ORCID Profile
0000-0001-9215-475X
Current Organisation
University of Toronto
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Publisher: Elsevier BV
Date: 12-2019
DOI: 10.1016/J.AJOG.2019.07.009
Abstract: Recent studies demonstrating shorter survival among cervical cancer patients undergoing minimally invasive versus open radical hysterectomy could not account for surgeon volume and require confirmation in other jurisdictions with larger s le sizes, longer follow-up, and data on disease recurrence. To determine if surgical approach is associated with oncologic outcomes in cervical cancer patients undergoing minimally invasive or open radical hysterectomy, while accounting for mechanistic factors including surgeon volume. We performed a population-based retrospective cohort study of cervical cancer patients undergoing primary radical hysterectomy by a gynecologic oncologist from 2006 to 2017 in Ontario, Canada. A multivariable marginal Cox proportional hazards model and cause-specific hazards model were used to evaluate the association of surgical approach with all-cause death and recurrence respectively, clustering at the surgeon level. We tested for interactions between surgical approach and either pathologic stage or surgeon volume. We identified 958 patients (minimally invasive 475 open 483) with mean age 45.9 and a median follow-up of 6 years. Of minimally invasive procedures, 89.6% were performed laparoscopically and 10.4% robotically. The unadjusted 5-year cumulative incidences of all-cause death (minimally invasive 12.5% open 5.4%), cervical cancer death (minimally invasive 9.3% open 3.3%), and recurrence (minimally invasive 16.2% open 8.4%) were significantly increased for minimally invasive radical hysterectomy in patients with stage IB disease, but not the cohort overall. After adjusting for patient factors and surgeon volume, minimally invasive radical hysterectomy was associated with increased rates of death (hazard ratio [HR], 2.20 95% confidence interval [CI], 1.15-4.19) and recurrence (HR, 1.97 95% CI, 1.10-3.50) compared to open radical hysterectomy in patients with stage IB disease (n = 534), but not IA disease (n = 244 HR, 0.73 95% CI, 0.13-4.01 HR, 0.34 95% CI, 0.10-1.10). Minimally invasive radical hysterectomy is associated with increased rates of death and recurrence in patients with stage IB cervical cancer even after controlling for surgeon volume open radical hysterectomy should be the recommended approach in this population. Although there may be a subset of patients with microscopic early-stage disease for whom minimally invasive radical hysterectomy remains safe, additional studies are required.
Publisher: BMJ
Date: 08-12-2021
Abstract: To determine if bilateral salpingo-oophorectomy, compared with ovarian conservation, is associated with all cause or cause specific death in women undergoing hysterectomy for non-malignant disease, and to determine how this association varies with age at surgery. Population based cohort study. Ontario, Canada from 1 January 1996 to 31 December 2015, and follow-up to 31 December 2017. 200 549 women (aged 30-70 years) undergoing non-malignant hysterectomy, stratified into premenopausal ( years), menopausal transition (45-49 years), early menopausal (50-54 years), and late menopausal (≥55 years) groups according to age at surgery median follow-up was 12 years (interquartile range 7-17). Bilateral salpingo-oophorectomy versus ovarian conservation. The primary outcome was all cause death. Secondary outcomes were non-cancer and cancer death. Within each age group, overlap propensity score weighted survival models were used to examine the association between bilateral salpingo-oophorectomy and mortality outcomes, while adjusting for demographic characteristics, gynaecological conditions, and comorbidities. To account for comparisons in four age groups, P .0125 was considered statistically significant. Bilateral salpingo-oophorectomy was performed in 19%, 41%, 69%, and 81% of women aged , 45-49, 50-54, and ≥55 years, respectively. The procedure was associated with increased rates of all cause death in women aged years (hazard ratio 1.31, 95% confidence interval 1.18 to 1.45, P .001 number needed to harm 71 at 20 years) and 45-49 years (1.16, 1.04 to 1.30, P=0.007 152 at 20 years), but not in women aged 50-54 years (0.83, 0.72 to 0.97, P=0.018) or ≥55 years (0.92, 0.82 to 1.03, P=0.16). Findings in women aged years were driven largely by increased non-cancer death. In secondary analyses identifying a possible change in the association between bilateral salpingo-oophorectomy and all cause death with advancing age at surgery, the hazard ratio gradually decreased during the menopausal transition and remained around 1 at all ages thereafter. In this observational study, bilateral salpingo-oophorectomy at non-malignant hysterectomy appeared to be associated with increased all cause mortality in women aged years, but not in those aged ≥50 years. While caution is warranted when considering bilateral salpingo-oophorectomy in premenopausal women without indication, this strategy for ovarian cancer risk reduction does not appear to be detrimental to survival in postmenopausal women.
