Adherence to guideline-based preoperative and intraoperative care during risk-reducing bilateral salpingo-oophorectomy among gynecologist-oncologists compared to general gynecologists (335)

Abstract

<b>Objectives:</b> Risk-reducing Bilateral Salpingoopherectomy (rrBSO) is the only intervention proven to reduce mortality from epithelial ovarian cancer in patients with hereditary breast and ovarian cancer (HBOC)-associated gene mutations. Optimal surgical technique for rrBSO includes five steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetrics and Gynecology. These five steps include: <i>1)</i> Abdominal survey; <i>2)</i> Peritoneal washings; <i>3)</i> Entering retroperitoneal space and creating pedicle 2cm from the ovary; <i>4)</i> Dividing pedicle at the uterus; and <i>5)</i> Removal in an endoscopic bag. rrBSO can be performed by both general gynecologists (GYN) and gynecologist oncologists (GO). We aimed to evaluate adherence to surgical guidelines for rrBSO when performed by GO compared to GYN and assess the utility of preoperative (preop) CA-125 and pelvic ultrasound as predictors of malignancy identified at the time of rrBSO. <b>Methods:</b> A retrospective review of patients who underwent rrBSO from October 1, 2015, to December 31, 2020, by faculty and privately employed physicians at three high volume academic sites within a healthcare system was performed. The primary outcome was compliance with all five steps of rrBSO as dictated by a surgeon. Secondary outcomes included the presence of a pre-malignant or malignant lesion at the time of rrBSO and association with preoperative imaging or CA-125. Patient demographics and clinical characteristics were collected. Descriptive statistics for continuous variables were calculated. Univariable logistic regression was used to screen variables with a p-value criterion of p < 0.05 for entry into the model selection procedure. Multivariate regression was used to identify differences in practice patterns. <b>Results:</b> A total of 236 patients were included. Among them, 122 (52%) cases were performed by a GO. Among the cases documented by GO, 27 (22%) performed all five steps of the procedure, 65 (53%) performed four steps, 26 (21%) performed three steps, four (3%) performed two steps, and none performed only one step. Among the 114 cases by GYN, four (4%) performed all five steps, 17 (15%) performed four steps, 50 (44%) performed three steps, 40 (35%) performed two steps, and three (3%) performed only one step. Univariable analysis demonstrated no association between demographic variables and procedure compliance. GO were significantly more likely to adhere to all five recommended surgical steps, (OR: 7.816, 95% CI: 2.640-23.138, p=0.0002). In total, five patients (2.12%) had pre-malignant or malignant lesions diagnosed at the time of rrBSO. None of the five patients had documented preop CA-125 or preop imaging, and all five cases occurred in patients undergoing surgery with GYN. <b>Conclusions:</b> Our results show a statistically significant difference in compliance to procedural steps of rrBSO between GYN and GO. This demonstrates a need for institution-wide education and implementation of procedural standards and standardized nomenclature for dictations to ensure provider adherence to rrBSO guidelines. Fig. 1