of being cost-effective at all WTP thresholds. Conclusions: Compared to active surveillance, olaparib+bevacizumab was the most cost-effective maintenance strategy for all-comers and non-BRCA HRD patients. At the same time, olaparib was most costeffective for women with BRCA mutations. The likelihood of any maintenance therapy being cost-effective for women with HR proficient disease was low. Objectives: Performed a cost-utility analysis comparing maintenance therapies for advanced epithelial ovarian cancer to surveillance based on genetic mutation. Methods: We developed Markov models of post-frontline treatment disease course until death for women diagnosed with stage III-IV epithelial ovarian cancer to compare niraparib, olaparib, bevacizumab, and olaparib+bevacizumab with active surveillance. Four subgroups were analyzed: (1) all-comers, (2) BRCA, (3) non-BRCA homologous recombination deficiency (HRD), and (4) homologous recombination proficient (HR proficient). Transition probabilities for progression-free survival and adverse events were derived from randomized controlled trials, for all-cause mortality from US life tables, and for disease-specific mortality after recurrence from SEER. Utilities for maintenance treatment, grade 3-4 adverse events, disease-free off treatment, recurrence, and death were derived from ovarian cancer-specific time trade-off studies. Costs of treatment, adverse events, recurrence, and death were obtained from Centers for Medicare & Medicaid Services (CMS) fee schedules and published studies. Analysis was conducted from CMS’s perspective. We considered a 3-month cycle length, a lifetime time horizon and applied a 3% annual discount rate. The primary outcome of interest was the incremental cost-effectiveness ratio (ICER), defined as the ratio of incremental cost to incremental quality-adjusted life-year (QALY). Uncertainty was evaluated using deterministic and probabilistic sensitivity analyses and represented by cost-effectiveness at willingness-to-pay (WTP) thresholds up to $200K/QALY. Results: For all-comers, surveillance and olaparib+bevacizumab were undominated (more effective and less costly), and the ICER of olaparib+bevacizumab in reference to surveillance was $182,823/ QALY. The probability of cost-effectiveness of olaparib+bevacizumab at a WTP threshold of $100K/QALY was 20%. For BRCA patients, surveillance and olaparib were nominated, and the ICER of olaparib was $49,896/QALY. The probability of olaparib being cost-effective at a WTP threshold of $100K/QALY was 71%. For non-BRCA HRD patients, surveillance and olaparib+bevacizumab were both undominated, and the ICER of olaparib+bevacizumab was $98,685/QALY. At a WTP threshold of $100,000/QALY, olaparib+bevacizumab had a higher probability of being cost-effective (48%) than niraparib (6%) or bevacizumab alone (4%). For HR proficient patients, surveillance was undominated and had the highest probability of being cost-effective at all WTP thresholds. Conclusions: Compared to active surveillance, olaparib+bevacizumab was the most cost-effective maintenance strategy for all-comers and non-BRCA HRD patients. At the same time, olaparib was most costeffective for women with BRCA mutations. The likelihood of any maintenance therapy being cost-effective for women with HR proficient disease was low.

ObjectivesTo evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.MethodsWe performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100 mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.ResultsAmong 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used enhanced recovery after surgery (ERAS) pathways. 29 (12.4%) patients had urinary catheter removal between 1–5 days postoperatively (group 1), 141 (60.3%) between 6–10 days (group 2), and 64 (27.3%) between 11–15 days (group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between group 1 (17.2%), group 2 (11.3%), and group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3–5 days) compared with group 2 (8 days, IQR 7–10 days) and group 3 (13 days, IQR 11–15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or re-admission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.ConclusionThere was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.