Clark Leslie H, Staley S Allison, Barber Emma L, Wysham Weiya Z, Kim Kenneth H, Soper John T
Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Am J Obstet Gynecol. 2016 Aug;215(2):217.e1-5. doi: 10.1016/j.ajog.2016.02.008. Epub 2016 Feb 11.
Gestational trophoblastic neoplasia is a rare gynecological malignancy often treated at tertiary referral centers. Patients frequently travel long distances to obtain care for gestational trophoblastic neoplasia, which may affect cancer outcomes in these patients.
We examined the association between distance traveled to obtain care and disease burden at time of presentation as well as recurrence.
We performed a retrospective cohort analysis of all patients diagnosed with gestational trophoblastic neoplasia from January 1995 to June 2015 at a high-volume tertiary referral center. Patients were included if they met International Federation of Gynecology and Obstetrics 2000 criteria for postmolar gestational trophoblastic neoplasia or had choriocarcinoma, placental-site trophoblastic tumor, or epithelioid trophoblastic tumor. Sixty patients were identified. Disease burden at presentation was examined using both the World Health Organization prognostic score and International Federation of Gynecology and Obstetrics. Patients who traveled more than 50 miles were considered long-distance travelers based on previous literature on the effect of distance traveled on cancer outcomes. Demographic, clinical, and pathological data were obtained by chart review. Bivariable comparisons were performed using the χ(2) test or Fisher exact test for categorical variables. The t test or Wilcoxon rank-sum test was used to compare continuous variables when normally or not normally distributed.
Most patients presented at stage I (61%) with low-risk gestational trophoblastic neoplasia (70%). Median distance to care was 40 miles (range, 4-384). Eighteen patients (30%) had no insurance and 42 (70%) had either private or public insurance. Patients traveling more than 50 miles for care were more likely to have high-risk gestational trophoblastic neoplasia (46% vs 19%, P = .03), but there was no difference in recurrence (13% vs 11%, P = .89). Patients with high-risk gestational trophoblastic neoplasia lived 63 miles farther (92 vs 28 miles, P < .001) than patients with low-risk gestational trophoblastic neoplasia. Long-distance travelers had a longer period between antecedent pregnancy and gestational trophoblastic neoplasia diagnosis (10 weeks vs 4.5 weeks, P = .009) and were more likely to receive multiagent chemotherapy (86% vs 61%, P = .03).
In this cohort, long distance traveled to obtain care for gestational trophoblastic neoplasia was associated with an increased risk of presenting with high-risk disease and requiring multiagent chemotherapy for treatment. Patients with high-risk gestational trophoblastic neoplasia traveled nearly 100 miles to obtain care. There may be a delay in diagnosis in women traveling more than 50 miles to obtain care; however, we found no difference in recurrence risk for long-distance travelers.
妊娠滋养细胞肿瘤是一种罕见的妇科恶性肿瘤，通常在三级转诊中心接受治疗。患者常常需要长途跋涉才能获得妊娠滋养细胞肿瘤的治疗，这可能会影响这些患者的癌症治疗效果。
我们研究了为获得治疗而出行的距离与就诊时疾病负担以及复发之间的关联。
我们对1995年1月至2015年6月在一家大型三级转诊中心被诊断为妊娠滋养细胞肿瘤的所有患者进行了回顾性队列分析。如果患者符合国际妇产科联盟2000年关于葡萄胎后妊娠滋养细胞肿瘤的标准，或患有绒毛膜癌、胎盘部位滋养细胞肿瘤或上皮样滋养细胞肿瘤，则纳入研究。共确定了60例患者。使用世界卫生组织预后评分和国际妇产科联盟来评估就诊时的疾病负担。根据先前关于出行距离对癌症治疗效果影响的文献，出行超过50英里的患者被视为长途旅行者。通过查阅病历获取人口统计学、临床和病理数据。分类变量采用χ²检验或Fisher精确检验进行双变量比较。当连续变量呈正态或非正态分布时，分别使用t检验或Wilcoxon秩和检验进行比较。
大多数患者为低风险妊娠滋养细胞肿瘤（70%），处于I期（61%）。到医疗机构的中位距离为40英里（范围为4 - 384英里）。18例患者（30%）没有保险，42例患者（70%）有私人或公共保险。出行超过50英里接受治疗的患者更有可能患有高风险妊娠滋养细胞肿瘤（46%对19%，P = .03），但复发率没有差异（13%对11%，P = .89）。高风险妊娠滋养细胞肿瘤患者比低风险妊娠滋养细胞肿瘤患者居住的地方距离医疗机构远63英里（92英里对28英里，P < .001）。长途旅行者在前次妊娠与妊娠滋养细胞肿瘤诊断之间的时间间隔更长（10周对4.5周，P = .009），并且更有可能接受多药化疗（86%对61%，P = .03）。
在这个队列中，为获得妊娠滋养细胞肿瘤治疗而长途出行与就诊时患有高风险疾病以及需要多药化疗进行治疗的风险增加有关。高风险妊娠滋养细胞肿瘤患者为了获得治疗要出行近100英里。出行超过50英里接受治疗的女性可能存在诊断延迟；然而，我们发现长途旅行者的复发风险没有差异。
