- Email: [email protected]
Even high risk women lack knowledge of obesity's impact on risk for endometrial cancer
Abstracts
experienced disease recurrence. Median time to recurrence was 17 months (range, 7–30). Median number of chemotherapy lines was 1 (range, 0–6). Median length of follow-up was 25 months (range, 0–88). At the time of last follow-up, 82% was without evidence of disease, 2.6% was alive with disease, and 15.4% was dead of disease. Conclusion: Due to the rare occurrence of lymph node metastasis, lymphadenectomy has limited diagnostic and prognostic value with mucinous adenocarcinoma of the ovary and may introduce unnecessary morbidity, particularly in patients who require re-operation. Survival periods are unusually long with rare disease recurrence. doi:10.1016/j.ygyno.2014.07.040
Predictors of survival following recurrence of cervical cancer A. Walter, J. Lauer, C. Gunderson, K. Slaughter, L. Perry, S. McMeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: Recurrent cervical cancer portends a poor prognosis. The purpose of this investigation is to identify the predictors of survival following the recurrence of cervical cancer. Methods: A retrospective chart review was performed in patients (pts) treated for cervical cancer (CXCA) from 1999 to 2011. Descriptive, clinico-pathologic, and survival data were collected. SAS 9.3 was used for statistical analyses. Results: During the 12 years of this study, 504 newly diagnosed CXCA pts were identified. 142 of the 504 patients were diagnosed with recurrence, and 128 had complete data for analysis. Univariate analysis was performed to identify potential predictors of survival; time from initial diagnosis to recurrence (dichotomized into those recurring less than 12 months of initial diagnosis and those greater than 12 months), race, smoking status, stage, BMI and histology. Significant predictors in univariate analysis were; time to recurrence HR = 1.75 (p = .0046), stage HR 1.13 (p = .0033), and squamous histology HR = 1.59 (p = .03). These were then evaluated in a multivariate model, only time to recurrence less than 12 months HR = 1.59 (p = .02) and stage HR 1.11 (p = .01) were predictors of death following recurrence. Conclusion: In multivariate analysis stage and time to recurrence of less than 12 months from initial diagnosis are independent predictors of death following recurrence of cervical carcinoma. Overall, survival remains poor in patients with recurrent cervical carcinoma; patients with long interval from diagnosis to recurrence and early stage may be more likely to benefit from aggressive therapy following recurrence. doi:10.1016/j.ygyno.2014.07.041
IB2 cervical carcinoma: Outcomes by primary therapy A. Walter, C. Gunderson, K. Slaughter, L. Perry, S. McMeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: Most IB2 cervical carcinomas are treated with primary platinum-based chemotherapy with concurrent radiation (CRT); however, radical hysterectomy (RH) remains an option for some. The purpose of this investigation is to compare baseline demographic and treatment outcomes. Methods: A retrospective chart review was performed in patients (pts) treated for cervical cancer (CXCA) from 1999 to 2011. Descriptive, clinico-pathologic, and survival data were collected. SAS 9.3 was used for statistical analyses. Results: During the 12 years of this study, 504 newly diagnosed CXCA pts were identified. 71 of the 504 patients were identified with IB2 disease; detailed treatment information was available for 65; they are the focus of this study. 30 patients were prescribed CRT as
395
primary therapy, and RH was performed for 35 patients. There was no difference between the two groups in terms of BMI, smoking status, race, insurance status, and histology. The CRT group was significantly older (median age: 49 vs. 43 years, p = .02) and had higher grade histology (p = .04). There were no significant differences in post-treatment complications including rates of venous thromboembolism, transfusions, ER visits, or hospital readmission within 60 days of treatment. Overall survival (3.46 vs. 7.94 years p = .37) and progression free survival were not different between CRT and RH at 3.03 years vs 4.89 years respectively (p = .47), and recurrence rates were similar (40% CRT vs 37% RH). Of the 35 patients in the RH group, 27 (74%) were treated with adjuvant therapy for high or intermediate risk factors. Conclusion: Patients with IB2 cervical carcinoma treated with radical surgery or primary CRT had similar outcomes in PFS, OS, and recurrence rates. The rate of adjuvant therapy is high in the RH group; however, this did not translate to increased short term morbidity. Knowledge of differences in long-term toxicity would be crucial to selecting therapies for these patients in an evidence-based manner. doi:10.1016/j.ygyno.2014.07.042
