Risks and Benefits of Surgical Preventive Strategies for Ovarian Cancer

Ovarian cancer is the deadliest gynecologic cancer and the fifth leading cause of cancer deaths among U.S. women. Due to the lack of effective screening tests, preventive surgeries are a critical component of reducing the burden of ovarian cancer. Surgeries to prevent ovarian cancer are structured around the removal of the ovaries (bilateral oophorectomy) and fallopian tubes (bilateral salpingectomy). However, the long-term risks and benefits of preventive surgeries for ovarian cancer remain poorly understood. The objectives of this dissertation were (1) to examine the uptake of opportunistic salpingectomy (OS) and factors associated with an increased likelihood of OS, (2) to evaluate the prevalence and predictors of occult cancer at the time of OS and bilateral salpingo-oophorectomy (BSO), and (3) to examine the association between BSO and distribution of fat and lean body mass. For the first study, we utilized inpatient and outpatient claims from 48 million privately insured women between 2010 and 2017. We found that OS for ovarian cancer prevention has rapidly diffused into clinical practice with the speed of adoption bolstered by the release of recommendations from national societies. In 2010, OS accounted for <1% of all sterilization encounters and benign hysterectomies compared to 20% of all sterilization encounters and benign hysterectomies in 2017. The largest increase in OS for sterilization rates occurred in women <45 years, while the largest increase in hysterectomy and OS rates occurred in women 45-55 years. OS rates increased in all U.S. geographic regions, in both rural and urban areas, across all types of health plans, and in women with and without a family history of breast or ovarian cancer. For the second study, we utilized inpatient and outpatient claims from 538,471 privately insured women undergoing benign gynecologic surgery between 2010 and 2017. The age-adjusted prevalence of occult cancer was 0.053% (95% CI: 0.047-0.059) overall and 0.042% (95% CI: 0.014-0.048) after excluding women with a family history of and genetic susceptibility to breast or ovarian cancer. The prevalence was similar in women undergoing OS for sterilization and hysterectomy and BSO. Independent predictors of an occult cancer diagnosis at surgery included age, family history of and genetic susceptibility to breast or ovarian cancer, surgical indication, and pre-surgical comorbidities. No women with an occult cancer diagnosis developed peritoneal cancer after BSO. In women without an occult cancer diagnosis, 12 developed peritoneal cancer after BSO (age-adjusted incidence: 4.57 per 100,000 women). For the last study, we used data from a population-based cross-sectional survey of 3,764 women with information on total and regional fat and lean body mass assessed using dual-energy x-ray absorptiometry (DXA) scans. We found that women with a history of BSO were more likely to have increased fat mass and decreased lean mass, particularly in the trunk and arms, compared to women without a history of BSO. The association between BSO and body composition was stronger in women who reported BSO <45 years and women with a normal body mass index at DXA scan. Overall, the results of this dissertation provide some of the first evidence showing a significant nationwide increase in the performance of OS for ovarian cancer prevention. Given the low prevalence of occult ovarian cancer in average-risk women and uncertainties regarding the efficacy of OS, whether OS for ovarian cancer prevention should be offered to all average-risk women warrants further investigation. In addition, our findings identify a subset of women who may benefit from additional monitoring after BSO. Collectively the results enhance our understanding of the risks and benefits of new and established preventive surgeries for ovarian cancer

