PDF herunterladen
CC BY 4.0 · Rev Bras Ginecol Obstet 2023; 45(07): e384-e392
DOI: 10.1055/s-0043-1772179
Original Article
Throphoblastic Disease

Geographical Health District and Distance Traveled Influence on Clinical Status at Admission of Patients with Gestational Trophoblastic Disease

A influência do distrito de saúde e da distância viajada sobre o estado clínico na apresentação de pacientes com doença trofoblástica gestacional
Valdete Aparecida Ribeiro da Silva 
1   Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
,
Izildinha Maestá 
1   Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
2   Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, São Paulo State University, Botucatu, SP, Brazil.
,
Roberto Antonio de Araújo Costa 
1   Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
3   Scientific Initiation Program by the São Paulo Research Foundation, Botucatu Medical School, São Paulo, SP, Brazil.
,
Aline de Ávila Campos 
1   Postgraduation Program in Tocogynecology, Botucatu Medical School, São Paulo State University, Botucatu, SP, Brazil.
3   Scientific Initiation Program by the São Paulo Research Foundation, Botucatu Medical School, São Paulo, SP, Brazil.
,
Antonio Braga 
4   Rio de Janeiro Trophoblastic Disease Center, Maternity School of the Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.
,
Neil Horowitz 
5   Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
6   Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
,
Kevin M. Elias 
5   Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
6   Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
,
Ross Berkowitz 
5   Division of Gynaecologic Oncology, Department of Obstetrics, Gynaecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
6   Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Brigham and Women's Hospital, Boston, MA, USA.
› Institutsangaben
› Weitere Informationen
   Lizenzen und Reprints

Abstract

Objective To assess the potential relationship of clinical status upon admission and distance traveled from geographical health district in women with gestational trophoblastic disease (GTD).

Methods This is a cross-sectional study including women with GTD from the 17 health districts from the São Paulo state (I–XVII), Brazil, referred to the Botucatu Trophoblastic Disease Center (specialized center, district VI), between 1990 and 2018. At admission, hydatidiform mole was assessed according to the risk score system of Berkowitz et al. Gestational trophoblastic neoplasia was evaluated using the International Federation of Gynecology and Obstetrics / World Health Organization (FIGO/WHO) staging/risk score. Data on demographics, clinical status and distance traveled were collected. Multiple regression analyses were performed.

Results This study included 366 women (335 hydatidiform mole, 31 gestational trophoblastic neoplasia). The clinical status at admission and distance traveled significantly differed between the specialized center district and other districts. Patients referred from health districts IX (β = 2.38 [0.87–3.88], p = 0.002) and XVI (β = 0.78 [0.02–1.55], p = 0.045) had higher hydatidiform mole scores than those from the specialized center district. Gestational trophoblastic neoplasia patients from district XVI showed a 3.32 increase in FIGO risk scores compared with those from the specialized center area (β = 3.32, 95% CI = 0.78–5.87, p = 0.010). Distance traveled by patients from districts IX (200km) and XVI (203.5km) was significantly longer than that traveled by patients from the specialized center district (76km).

Conclusion Patients from health districts outside the specialized center area had higher risk scores for both hydatidiform mole and gestational trophoblastic neoplasia at admission. Long distances (>80 km) seemed to adversely influence gestational trophoblastic disease clinical status at admission, indicating barriers to accessing specialized centers.

Resumo

Objetivo Avaliar a possível relação entre estado clínico na apresentação e distância percorrida a partir do distrito de saúde em mulheres com doença trofoblástica gestacional.

Métodos Estudo transversal incluindo mulheres com doença trofoblástica gestacional dos 17 distritos de saúde do estado de São Paulo (I–XVII), Brasil, encaminhadas ao Centro de Doenças Trofoblásticas de Botucatu (distrito VI), entre 1990 e 2018. Na admissão, avaliaram-se mola hidatiforme pelo sistema de pontuação de risco de Berkowitz et al. e neoplasia trofoblástica gestacional pelo escore de risco/estadiamento Federação Internacional de Ginecologia e Obstetrícia / Organização Mundial da Saúde (FIGO/OMS). Coletaram-se dados demográficos, clínicos e distância percorrida e análises de regressão múltipla foram realizadas.

Resultados Este estudo incluiu 366 mulheres (335 mola hidatiforme, 31 neoplasia trofoblástica gestacional). O estado clínico na apresentação e distância percorrida diferiram significativamente entre o centro especializado e demais distritos. Nas pacientes encaminhadas pelos distritos IX (β = 2,38 [0,87–3,88], p = 0,002) e XVI (β = 0,78 [0,02–1,55], p = 0,045), os escores de mola hidatiforme foram maiores que no centro especializado. As pacientes com neoplasia trofoblástica gestacional do distrito XVI apresentaram escores FIGO 3,32 vezes maior que no centro especializado (β = 3,32, 95% CI = 0,78–5,87, p = 0,010). A distância percorrida pelas pacientes dos distritos IX (200km) e XVI (203,5km) foi significativamente maior do que a percorrida pelas pacientes do centro especializado (76km).