Are current treatments effective, in gynecologic cancer patients with central nervous system metastasis? A. Walter, C. Guderson, K. Slaughter, L. Perry, S. Mcmeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: CNS metastasis with gynecologic malignancy is a rare event associated with poor prognosis; fewer than 30% survive N12 months. Palliative treatment is often used, with cerebral tumor control and prevention of CNS recurrence the primary outcome. We evaluated various treatment strategies in the gynecologic cancer population. Methods: An IRB-approved retrospective chart review was performed identifying all patients diagnosed with a primary gynecologic malignancy treated for CNS metastasis from 2005 to 2014 at a single academic center. SAS 9.3 was used for statistical analyses. Results: Thirty-five patients were identified. Median age was 61 years (range, 41–79). The majority had ovarian cancer (54%), 37% endometrial cancer, and 9% squamous cell cervical cancer. 57% of patients were treated with whole brain radiation therapy (WBRT), 14% stereotactic radiosurgery alone (SRS), 14% combined surgery and SRS, 6% combined SRS + WBRT, and 2 patients hospice. 17% had a CNS recurrence; 60% of patients initially treated with surgery + SRS recurred, 10% initially treated with WBRT recurred, and 20% treated with SRS only recurred. There was non-significant trend in recurrence risk in patients receiving directed therapy 10% vs. 31% (p = .1307). All patients had Karnofsky performance status N80; number of CNS lesions, histologic type and presence of extra-cranial disease were not associated with recurrence. Of the 6 patients that recurred, 4 had re-treatment with WBRT and achieved CNS tumor control; 2 patients elected for hospice. All patients that received locally directed therapy were salvaged. Conclusion: Treatment of CNS metastases varies widely, with local treatment strategies failing more frequently. Despite recurrences in nearly one-fifth of patients, salvage therapy is successful with multiple treatment strategies effectively achieving palliation. doi:10.1016/j.ygyno.2014.07.043
Even high risk women lack knowledge of obesity's impact on risk for endometrial cancer A. Beavisa,b, S. Cheemac, C. Holschneiderb, E. Duffya, M. Amneusb. a David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, bOlive ViewUCLA Medical Center, Sylmar, CA, USA, cUCLA School of Public Health, USA.
396
Abstracts
Objectives: Obesity is a major modifiable risk factor for endometrial cancer and also negatively impacts survivorship after the treatment of this largely curable disease. This study evaluated women's knowledge of the health risks associated with obesity, as well as patient recollections of physician communication about weight status. Methods: A survey of patient awareness of obesity's associated health risks was given to women presenting to a gynecology clinic at a public safety net hospital. Standard statistical methods of t-test, Chi-square test, and logistic regression were employed. Results: A total of 163 subjects were surveyed: 120 controls (group 1) and 43 women with endometrial cancer or hyperplasia (group 2). Overall, 78% of subjects were overweight or obese, 67% was Hispanic, and 51% had an annual income b$12,000. Group 2 was significantly older, had higher BMI, and had a smaller proportion of patients of Hispanic ethnicity. For all subjects, 67% was able to identify obesity as a risk factor for heart disease and hypertension, but significantly fewer (p b 0.01) correctly identified its impact on endometrial cancer (37%), colon cancer (32%), breast cancer (34%), and infertility risk (35%). Only 54% of women with endometrial cancer or hyperplasia correctly identified obesity as a risk factor for endometrial cancer. However, they demonstrated significantly better knowledge of this and other risks including breast cancer, heart disease, and infertility than group 1 (p b 0.05; see figure). 75% of overweight and obese women reported being told to lose weight by their physician, but only 55% reported being told they were “overweight” or “obese.” This was not different between groups 1 and 2. Age, low education (≤5th grade), language, Hispanic ethnicity, and BMI were not significant predictors of knowledge of obesity's impact on risk of endometrial cancer. Conclusion: While women with endometrial cancer or hyperplasia are more frequently aware of obesity's influence on risk for gynecologic health problems, there are still clear gaps in their knowledge. Physicians may be reluctant to speak frankly to obese patients about their weight. Improving obese endometrial cancer patient's awareness of their own obesity and the associated health risks may be a critical step in the development of successful survivorship programs for endometrial cancer patients.