Publisher: Elsevier BV
Date: 02-2022
DOI: 10.1016/J.AJOG.2021.09.020
Abstract: Opportunistic bilateral salpingo-oophorectomy is often offered to patients undergoing benign hysterectomy to prevent ovarian cancer, but the magnitude of risk reduction obtained with bilateral salpingo-oophorectomy in this population remains unclear and must be weighed against potential risks of ovarian hormone deficiency. This study aimed to quantify the relative and absolute risk reduction in ovarian cancer incidence and death associated with bilateral salpingo-oophorectomy at the time of benign hysterectomy. We performed a population-based cohort study of all adult women (≥20 years) undergoing benign hysterectomy from 1996 to 2010 in Ontario, Canada. Patients with ovarian pathology, previous breast or gynecologic cancer, or evidence of genetic susceptibility to malignancy were excluded. Inverse probability of treatment-weighted Fine-Gray subdistribution hazard models were used to quantify the effect of bilateral salpingo-oophorectomy on ovarian cancer incidence and death while accounting for competing risks and adjusting for demographic characteristics, gynecologic conditions, and comorbidities. Analyses were performed in all women and specifically in women of postmenopausal age (≥50 years) at the time of hysterectomy. We identified 195,282 patients (bilateral salpingo-oophorectomy, 24% ovarian conservation, 76%) with a median age of 45 years (interquartile range, 40-51 years). Over a median follow-up of 16 years (interquartile range, 12-20 years), 548 patients developed ovarian cancer (0.3%), and 16,170 patients (8.3%) died from any cause. Bilateral salpingo-oophorectomy was associated with decreased ovarian cancer incidence (hazard ratio, 0.23 95% confidence interval, 0.14-0.38 P<.001) and decreased ovarian cancer death (hazard ratio, 0.30 95% confidence interval, 0.16-0.57 P<.001). At 20 years follow-up, the weighted cumulative incidences of ovarian cancer were 0.08% and 0.46% with bilateral salpingo-oophorectomy and ovarian conservation, respectively, yielding an absolute risk reduction of 0.38% (95% confidence interval, 0.32-0.45 number needed to treat, 260). After restricting to women aged ≥50 years at hysterectomy, the absolute risk reduction was 0.62% (95% confidence interval, 0.47-0.77 number needed to treat, 161). Bilateral salpingo-oophorectomy resulted in a significant absolute reduction in ovarian cancer among women undergoing benign hysterectomy. Population-average risk estimates derived in this study should be balanced against other potential implications of bilateral salpingo-oophorectomy to inform practice guidelines, patient decision-making, and surgical management.
Publisher: Elsevier BV
Date: 04-2022
DOI: 10.1016/J.UROLONC.2021.12.006
Abstract: A second transurethral resection of the bladder tumor (TURBT) within 2 - 6 weeks after initial TURBT is thought to have diagnostic, therapeutic, and prognostic benefits in T1 bladder cancer (BC). However, little is known about the real-world uptake of this guideline-endorsed intervention. We aimed (1) to measure re-resection rates over time, (2) to investigate if a guideline revision (April 2008) explicitly endorsing re-resection within 2 - 6 weeks in all T1 BC patients led to an increase in re-resection rates, and (3) to investigate the uptake among different groups of surgeons. Province-wide BC pathology reports (January 2001 to December 2015 Ontario, Canada) were linked with health administrative data to (1) identify primary cases of T1 BC and to (2) ascertain whether these patients received re-resection. The resulting patients were then aggregated into quarterly time series and investigated by descriptive analysis, interventional autoregressive moving average (ARIMA) modeling, and Poisson regression analysis. A cohort of 7,373 patients was aggregated into a time series. We observed a linear increase in re-resection rates from 8.4% in 2001 to 28.3% in 2015. An actual effect of the guideline revision in April 2008 on re-resection rates could not be detected (P = 0.41). However, we observed a rather heterogeneous uptake behavior among different groups of surgeons. Specifically, female surgeons, more junior surgeons, high-volume surgeons, Canadian graduates, and surgeons without an academic affiliation were all independently more likely to re-resect their patients (all P-values < 0.05 in adjusted analysis). Re-resection rates in primary T1 BC increased between 2001 and 2015 in the province of Ontario regardless of the guideline revision in April 2008. Our study demonstrates that the uptake of this guideline-endorsed intervention varies among different groups of surgeons and therefore warrants further research to identify barriers to change that can be addressed by tailored interventions.
Publisher: American Medical Association (AMA)
Date: 04-2018
Publisher: Springer Science and Business Media LLC
Date: 13-07-2013
DOI: 10.1245/S10434-013-3123-2
Abstract: To assess patterns of uptake and outcomes of laparoscopic colon and rectal cancer surgery in Ontario, and the potential influence of surgical fee incentives instituted on October 1, 2005. We used Ontario administrative databases from fiscal years 2002 to 2009. Study outcomes were uptake rates of laparoscopic surgery, hospital length of stay, 30-day operative mortality, cancer-specific survival, and overall survival. The main descriptor for multivariable regression models was a 5% increase in rate of laparoscopic colon cancer surgery in the previous year. The annual rate of laparoscopic colon and rectal cancer surgery, respectively, rose from 8.7 to 38.9% and from 4.8 to 19.6%. The greatest increase in rate of laparoscopic colon surgery occurred shortly after October 1, 2005. For each 5% increase in rate of laparoscopic surgery, the odds of 30-day mortality was 1.0 [95% confidence interval (CI) 0.96-1.01, p = 0.264], the hazard of cancer-specific survival was 1.0 (95% CI 0.97-1.00, p = 0.139), the hazard of overall survival was 1.0 (95% CI 0.98-1.00, p = 0.051), and length of hospital stay was lower (estimate = -0.10, 95% CI -0.14 to -0.06, p < 0.001). In Ontario by the year 2009, 39% of colon and 20% of rectal cancer surgery was provided laparoscopically. Increased rates were associated with a minimal decrease in hospital length of stay and no changes in 30-day mortality, cancer-specific survival, or overall survival. Financial incentives were likely responsible for the marked increase in laparoscopic colon cancer surgery observed after October 1, 2005.
Publisher: Longwoods Publishing
Date: 28-02-2020
No related grants have been discovered for Ning Liu.