Hospital-level Factors Affect Use of Sentinel Lymph Node Biopsy in Early Vulvar Cancer
Key findings
- This study used the National Cancer Database to investigate the relationship between hospital factors and the use of sentinel lymph node biopsy (SLNB) in 3,532 patients with clinical stage IB vulvar squamous cell carcinoma
- Patients receiving care at low-volume hospitals (0–7 vulvectomies/year) were 56% less likely to undergo SLNB than those treated at high-volume hospitals (16–44 vulvectomies/year)
- Patients treated at minority-serving hospitals (those in the top decile of the proportion of Black/Hispanic patients treated) were 61% less likely to undergo SLNB than those treated at non–minority-serving hospitals
- Regardless of pathologic nodal status, SLNB was not associated with worse survival compared with inguinofemoral lymph node dissection
- To ensure patient access to SLNB, more gynecologic oncologists, radiologists, and supporting clinicians should be trained in the technique and best practices
National Cancer Comprehensive Network guidelines recommend nodal assessment via complete inguinofemoral lymph node dissection (IFLD) or sentinel lymph node biopsy (SLNB) for patients with early-stage vulvar cancer. Several studies have linked SLNB to improved surgical outcomes and decreased morbidity without negative effects on survival.
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However, SLNB requires a substantial initial investment in interdisciplinary resources at the hospital level. Alexandra S. Bercow, MD, fellow in the Center for Gynecologic Oncology at Massachusetts General Hospital, and colleagues report in Gynecologic Oncology that patients treated for early-stage vulvar cancer at minority-serving or low-volume hospitals have substantially decreased odds of undergoing SLNB.
Methods
In September 2021, the researchers used the National Cancer Database to identify 3,532 patients diagnosed with stage IB invasive vulvar squamous cell carcinoma between 2012 and 2018 and underwent primary vulvectomy with LN evaluation. Stage IB is clinically negative nodes with no evidence of metastatic disease and a T1b tumor.
Frequency and Predictors of SLNB
Of the 3,532 patients studied:
- 32% did not undergo guideline-concordant LN evaluation
- 71% underwent IFLD alone
- 29% underwent SLNB with or without IFLD
In multivariable analyses, patients were significantly less likely to undergo SLNB if they:
- Were treated at minority-serving hospitals (those in the top decile of the proportion of Black/Hispanic patients treated)—OR, 0.39; P=0.008 vs. non–minority-serving hospitals
- Were treated at low-volume hospitals (0–7 vulvectomies/year)—OR, 0.44; P=0.001 vs. high-volume hospitals (16-44 vulvectomies/year)
- Had Medicaid insurance—OR, 0.61; P=0.04 vs. private insurance
- Were uninsured—OR, 0.47; P=0.04 vs. private insurance
Survival
In adjusted analyses, SLNB with or without IFLD was not associated with worse overall survival compared with IFLD alone, regardless of whether nodal pathology was positive or negative.
Trends
During the study period, the change in SLNB utilization was:
+136% at low-volume hospitals
+126% at high-volume hospitals
+106% at non–minority-serving hospitals
−67% at minority-serving hospitals
The Path Forward
The reflexive response to these results would be to recommend consolidating vulvar cancer care at high-volume centers. Unfortunately, that would probably exacerbate disparities in care for patients who can't access such centers because of distance or lack of insurance coverage.
It seems more important to train gynecologic oncologists (as well as radiologists, perioperative nurses, and surgical staff) in the SLNB technique and best practices. Low-volume and minority-serving hospitals must receive the resources necessary to provide quality care in all ways for patients with vulvar cancer.
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