Methods: A retrospective chart review of women who underwent surgery for adnexal masses at an inner-city public hospital in Chicago, IL was performed between July 2006 and July 2011. Institutional Review Board approval was obtained. Chi-square tests were used for statistical analysis. P-value b 0.05 was considered significant. Results: Overall, 621 patients underwent surgery for adnexal masses during the study period and 540 met inclusion criteria. Mean age was 44.7 +/−13.3 years (mean +/−SD). The majority of patients were Hispanic (203/540, 37.6%) or African-American (160/540, 29.6%). Twothirds (359/540, 66.5%) of patients were premenopausal. The most common presenting symptom was abdominal pain (425/540, 78.7%). Over two-thirds (376/540, 69.6%) of masses were unilateral and the majority (464/540, 85.9%) of masses were complex on imaging. The average size of adnexal mass on preoperative imaging was 10.8 cm +/− 6.2 cm (mean +/− SD) with a range of 1.1 cm to 40 cm. Surgical management included both laparoscopic and abdominal approaches. Approximately two-thirds (369/540, 68.3%) of adnexal masses were benign, with the most common tissue diagnosis being mature teratoma. Malignancy was diagnosed in nearly one-third of patients (171/540, 31.7%) with nearly one-half of cases (83/171, 48.5%) occurring in premenopausal women. Preoperative characteristics such as tumor size (P b 0.0001), tumor morphology (P b 0.0001), ascites (P b 0.0001), and CA125 levels (P b 0.0001) were independently associated with malignancy. The presence of omental caking or lymphadenopathy on preoperative imaging was not significantly associated with malignancy at time of surgery. Conclusion: Nearly one-third of women presenting with adnexal masses to an urban public hospital have malignant disease. Malignant adnexal masses were identified more frequently in premenopausal women compared to national cancer statistics. Further studies should focus on preoperative evaluation in this population and its role in influencing referral patterns in women presenting with adnexal masses in resource poor settings. doi:10.1016/j.ygyno.2014.07.045
Effect of intraperitoneal bupivacaine on post-operative pain in the gynecologic oncology patient C. Rivard, R. Isaksson Vogel, D. Teoh.
doi:10.1016/j.ygyno.2014.07.044
Prevalence and characteristics of adnexal masses at an inner-city public hospital A. Strohla,b, A. Battarbeea,b, A. Patela, A. Rolstona, R. Malapatia. aJohn H. Stroger Hospital, Chicago, IL, USA, bNorthwestern Memorial Hospital, Chicago, IL, USA. Objectives: To describe the prevalence and characteristics of adnexal masses found in women presenting to an urban county hospital.
Objectives: Administration of intraperitoneal local anesthetics decreases post-operative pain in patients undergoing laparoscopic general surgery procedures. However, the gynecology literature shows mixed results and there are no studies evaluating the effect of intraperitoneal local anesthetics in laparoscopic gynecologic oncology procedures. The goal of this study was to evaluate if the administration of intraperitoneal bupivacaine decreased post-operative pain in patients undergoing laparoscopic gynecologic oncology surgery. Methods: This was a retrospective review of all women undergoing a laparoscopic procedure with a single gynecologic oncology surgeon from 9/2011 to 6/2013. From 9/2011 to 8/13/12, 0.25% bupivacaine was injected preperitoneally at all port sites. After 8/13/2012 this surgeon added the intraperitoneal administration of 0.25% bupivacaine at the end of every laparoscopic procedure. Amount of narcotic pain medication used (morphine equivalents) and pain scores was compared between those patients who received intraperitoneal bupivacaine and those who did not. Results: There were no baseline differences between the two groups. The rate of intra-operative complications did not differ by the use of bupivacaine (3.8% vs. 2.6%, p = 1.0). Those patients who received bupivacaine intraperitoneally had lower median narcotic use on the day of surgery and the first post-operative day compared to those who did not receive bupivacaine (day 0: 7.0 mg morphine equivalents vs. 11.0 mg, p = 0.007; day 1: 0.3 mg vs. 1.7 mg, p = 0.0002). The median patient reported pain score on the day of surgery was