Risks and Benefits of Surgical Preventive Strategies for Ovarian Cancer

Ovarian cancer is the deadliest gynecologic cancer and the fifth leading cause of cancer deaths among U.S. women. Due to the lack of effective screening tests, preventive surgeries are a critical component of reducing the burden of ovarian cancer. Surgeries to prevent ovarian cancer are structured around the removal of the ovaries (bilateral oophorectomy) and fallopian tubes (bilateral salpingectomy). However, the long-term risks and benefits of preventive surgeries for ovarian cancer remain poorly understood. The objectives of this dissertation were (1) to examine the uptake of opportunistic salpingectomy (OS) and factors associated with an increased likelihood of OS, (2) to evaluate the prevalence and predictors of occult cancer at the time of OS and bilateral salpingo-oophorectomy (BSO), and (3) to examine the association between BSO and distribution of fat and lean body mass. For the first study, we utilized inpatient and outpatient claims from 48 million privately insured women between 2010 and 2017. We found that OS for ovarian cancer prevention has rapidly diffused into clinical practice with the speed of adoption bolstered by the release of recommendations from national societies. In 2010, OS accounted for <1% of all sterilization encounters and benign hysterectomies compared to 20% of all sterilization encounters and benign hysterectomies in 2017. The largest increase in OS for sterilization rates occurred in women <45 years, while the largest increase in hysterectomy and OS rates occurred in women 45-55 years. OS rates increased in all U.S. geographic regions, in both rural and urban areas, across all types of health plans, and in women with and without a family history of breast or ovarian cancer. For the second study, we utilized inpatient and outpatient claims from 538,471 privately insured women undergoing benign gynecologic surgery between 2010 and 2017. The age-adjusted prevalence of occult cancer was 0.053% (95% CI: 0.047-0.059) overall and 0.042% (95% CI: 0.014-0.048) after excluding women with a family history of and genetic susceptibility to breast or ovarian cancer. The prevalence was similar in women undergoing OS for sterilization and hysterectomy and BSO. Independent predictors of an occult cancer diagnosis at surgery included age, family history of and genetic susceptibility to breast or ovarian cancer, surgical indication, and pre-surgical comorbidities. No women with an occult cancer diagnosis developed peritoneal cancer after BSO. In women without an occult cancer diagnosis, 12 developed peritoneal cancer after BSO (age-adjusted incidence: 4.57 per 100,000 women). For the last study, we used data from a population-based cross-sectional survey of 3,764 women with information on total and regional fat and lean body mass assessed using dual-energy x-ray absorptiometry (DXA) scans. We found that women with a history of BSO were more likely to have increased fat mass and decreased lean mass, particularly in the trunk and arms, compared to women without a history of BSO. The association between BSO and body composition was stronger in women who reported BSO <45 years and women with a normal body mass index at DXA scan. Overall, the results of this dissertation provide some of the first evidence showing a significant nationwide increase in the performance of OS for ovarian cancer prevention. Given the low prevalence of occult ovarian cancer in average-risk women and uncertainties regarding the efficacy of OS, whether OS for ovarian cancer prevention should be offered to all average-risk women warrants further investigation. In addition, our findings identify a subset of women who may benefit from additional monitoring after BSO. Collectively the results enhance our understanding of the risks and benefits of new and established preventive surgeries for ovarian cancer

Detection of Subclinical Disease with Baseline and Surveillance Imaging in High-Risk Cutaneous Squamous Cell Carcinomas

BACKGROUND: There are limited studies on imaging for management of high-risk cutaneous squamous cell carcinoma (HRCSSC). OBJECTIVE: To evaluate the impact of baseline (i.e. at diagnosis) and surveillance (i.e. subsequent time points following diagnosis) imaging on management of HRCSCCs. METHODS: All primary CSSCs treated at Brigham and Women\u27s Hospital (BWH) Mohs Surgery Clinic and Dana-Farber Cancer Institute High-Risk Skin Cancer Clinic from 1/1/2017-6/1/2019 were reviewed to identify tumors that underwent baseline or surveillance imaging. Tumors that underwent imaging were reviewed to determine the impact of imaging on management and ability of imaging to identify subclinical disease. RESULTS: Eighty-three patients underwent imaging for 87 primary HRCSCCs, of which 48 (58%) underwent surveillance imaging. 146 (59%) abnormal results were obtained from 248 imaging studies. Management was altered by 42 (24%) studies. Imaging detected subclinical disease in 21% of cases studied. A majority (56%) of detections were not seen initially but rather during surveillance imaging in the 2 years post treatment. LIMITATIONS: Single institution retrospective design. CONCLUSIONS: Imaging identifies subclinical disease in HRSCC. Prospective studies are needed to determine best practices for screening and surveillance in HRCSCC

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

IMPORTANCE Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. OBJECTIVE To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. MAIN OUTCOMES AND MEASURES Incident skin cancerwas determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). RESULTS Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). CONCLUSIONS AND RELEVANCE Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.American Academy of Dermatology and Galderma12 month embargo; Published Online: January 11, 2017.This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]