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What is the most cost-effective strategy in approaching the treatment of newly diagnosed endometrial cancer
Abstracts / Gynecologic Oncology 131 (2013) 248–276
Is leukocytosis a harbinger of poor prognosis in ovarian cancer akin to thrombocytosis? C.C. Gundersona, K.N. Slaughtera, E.D. Thomasa, R. Farrella, K. Dingb, J.K. Lauera, L.J. Perrya, D.S. McMeekina, K.N. Moorea. aUniversity of Oklahoma Health Sciences Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Oklahoma City, OK, USA, bThe University of Oklahoma Health Sciences Center, College of Public Health, Department of Biostatistics and Epidemiology, Oklahoma City, OK, USA. Objectives: Thrombocytosis (TBC) is often a marker of occult malignancy and is a poor prognostic factor in ovarian cancer. Shorter time to progression, decreased overall survival, and advanced stage disease have been noted with TBC. Preoperative leukocytosis (LC) has been shown to be an independent poor prognostic factor in carcinoma of the cervix and endometrium; however, the prognosis of LC with ovary cancer is less clear. Methods: A retrospective chart review was performed of patients (pts) treated for Stage I–IV high grade serous ovarian carcinoma at a single center from 1/2010 to 12/2012. Demographic, clinicopathologic, and treatment characteristics were recorded. Progression free survival (PFS) and overall survival (OS) were calculated for each pt. SAS 9.2 was used for all statistical analyses. Results: 348 pts met study criteria. Median age was 64 years (range, 17–94), and 90% were Caucasian. 91.4% had performance status of 0 at diagnosis. 21.4% had TBC (platelet count N 450,000) preoperatively (pre-op), and median platelet count was 333,000 (range, 112,000– 897,000). 10.6% of pts had pre-op LC (white blood cell count N 11,000), and median pre-op WBC was 8000 (range, 3500–44,310). 80% had an optimal debulking surgery, and 12.6% received neoadjuvant or primary chemotherapy. Median number of chemotherapy lines was 2 (range, 0–11). Median PFS was 26.2 months (range, 0.9–85.8), and median OS was 56.5 months (range, 0.3–173.2). TBC was not associated with a decrease in PFS (p = 0.07) or OS (p = 0.44), but TBC was associated with advanced stage disease (p = 0.003) and shorter time to recurrence (p = 0.0004) after controlling for stage. Pts with TBC who received Bevacizumab did not have shorter PFS (p = 0.95) or OS (p = 0.36). Pts with TBC had a median PFS of 17 months, median OS of 38.4 months, and median time to recurrence of 15 months. LC was also not associated with shorter PFS (p = 0.24, median: 30), shorter OS (p = 0.71, median: 47.7), shorter interval to recurrence (p = 0.15, median: 18.2), or advanced stage disease (p = 0.84). This remained true even when WBC threshold was increased to 15,000. Conclusions: Our results validate TBC as a poor prognostic marker with carcinoma of the ovary; however, pre-operative LC does not appear predictive of outcomes with high grade serous ovarian cancer.
doi:10.1016/j.ygyno.2013.07.042
Clinical utility and cost assessment of proteinuria monitoring for patients receiving bevacizumab in a gynecology oncology clinic C. Lee, L. Alwan, X. Sun, K. McLean, R. Urban. University of Washington Medicine/Seattle Cancer Care Alliance, Seattle, WA, USA. Objectives: To determine the prevalence and severity of proteinuria in women with gynecologic cancers receiving bevacizumab and identify patient and disease‐specific factors that may increase the risk of proteinuria; and to assess potential institutional cost-savings for monitoring proteinuria. Methods: A retrospective chart review was performed at a tertiary, academic gynecologic oncology clinic. Charts of female patients over 18 years of age receiving bevacizumab for ovarian, cervical, or endometrial cancer were evaluated for the development of proteinuria. Proteinuria was assessed using the NCI grading system, version 4.03. Patient and disease-specific risk factors, including age, bevacizumab
263
dose (incremental and total), serum creatinine, concurrent nephrotoxic drugs, and other baseline comorbidities were evaluated using logistic regression to determine correlations of risk factors with proteinuria. Cost assessment was performed using institutional cost data for urine dipstick and urine protein-to-creatinine (UPC) ratio tests. Results: Eighty-nine patients (56 with ovarian, 17 with endometrial, and 15 with cervical cancer) were included (1 unknown diagnosis). The prevalence of proteinuria of all grades was 35%. The mean number of bevacizumab cycles was 13 (2 to 64 cycles). The majority of patients experienced grade 1 proteinuria (70%, 62 patients). Grade 3 proteinuria was only observed in 2 patients (2%); one patient had chronic kidney disease and both had uncontrolled hypertension. There was no association between cumulative bevacizumab dose, baseline hypertension, concurrent drugs, or serum creatinine with the development of proteinuria. An estimated 35 patients treated for one year with bevacizumab incurred an annual UPC ratio monitoring cost of $59,202. The estimated cost of monitoring with urine dipstick tests, in place of UPC ratios, was $27,642, a difference of $31,560 per year. Conclusions: The prevalence of clinically significant proteinuria was low in patients receiving bevacizumab for gynecologic cancers. Measuring frequent UPC ratios may be unnecessary due to the low rate of grade 3 proteinuria observed in this study. Potential cost savings may be realized with less frequent monitoring of UPC ratios and monitoring patients at low risk for this toxicity with urine dipstick tests. Less frequent monitoring may allow patients deriving clinical benefit to continue on bevacizumab in the absence of clinically significant proteinuria. doi:10.1016/j.ygyno.2013.07.043