experienced disease recurrence. Median time to recurrence was 17 months (range, 7–30). Median number of chemotherapy lines was 1 (range, 0–6). Median length of follow-up was 25 months (range, 0–88). At the time of last follow-up, 82% was without evidence of disease, 2.6% was alive with disease, and 15.4% was dead of disease. Conclusion: Due to the rare occurrence of lymph node metastasis, lymphadenectomy has limited diagnostic and prognostic value with mucinous adenocarcinoma of the ovary and may introduce unnecessary morbidity, particularly in patients who require re-operation. Survival periods are unusually long with rare disease recurrence. doi:10.1016/j.ygyno.2014.07.040
Predictors of survival following recurrence of cervical cancer A. Walter, J. Lauer, C. Gunderson, K. Slaughter, L. Perry, S. McMeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: Recurrent cervical cancer portends a poor prognosis. The purpose of this investigation is to identify the predictors of survival following the recurrence of cervical cancer. Methods: A retrospective chart review was performed in patients (pts) treated for cervical cancer (CXCA) from 1999 to 2011. Descriptive, clinico-pathologic, and survival data were collected. SAS 9.3 was used for statistical analyses. Results: During the 12 years of this study, 504 newly diagnosed CXCA pts were identified. 142 of the 504 patients were diagnosed with recurrence, and 128 had complete data for analysis. Univariate analysis was performed to identify potential predictors of survival; time from initial diagnosis to recurrence (dichotomized into those recurring less than 12 months of initial diagnosis and those greater than 12 months), race, smoking status, stage, BMI and histology. Significant predictors in univariate analysis were; time to recurrence HR = 1.75 (p = .0046), stage HR 1.13 (p = .0033), and squamous histology HR = 1.59 (p = .03). These were then evaluated in a multivariate model, only time to recurrence less than 12 months HR = 1.59 (p = .02) and stage HR 1.11 (p = .01) were predictors of death following recurrence. Conclusion: In multivariate analysis stage and time to recurrence of less than 12 months from initial diagnosis are independent predictors of death following recurrence of cervical carcinoma. Overall, survival remains poor in patients with recurrent cervical carcinoma; patients with long interval from diagnosis to recurrence and early stage may be more likely to benefit from aggressive therapy following recurrence. doi:10.1016/j.ygyno.2014.07.041
IB2 cervical carcinoma: Outcomes by primary therapy A. Walter, C. Gunderson, K. Slaughter, L. Perry, S. McMeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: Most IB2 cervical carcinomas are treated with primary platinum-based chemotherapy with concurrent radiation (CRT); however, radical hysterectomy (RH) remains an option for some. The purpose of this investigation is to compare baseline demographic and treatment outcomes. Methods: A retrospective chart review was performed in patients (pts) treated for cervical cancer (CXCA) from 1999 to 2011. Descriptive, clinico-pathologic, and survival data were collected. SAS 9.3 was used for statistical analyses. Results: During the 12 years of this study, 504 newly diagnosed CXCA pts were identified. 71 of the 504 patients were identified with IB2 disease; detailed treatment information was available for 65; they are the focus of this study. 30 patients were prescribed CRT as
395
primary therapy, and RH was performed for 35 patients. There was no difference between the two groups in terms of BMI, smoking status, race, insurance status, and histology. The CRT group was significantly older (median age: 49 vs. 43 years, p = .02) and had higher grade histology (p = .04). There were no significant differences in post-treatment complications including rates of venous thromboembolism, transfusions, ER visits, or hospital readmission within 60 days of treatment. Overall survival (3.46 vs. 7.94 years p = .37) and progression free survival were not different between CRT and RH at 3.03 years vs 4.89 years respectively (p = .47), and recurrence rates were similar (40% CRT vs 37% RH). Of the 35 patients in the RH group, 27 (74%) were treated with adjuvant therapy for high or intermediate risk factors. Conclusion: Patients with IB2 cervical carcinoma treated with radical surgery or primary CRT had similar outcomes in PFS, OS, and recurrence rates. The rate of adjuvant therapy is high in the RH group; however, this did not translate to increased short term morbidity. Knowledge of differences in long-term toxicity would be crucial to selecting therapies for these patients in an evidence-based manner. doi:10.1016/j.ygyno.2014.07.042