Conclusão Pacientes de distritos de saúde fora da cobertura do centro especializado apresentaram escores de risco mais alto para mola hidatiforme e para neoplasia trofoblástica gestacional na admissão. Longas distâncias (>80 km) pareceram influenciar negativamente o estado clínico da doença trofoblástica gestacional na apresentação, indicando barreiras no acesso a centros especializados.

Keywords

gestational trophoblastic disease - geographical health district - distance traveled - clinical status - referral center

Palavras-chave

doença trofoblástica gestacional - distrito de saúde - distância viajada - estado clínico - centro de referência

Contributions

da Silva VAR – reviewed the literature, collected and managed data from the databases of Botucatu Trophoblastic Disease Center (São Paulo State University), wrote the initial draft of the manuscript. Maestá I – conceived and designed the study, contributed to and revised the manuscript; audited data collected from Botucatu Trophoblastic Disease Center database (São Paulo State University). Costa RAdeA – contributed to data analysis and interpretation, reviewed the literature for discussion. Campos AdeA – reviewed the literature, collected and managed data from the databases of Botucatu Trophoblastic Disease Center (São Paulo State University), wrote the initial draft of the manuscript. Braga A – contributed to data management and analysis and revised the manuscript. Horowitz NS – contributed to data analysis and interpretation and revised the manuscript. Elias KM – conceived the analysis strategy, contributed to the manuscript. Berkowitz RS – supervised the study and revised the manuscript.