What is the most cost-effective strategy in approaching the treatment of newly diagnosed endometrial cancer C. Kushnira, K. Kenslerb, K. Frickb, R. GiuntoliIIa. aThe Kelly Gynecologic Oncology Service, Baltimore, MD, USA, bThe Bloomberg School of Public Health, Baltimore, MD, USA. Objectives: To determine the cost-effectiveness of three strategies in women undergoing minimally invasive surgery for newly diagnosed endometrial cancer. Methods: A decision analysis model compared three surgical strategies:1) routine comprehensive lymphadenectomy (LND) independent of intraoperative risk factors and pre-operative endmetrial biopsy; 2) selective lymphadenectomy based on frozen section including tumor rade, depth of invasion, and tumor size; and 3) preoperative endometrial biopsy based on grade of tumor and intraoperative size. We restricted our analysis to endometriod adenocarcinoma. Published data were used to estimate stage distribution, incidence of lymphedema, cost of lymphedema. Cost to third party payers for cost of surgery and radiation were determined from patient records. We determined our acuracy of frozen section analysis by reviewing our data from 1998 to 2008. Using routine LND as the control arm, incremental costs were determined. Results: 624 patients were evaluated to determine the frozen section accuracy. We concluded that 4% of patients would have a clinically significant difference in final pathology and would require radiation or re-operation. We determined the expected cost per patient for routine LND to be $27.950.00, for Frozen section $25,495.00, and for pre-op grade/intra-op size $28,024.00. As compared to routine LND, the incremental cost of frozen section was $2454.00 and for pre-op grade/intraoperative size was $74.00 Conclusions: A strategy of selective lymphadenectomy based on frozen section for patients with endometrial cancer is the most cost effective strategy in institutions with accurate intraoperative pathologic evaluation. doi:10.1016/j.ygyno.2013.07.044
Is leukocytosis a harbinger of poor prognosis in ovarian cancer akin to thrombocytosis? C.C. Gundersona, K.N. Slaughtera, E.D. Thomasa, R. Farrella, K. Dingb, J.K. Lauera, L.J. Perrya, D.S. McMeekina, K.N. Moorea. aUniversity of Oklahoma Health Sciences Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Oklahoma City, OK, USA, bThe University of Oklahoma Health Sciences Center, College of Public Health, Department of Biostatistics and Epidemiology, Oklahoma City, OK, USA. Objectives: Thrombocytosis (TBC) is often a marker of occult malignancy and is a poor prognostic factor in ovarian cancer. Shorter time to progression, decreased overall survival, and advanced stage disease have been noted with TBC. Preoperative leukocytosis (LC) has been shown to be an independent poor prognostic factor in carcinoma of the cervix and endometrium; however, the prognosis of LC with ovary cancer is less clear. Methods: A retrospective chart review was performed of patients (pts) treated for Stage I–IV high grade serous ovarian carcinoma at a single center from 1/2010 to 12/2012. Demographic, clinicopathologic, and treatment characteristics were recorded. Progression free survival (PFS) and overall survival (OS) were calculated for each pt. SAS 9.2 was used for all statistical analyses. Results: 348 pts met study criteria. Median age was 64 years (range, 17–94), and 90% were Caucasian. 91.4% had performance status of 0 at diagnosis. 21.4% had TBC (platelet count N 450,000) preoperatively (pre-op), and median platelet count was 333,000 (range, 112,000– 897,000). 10.6% of pts had pre-op LC (white blood cell count N 11,000), and median pre-op WBC was 8000 (range, 3500–44,310). 80% had an optimal debulking surgery, and 12.6% received neoadjuvant or primary chemotherapy. Median number of chemotherapy lines was 2 (range, 0–11). Median PFS was 26.2 months (range, 0.9–85.8), and median OS was 56.5 months (range, 0.3–173.2). TBC was not associated with a decrease in PFS (p = 0.07) or OS (p = 0.44), but TBC was associated with advanced stage disease (p = 0.003) and shorter time to recurrence (p = 0.0004) after controlling for stage. Pts with TBC who received Bevacizumab did not have shorter PFS (p = 0.95) or OS (p = 0.36). Pts with TBC had a median PFS of 17 months, median OS of 38.4 months, and median time to recurrence of 15 months. LC was also not associated with shorter PFS (p = 0.24, median: 30), shorter OS (p = 0.71, median: 47.7), shorter interval to recurrence (p = 0.15, median: 18.2), or advanced stage disease (p = 0.84). This remained true even when WBC threshold was increased to 15,000. Conclusions: Our results validate TBC as a poor prognostic marker with carcinoma of the ovary; however, pre-operative LC does not appear predictive of outcomes with high grade serous ovarian cancer.