Are current treatments effective, in gynecologic cancer patients with central nervous system metastasis? A. Walter, C. Guderson, K. Slaughter, L. Perry, S. Mcmeekin, K. Moore. University of Oklahoma Stephenson Cancer Center, USA. Objectives: CNS metastasis with gynecologic malignancy is a rare event associated with poor prognosis; fewer than 30% survive N12 months. Palliative treatment is often used, with cerebral tumor control and prevention of CNS recurrence the primary outcome. We evaluated various treatment strategies in the gynecologic cancer population. Methods: An IRB-approved retrospective chart review was performed identifying all patients diagnosed with a primary gynecologic malignancy treated for CNS metastasis from 2005 to 2014 at a single academic center. SAS 9.3 was used for statistical analyses. Results: Thirty-five patients were identified. Median age was 61 years (range, 41–79). The majority had ovarian cancer (54%), 37% endometrial cancer, and 9% squamous cell cervical cancer. 57% of patients were treated with whole brain radiation therapy (WBRT), 14% stereotactic radiosurgery alone (SRS), 14% combined surgery and SRS, 6% combined SRS + WBRT, and 2 patients hospice. 17% had a CNS recurrence; 60% of patients initially treated with surgery + SRS recurred, 10% initially treated with WBRT recurred, and 20% treated with SRS only recurred. There was non-significant trend in recurrence risk in patients receiving directed therapy 10% vs. 31% (p = .1307). All patients had Karnofsky performance status N80; number of CNS lesions, histologic type and presence of extra-cranial disease were not associated with recurrence. Of the 6 patients that recurred, 4 had re-treatment with WBRT and achieved CNS tumor control; 2 patients elected for hospice. All patients that received locally directed therapy were salvaged. Conclusion: Treatment of CNS metastases varies widely, with local treatment strategies failing more frequently. Despite recurrences in nearly one-fifth of patients, salvage therapy is successful with multiple treatment strategies effectively achieving palliation. doi:10.1016/j.ygyno.2014.07.043
Even high risk women lack knowledge of obesity's impact on risk for endometrial cancer A. Beavisa,b, S. Cheemac, C. Holschneiderb, E. Duffya, M. Amneusb. a David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, bOlive ViewUCLA Medical Center, Sylmar, CA, USA, cUCLA School of Public Health, USA.
396
Abstracts
Objectives: Obesity is a major modifiable risk factor for endometrial cancer and also negatively impacts survivorship after the treatment of this largely curable disease. This study evaluated women's knowledge of the health risks associated with obesity, as well as patient recollections of physician communication about weight status. Methods: A survey of patient awareness of obesity's associated health risks was given to women presenting to a gynecology clinic at a public safety net hospital. Standard statistical methods of t-test, Chi-square test, and logistic regression were employed. Results: A total of 163 subjects were surveyed: 120 controls (group 1) and 43 women with endometrial cancer or hyperplasia (group 2). Overall, 78% of subjects were overweight or obese, 67% was Hispanic, and 51% had an annual income b$12,000. Group 2 was significantly older, had higher BMI, and had a smaller proportion of patients of Hispanic ethnicity. For all subjects, 67% was able to identify obesity as a risk factor for heart disease and hypertension, but significantly fewer (p b 0.01) correctly identified its impact on endometrial cancer (37%), colon cancer (32%), breast cancer (34%), and infertility risk (35%). Only 54% of women with endometrial cancer or hyperplasia correctly identified obesity as a risk factor for endometrial cancer. However, they demonstrated significantly better knowledge of this and other risks including breast cancer, heart disease, and infertility than group 1 (p b 0.05; see figure). 75% of overweight and obese women reported being told to lose weight by their physician, but only 55% reported being told they were “overweight” or “obese.” This was not different between groups 1 and 2. Age, low education (≤5th grade), language, Hispanic ethnicity, and BMI were not significant predictors of knowledge of obesity's impact on risk of endometrial cancer. Conclusion: While women with endometrial cancer or hyperplasia are more frequently aware of obesity's influence on risk for gynecologic health problems, there are still clear gaps in their knowledge. Physicians may be reluctant to speak frankly to obese patients about their weight. Improving obese endometrial cancer patient's awareness of their own obesity and the associated health risks may be a critical step in the development of successful survivorship programs for endometrial cancer patients.
