התמלול המלא של Home the Same Day? Testing the Limits in Ovarian Cancer Debulking Surgery

long as all of their extra abdominal disease has resolved in response to neoadjugemotherapy. 00:05:06.240 --> 00:05:22.879 So I think, you know, that for example, patients who are stage four from a pleural effusion that dries up after three cycles are I think very reasonable candidates for minimally invasive interval debulking surgery, as long as you know the operation seems otherwise feasible. 00:05:23.040 --> 00:05:43.439 And even patients who have measurable solid disease in their chest, you know, pericardial nodes or something like this, if those resolve completely in the setting of neoadjug chemotherapy and there is no plan to resect, then I think again, patients like that can be good candidates for minimally invasive surgery. 00:05:43.839 --> 00:05:44.639 Yeah, that's a good point. 00:05:44.800 --> 00:05:48.079 I guess it's just about kind of changing sort of how we think about things. 00:05:48.240 --> 00:05:48.480 Yeah. 00:05:48.639 --> 00:05:50.079 Thanks, thanks for providing that. 00:05:50.319 --> 00:06:03.839 Okay, so Robbie, your study showed that the rate of same-day discharge increased from 1.3% in 2010 to almost 15% in 2021, which you know is encouraging, but you know, it still seems much lower than it could be. 00:06:04.000 --> 00:06:20.000 You know, I suspect that many people associate interbully bulking surgery as having multiple complex procedures, but in fact, 85% of the patients in your study who achieved same-day discharge actually had, you know, just hysterectomy, bilateral stopping, ufrectomy, and omentectomy only. 00:06:20.160 --> 00:06:21.199 So, what's going on? 00:06:21.439 --> 00:06:27.040 You know, what do you think are the main barriers in this group to achieving higher same-day discharge? 00:06:27.360 --> 00:06:28.800 Yeah, that's a good question. 00:06:28.959 --> 00:06:31.519 I think it's likely multifactorial. 00:06:31.680 --> 00:06:32.319 So, like Dr. 00:06:32.480 --> 00:06:40.639 Melaman mentioned, minimally invasive surgery for interval cider reduction in advanced ovarian cancer is relatively novel. 00:06:40.879 --> 00:06:51.519 And without clear randomized data that says that it's safe for patients, there might be hesitancy from a provider or a patient perspective to discharge home on the same day. 00:06:51.680 --> 00:06:57.680 This likely also makes it difficult to implement institutional pathways for same-day discharge. 00:06:58.000 --> 00:07:04.240 Also, we saw that patients who were older were less likely to go home on the same day. 00:07:04.399 --> 00:07:12.800 And we could speculate that there might be a hesitancy to send these older, more frail patients home due to their overall state of health. 00:07:13.040 --> 00:07:16.079 So, for example, in endometrial cancer, like Dr. 00:07:16.160 --> 00:07:23.199 Melliman mentioned, those patients undergoing staging surgery, they usually present like at their baseline state of health. 00:07:23.360 --> 00:07:25.839 They tend to go home on the same day of surgery.