Publikationsverlauf

Eingereicht: 24. November 2022

Angenommen: 12. Februar 2023

Artikel online veröffentlicht:
18. August 2023

© 2023. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Kohorn EI. Worldwide survey of the results of treating gestational trophoblastic disease. J Reprod Med 2014; 59 (3-4): 145-153
    PubMedGoogle Scholar
  • 2 Braga A, Uberti EMH, Fajardo MdoC, Viggiano M, Sun SY, Grillo BM. et al. Epidemiological report on the treatment of patients with gestational trophoblastic disease in 10 Brazilian referral centers: results after 12 years since International FIGO 2000 Consensus. J Reprod Med 2014; 59 (5-6): 241-247
    PubMedGoogle Scholar
  • 3 Clark LH, Staley SA, Barber EL, Wysham WZ, Kim KH, Soper JT. The effect of distance traveled on disease outcomes in gestational trophoblastic neoplasia. Am J Obstet Gynecol 2016; 215 (02) 217.e1-217.e5
    CrossrefPubMedGoogle Scholar
  • 4 Feltmate CM, Batorfi J, Fulop V, Goldstein DP, Doszpod J, Berkowitz RS. Human chorionic gonadotropin follow-up in patients with molar pregnancy: a time for reevaluation. Obstet Gynecol 2003; 101 (04) 732-736
    PubMedGoogle Scholar
  • 5 CONASS Conselho Nacional de Secretários de Saúde [Internet]. Brasília: CONASS; 2011 [cited 2017 Set 2]. Available from: www.conass.org.br
    PubMedGoogle Scholar
  • 6 Gottesfeld KR, Taylor ES, Thompson HE, Holmes JH. Diagnosis of hydatidiform mole by ultrasound. Obstet Gynecol 1967; 30 (02) 163-171
    PubMedGoogle Scholar
  • 7 Fine C, Bundy AL, Berkowitz RS, Boswell SB, Berezin AF, Doubilet PM. Sonographic diagnosis of partial hydatidiform mole. Obstet Gynecol 1989; 73 (3 Pt 1): 414-418
    PubMedGoogle Scholar
  • 8 Szulman AE, Surti U. The syndromes of hydatidiform mole. II. Morphologic evolution of the complete and partial mole. Am J Obstet Gynecol 1978; 132 (01) 20-27
    PubMedGoogle Scholar
  • 9 Sebire NJ, Makrydimas G, Agnantis NJ, Zagorianakou N, Rees H, Fisher RA. Updated diagnostic criteria for partial and complete hydatidiform moles in early pregnancy. Anticancer Res 2003; 23 (2C): 1723-1728
    PubMedGoogle Scholar
  • 10 Chilosi M, Lestani M, Piazzola E, Guasparri I, Mariuzzi GM. Genomic imprinting in human biology and pathology. Adv Clin Path 1998; 2 (01) 15-24
    PubMedGoogle Scholar
  • 11 FIGO Oncology Committee. FIGO staging for gestational trophoblastic neoplasia 2000. Int J Gynaecol Obstet 2002; 77 (03) 285-287
    CrossrefPubMedGoogle Scholar
  • 12 Berkowitz RS, Goldstein DP, DuBeshter B, Bernstein MR. Management of complete molar pregnancy. J Reprod Med 1987; 32 (09) 634-639
    PubMedGoogle Scholar
  • 13 World Health Organization. Recognizing adolescence. In: Health for the world's adolescents: a second chance in the second decade [Internet]. Geneva: WHO; 2014 [cited 2022 May 2]. Available from: https://apps.who.int/adolescent/second-decade/section2/pge1/recognizing-adolescence.html
    PubMedGoogle Scholar
  • 14 Soares RR, Maestá I, Colón J, Braga A, Salazar A, Charry RC. et al. Complete molar pregnancy in adolescents from North and South America: Clinical presentation and risk of gestational trophoblastic neoplasia. Gynecol Oncol 2016; 142 (03) 496-500
    CrossrefPubMedGoogle Scholar
  • 15 Bianconi MI, Otero S, Moscheni O, Alvarez L, Storino C, Jankilevich G. Gestational trophoblastic disease: a 21-year review of the clinical experience at an Argentinean public hospital. J Reprod Med 2012; 57 (7-8): 341-349
    PubMedGoogle Scholar
  • 16 Simms-Stewart D, Mcdonald G, Flet c, her H, Bromfield M, Williams N, Bambury I, James K. A review of molar pregnancy at the university hospital of the West Indies over a 16-year period. J Obstet Gynaecol 2013; 33 (03) 298-300
    CrossrefPubMedGoogle Scholar
  • 17 Cagayan MS. Hydatidiform mole and its complications: review of patient profiles and management at the university of the Philippines-Philippine General Hospital. J Reprod Med 2014; 59 (5-6): 235-240
    PubMedGoogle Scholar
  • 18 Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet 2010; 376 (9742) 717-729
    CrossrefPubMedGoogle Scholar
  • 19 Berkowitz RS, Goldstein DP. Current advances in the management of gestational trophoblastic disease. Gynecol Oncol 2013; 128 (01) 3-5
    CrossrefPubMedGoogle Scholar
  • 20 Jauniaux E, Memtsa M, Johns J, Ross JA, Jurkovic D. New insights in the pathophysiology of complete hydatidiform mole. Placenta 2018; 62: 28-33
    CrossrefPubMedGoogle Scholar
  • 21 Jauniaux E, Memtsa M, Johns J, Ross JA, Sebire NJ, Jurkovic D. Ultrasound diagnosis of complete and partial hydatidiform moles in early pregnancy failure: An inter-observer study. Placenta 2020; 97: 65-67
    CrossrefPubMedGoogle Scholar
  • 22 Maestá I, Moreira MdeFS, Rezende-Filho J, Bianconi IM, Jankilevich G, Otero S. et al. Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America. Int J Gynecol Cancer 2020; 30 (09) 1366-1371
    CrossrefPubMedGoogle Scholar
  • 23 Sita-Lumsden A, Short D, Lindsay I, Sebire NJ, Adjogatse D, Seckl MJ, Savage PM. Treatment outcomes for 618 women with gestational trophoblastic tumours following a molar pregnancy at the Charing Cross Hospital, 2000-2009. Br J Cancer 2012; 107 (11) 1810-1814
    CrossrefPubMedGoogle Scholar
  • 24 Maestá I, Growdon WB, Goldstein DP, Bernstein MR, Horowitz NS, Rudge MVC, Berkowitz RS. Prognostic factors associated with time to hCG remission in patients with low-risk postmolar gestational trophoblastic neoplasia. Gynecol Oncol 2013; 130 (02) 312-316
    CrossrefPubMedGoogle Scholar
  • 25 Bristow RE, Chang J, Ziogas A, Anton-Culver H, Vieira VM. Spatial analysis of adherence to treatment guidelines for advanced-stage ovarian cancer and the impact of race and socioeconomic status. Gynecol Oncol 2014; 134 (01) 60-67
    CrossrefPubMedGoogle Scholar
  • 26 Temkin SM, Fleming SA, Amrane S, Schluterman N, Terplan M. Geographic disparities amongst patients with gynecologic malignancies at an urban NCI-designated cancer center. Gynecol Oncol 2015; 137 (03) 497-502
    CrossrefPubMedGoogle Scholar
  • 27 Nasioudis D, Musselman K, Gordhandas S, Bernstein MR, Horowitz NS, Rudge MVC, Berkowitz RS. Disparities in the use of adjuvant external beam radiation therapy in node-positive cervical cancer patients following hysterectomy. Am J Clin Oncol 2020; 43 (01) 43-46
    CrossrefPubMedGoogle Scholar
  • 28 Jones AP, Haynes R, Sauerzapf V, Crawford SM, Zhao H, Forman D. Travel times to health care and survival from cancers in Northern England. Eur J Cancer 2008; 44 (02) 269-274
    CrossrefPubMedGoogle Scholar
  • 29 Stitzenberg KB, Sigurdson ER, Egleston BL, Starkey RB, Meropol NJ. Centralization of cancer surgery: implications for patient access to optimal care. J Clin Oncol 2009; 27 (28) 4671-4678
    CrossrefPubMedGoogle Scholar
  • 30 Crawford SM, Sauerzapf V, Haynes R, Zhao H, Forman D, Jones AP. Social and geographical factors affecting access to treatment of lung cancer. Br J Cancer 2009; 101 (06) 897-901
    CrossrefPubMedGoogle Scholar