Methods: A retrospective chart review of women who underwent surgery for adnexal masses at an inner-city public hospital in Chicago, IL was performed between July 2006 and July 2011. Institutional Review Board approval was obtained. Chi-square tests were used for statistical analysis. P-value b 0.05 was considered significant. Results: Overall, 621 patients underwent surgery for adnexal masses during the study period and 540 met inclusion criteria. Mean age was 44.7 +/−13.3 years (mean +/−SD). The majority of patients were Hispanic (203/540, 37.6%) or African-American (160/540, 29.6%). Twothirds (359/540, 66.5%) of patients were premenopausal. The most common presenting symptom was abdominal pain (425/540, 78.7%). Over two-thirds (376/540, 69.6%) of masses were unilateral and the majority (464/540, 85.9%) of masses were complex on imaging. The average size of adnexal mass on preoperative imaging was 10.8 cm +/− 6.2 cm (mean +/− SD) with a range of 1.1 cm to 40 cm. Surgical management included both laparoscopic and abdominal approaches. Approximately two-thirds (369/540, 68.3%) of adnexal masses were benign, with the most common tissue diagnosis being mature teratoma. Malignancy was diagnosed in nearly one-third of patients (171/540, 31.7%) with nearly one-half of cases (83/171, 48.5%) occurring in premenopausal women. Preoperative characteristics such as tumor size (P b 0.0001), tumor morphology (P b 0.0001), ascites (P b 0.0001), and CA125 levels (P b 0.0001) were independently associated with malignancy. The presence of omental caking or lymphadenopathy on preoperative imaging was not significantly associated with malignancy at time of surgery. Conclusion: Nearly one-third of women presenting with adnexal masses to an urban public hospital have malignant disease. Malignant adnexal masses were identified more frequently in premenopausal women compared to national cancer statistics. Further studies should focus on preoperative evaluation in this population and its role in influencing referral patterns in women presenting with adnexal masses in resource poor settings. doi:10.1016/j.ygyno.2014.07.045
Effect of intraperitoneal bupivacaine on post-operative pain in the gynecologic oncology patient C. Rivard, R. Isaksson Vogel, D. Teoh.
doi:10.1016/j.ygyno.2014.07.044
Prevalence and characteristics of adnexal masses at an inner-city public hospital A. Strohla,b, A. Battarbeea,b, A. Patela, A. Rolstona, R. Malapatia. aJohn H. Stroger Hospital, Chicago, IL, USA, bNorthwestern Memorial Hospital, Chicago, IL, USA. Objectives: To describe the prevalence and characteristics of adnexal masses found in women presenting to an urban county hospital.
Objectives: Administration of intraperitoneal local anesthetics decreases post-operative pain in patients undergoing laparoscopic general surgery procedures. However, the gynecology literature shows mixed results and there are no studies evaluating the effect of intraperitoneal local anesthetics in laparoscopic gynecologic oncology procedures. The goal of this study was to evaluate if the administration of intraperitoneal bupivacaine decreased post-operative pain in patients undergoing laparoscopic gynecologic oncology surgery. Methods: This was a retrospective review of all women undergoing a laparoscopic procedure with a single gynecologic oncology surgeon from 9/2011 to 6/2013. From 9/2011 to 8/13/12, 0.25% bupivacaine was injected preperitoneally at all port sites. After 8/13/2012 this surgeon added the intraperitoneal administration of 0.25% bupivacaine at the end of every laparoscopic procedure. Amount of narcotic pain medication used (morphine equivalents) and pain scores was compared between those patients who received intraperitoneal bupivacaine and those who did not. Results: There were no baseline differences between the two groups. The rate of intra-operative complications did not differ by the use of bupivacaine (3.8% vs. 2.6%, p = 1.0). Those patients who received bupivacaine intraperitoneally had lower median narcotic use on the day of surgery and the first post-operative day compared to those who did not receive bupivacaine (day 0: 7.0 mg morphine equivalents vs. 11.0 mg, p = 0.007; day 1: 0.3 mg vs. 1.7 mg, p = 0.0002). The median patient reported pain score on the day of surgery was