doi:10.1016/j.ygyno.2013.07.042
Clinical utility and cost assessment of proteinuria monitoring for patients receiving bevacizumab in a gynecology oncology clinic C. Lee, L. Alwan, X. Sun, K. McLean, R. Urban. University of Washington Medicine/Seattle Cancer Care Alliance, Seattle, WA, USA. Objectives: To determine the prevalence and severity of proteinuria in women with gynecologic cancers receiving bevacizumab and identify patient and disease‐specific factors that may increase the risk of proteinuria; and to assess potential institutional cost-savings for monitoring proteinuria. Methods: A retrospective chart review was performed at a tertiary, academic gynecologic oncology clinic. Charts of female patients over 18 years of age receiving bevacizumab for ovarian, cervical, or endometrial cancer were evaluated for the development of proteinuria. Proteinuria was assessed using the NCI grading system, version 4.03. Patient and disease-specific risk factors, including age, bevacizumab
263
dose (incremental and total), serum creatinine, concurrent nephrotoxic drugs, and other baseline comorbidities were evaluated using logistic regression to determine correlations of risk factors with proteinuria. Cost assessment was performed using institutional cost data for urine dipstick and urine protein-to-creatinine (UPC) ratio tests. Results: Eighty-nine patients (56 with ovarian, 17 with endometrial, and 15 with cervical cancer) were included (1 unknown diagnosis). The prevalence of proteinuria of all grades was 35%. The mean number of bevacizumab cycles was 13 (2 to 64 cycles). The majority of patients experienced grade 1 proteinuria (70%, 62 patients). Grade 3 proteinuria was only observed in 2 patients (2%); one patient had chronic kidney disease and both had uncontrolled hypertension. There was no association between cumulative bevacizumab dose, baseline hypertension, concurrent drugs, or serum creatinine with the development of proteinuria. An estimated 35 patients treated for one year with bevacizumab incurred an annual UPC ratio monitoring cost of $59,202. The estimated cost of monitoring with urine dipstick tests, in place of UPC ratios, was $27,642, a difference of $31,560 per year. Conclusions: The prevalence of clinically significant proteinuria was low in patients receiving bevacizumab for gynecologic cancers. Measuring frequent UPC ratios may be unnecessary due to the low rate of grade 3 proteinuria observed in this study. Potential cost savings may be realized with less frequent monitoring of UPC ratios and monitoring patients at low risk for this toxicity with urine dipstick tests. Less frequent monitoring may allow patients deriving clinical benefit to continue on bevacizumab in the absence of clinically significant proteinuria. doi:10.1016/j.ygyno.2013.07.043
What is the most cost-effective strategy in approaching the treatment of newly diagnosed endometrial cancer C. Kushnira, K. Kenslerb, K. Frickb, R. GiuntoliIIa. aThe Kelly Gynecologic Oncology Service, Baltimore, MD, USA, bThe Bloomberg School of Public Health, Baltimore, MD, USA. Objectives: To determine the cost-effectiveness of three strategies in women undergoing minimally invasive surgery for newly diagnosed endometrial cancer. Methods: A decision analysis model compared three surgical strategies:1) routine comprehensive lymphadenectomy (LND) independent of intraoperative risk factors and pre-operative endmetrial biopsy; 2) selective lymphadenectomy based on frozen section including tumor rade, depth of invasion, and tumor size; and 3) preoperative endometrial biopsy based on grade of tumor and intraoperative size. We restricted our analysis to endometriod adenocarcinoma. Published data were used to estimate stage distribution, incidence of lymphedema, cost of lymphedema. Cost to third party payers for cost of surgery and radiation were determined from patient records. We determined our acuracy of frozen section analysis by reviewing our data from 1998 to 2008. Using routine LND as the control arm, incremental costs were determined. Results: 624 patients were evaluated to determine the frozen section accuracy. We concluded that 4% of patients would have a clinically significant difference in final pathology and would require radiation or re-operation. We determined the expected cost per patient for routine LND to be $27.950.00, for Frozen section $25,495.00, and for pre-op grade/intra-op size $28,024.00. As compared to routine LND, the incremental cost of frozen section was $2454.00 and for pre-op grade/intraoperative size was $74.00 Conclusions: A strategy of selective lymphadenectomy based on frozen section for patients with endometrial cancer is the most cost effective strategy in institutions with accurate intraoperative pathologic evaluation. doi:10.1016/j.ygyno.2013.07.044