Lymph Node Evaluation Underutilized for Early-stage Vulvar Cancer
- This study of the National Cancer Database examined the uptake of National Comprehensive Cancer Network guidelines about inguinofemoral lymph node (LN) evaluation in patients with early-stage vulvar cancer
- The proportion of indicated LN evaluation was 66.1% in the overall cohort of 5,685 patients with early-stage, invasive vulvar squamous cell carcinoma and 49.4% of the 646 patients ages 80 and older
- In adjusted models, older and Black individuals, people with more comorbidities, and patients at low-volume hospitals (0–7 vulvectomies/year) were significantly less likely to undergo LN evaluation
- Omission of LN evaluation in the general cohort and the older subgroup was not associated with improved overall survival and was tied to decreased administration of adjuvant therapy
Clinical trials have demonstrated the safety of sentinel lymph node (LN) biopsy as an alternative to inguinal femoral lymphadenectomy for selected women with vulvar cancer. The National Comprehensive Cancer Network recommends LN evaluation via complete inguinofemoral dissection or sentinel biopsy in patients with early-stage vulvar cancer and clinically negative nodes.
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Implementation of this novel technique has been gradual, however, given certain barriers: surgeon skillset, operative resources and access to lymphoscintigraphy. Researchers at Massachusetts General Hospital recently documented that 34% of eligible patients don't undergo LN evaluation but withholding LN evaluation doesn't protect against mortality.
Alexandra S. Bercow, MD, fellow in gynecologic oncology, Alexander Melamed, MD, MPH, gynecologic oncologist, Varvara Mazina, MD, fellow in gynecologic oncology, Marcela G. del Carmen, MD, MPH, gynecologic oncologist and president of the Massachusetts General Physicians Organization, Annekathryn Goodman, MD, MPH, gynecologic oncologist and co-director of Women's Global Health, Amy Bregar, MD, gynecologic oncologist and associate director of the Gynecologic Oncology Fellowship Program, and Eric L. Eisenhauer, MD, chief of Gynecologic Oncology and director of the Gynecologic Oncology Fellowship Program, all affiliated with the Department of Obstetrics and Gynecology, and colleagues published the details in Obstetrics & Gynecology.
The data source for the study was the National Cancer Database, a joint project of the American Cancer Society and the American College of Surgeons. The team identified 5,685 patients with invasive vulvar squamous cell carcinoma who underwent primary vulvectomy for T1b and T2 primary tumors at 731 hospitals between January 2012 and December 2018.
Rates of Lymph Node Evaluation
3,756 patients (66.1%) underwent indicated LN evaluation; among the 646 patients ages 80 and older, the figure was 49.4%. LN evaluation was defined as sentinel biopsy, complete lymphadenectomy, or both.
In a logistic regression model, lower odds of LN evaluation were significantly associated with the following:
- Age ≥80—OR, 0.30 vs. age <50
- Medicare insurance—OR, 0.78 vs. private insurance
- Black race—OR, 0.72 vs. white race
- Charlson–Deyo comorbidity index score ≥2—OR, 0.78 vs. score of 0
Treatment at intermediate-volume hospitals (8–15 vulvectomies/year) or high-volume hospitals (16–44 vulvectomies/year) was associated with higher odds of LN evaluation (OR of 1.44 and 1.62, respectively) than treatment at low-volume hospitals (0–7 vulvectomies/year).
Compared with patients who did not have LN evaluation, those who did have:
- Longer hospital stays after surgery—2 days vs. 1 day (OR, 5.10)
- Higher 30-day readmission rates—4.3% vs. 2.6% (OR, 1.67)
- Higher rates of adjuvant radiation—17% vs. 12% (OR, 1.79)
- Higher rates of adjuvant chemotherapy—7.1% vs. 5.3% (OR, 1.39)
In an adjusted analysis, individuals who underwent LN evaluation with negative nodes had significantly better overall survival than those who did not undergo the procedure (HR, 0.49). There was no difference in survival between patients with LN evaluation was omitted and those who underwent LN evaluation with positive nodes.
In an analysis restricted to older patients (ages ≥80), LN evaluation was associated with the following:
- No difference in odds of readmission compared with older patients who did not have LN evaluation
- Higher odds of receiving adjuvant radiation—OR, 1.87
- No difference in odds of receiving chemotherapy
Survival results for older patients mirrored those in the general cohort. Patients who underwent LN evaluation with negative nodes had significantly better overall survival than those who did not undergo the procedure. There was no difference in overall survival between patients who did not undergo LN evaluation and those who underwent LN evaluation with positive nodes.
Improving Care for Older Patients
Considering how cancer treatment affects quality of life, physicians may be conservative about LN assessment for older patients with multiple medical comorbidities. However, a disparity in LN evaluation was evident in this study even after adjustment for the comorbidity index.
It's also possible older patients with vulvar cancer are being undertreated in an attempt to improve all-cause mortality. However, survival was no better in older patients who had LN evaluation withheld than those who underwent the procedure and had pathologically positive nodes, even after adjustment for comorbidities and adjuvant therapy.
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