00:07:26.079 --> 00:07:36.399 But those patients who are going undergoing interval debulking surgery for ovarian cancer have already gone through usually at least three cycles of chemotherapy and they tend to be more frail. 00:07:36.639 --> 00:07:40.240 It might be that providers are a little hesitant to send these patients home. 00:07:40.399 --> 00:07:44.959 And these patients may also feel uncomfortable with the idea of a same-day discharge. 00:07:45.279 --> 00:07:55.279 And of course, I would be remiss if I didn't highlight the disparities that we noted in our same-day discharge population as compared to those patients who were admitted. 00:07:55.439 --> 00:08:05.839 Those patients who had a higher household annual income, and also those patients who received care in the Northeast or the West were more likely to be discharged home on the same day. 00:08:06.000 --> 00:08:13.600 And national disparities in practice patterns, as well as differential access to care, likely impacted the rate of same-day discharge. 00:08:13.759 --> 00:08:26.639 And as we gather more data about the safety and the efficacy of minimally invasive surgery for interval cytorreduction, it would be important to establish standardized practice patterns so we can mitigate such disparities in the future. 00:08:26.959 --> 00:08:27.199 Great. 00:08:27.279 --> 00:08:27.519 Thanks. 00:08:27.600 --> 00:08:32.960 Yeah, those are all uh really interesting points that we need to be paying attention to uh moving forward. 00:08:33.200 --> 00:08:35.039 Okay, another question for you, Alex. 00:08:35.279 --> 00:08:41.519 Same-day discharge is often framed as you know, patient-centered and evidence of high value care. 00:08:41.600 --> 00:08:50.879 But you know, how do we know uh when it truly reflects patient preference versus institutional pressures for shorter length of stay and lower costs? 00:08:51.279 --> 00:08:54.799 Yeah, I think that is such an important question. 00:08:54.960 --> 00:09:06.320 You know, if you look globally in terms of lengths of stay after similar procedures, you see huge differences in practice from country to country. 00:09:06.480 --> 00:09:15.679 You see, countries where folks will stay for two weeks in the hospital for an operation, where in the United States they might go home, you know, after three days. 00:09:15.840 --> 00:09:28.879 And I think that it's really important to consider both cultural differences in terms of expectation and what makes patients feel taken care of, you know, I think that's really, really important to consider. 00:09:28.960 --> 00:09:38.000 And I do think thinking about what is really patient-centered and what is really, you know, a uh financial decision for the health system is also important to think about. 00:09:38.159 --> 00:09:49.519 But despite the fact that patients may feel, or some patients may feel that staying in the hospital longer is better care because more is better. 00:09:49.679 --> 00:09:59.440 I think there are some key advantages to going home, at least from the hospital that I work in, that once you kind of attune patients to, they certainly appreciate it. 00:09:59.519 --> 00:10:02.159 Uh, the things I'm thinking of is sleeping in one's own bed. 00:10:02.240 --> 00:10:04.080 You know, hospital beds are not comfortable. 00:10:04.159 --> 00:10:06.559 I know patients sleep better when they go home. 00:10:06.799 --> 00:10:11.519 Another patient-centered thing that I think of is access to your own pain medicine, right? 00:10:11.679 --> 00:10:15.519 Even when you're on oral pain medications in the hospital, you have to call the nurse. 00:10:15.600 --> 00:10:18.320 The nurse may have three patients, she may be dealing with something else. 00:10:18.399 --> 00:10:22.480 And so you're sort of at the mercy of what it is to be an inpatient. 00:10:22.559 --> 00:10:23.840 You're dependent on the system. 00:10:24.000 --> 00:10:31.120 So, and then the third thing I will point out, and maybe this is not true for the hospitals that you work in, but in our hospital, the food is pretty terrible. 00:10:31.279 --> 00:10:35.360 And I have not had one patient, you know, compliment us on the food services. 00:10:35.440 --> 00:10:38.320 And, you know, people eat better and feel better if they go home. 00:10:38.399 --> 00:10:53.360 And so I think when you point out the kind of those natural advantages and you reassure patients that medically, you as the doctor aren't worried, then I think that mitigates some of the fear from the patient's perspective that they're just being rushed out to save money. 00:10:53.600 --> 00:10:54.879 Yeah, those are great points. 00:10:54.960 --> 00:11:03.360 And uh, you know, we've all had different patients who want to leave like immediately, and other patients who, you know, just feel comfortable, you know, staying the night. 00:11:03.440 --> 00:11:08.320 And so I think in many cases, oftentimes we're sort of, you know, not really taking that into account. 00:11:08.639 --> 00:11:12.080 Okay, well, we've heard uh some really excellent points from our study authors. 00:11:12.159 --> 00:11:15.519 We're now gonna hand it over to our editorialist, Alejandro. 00:11:15.600 --> 00:11:18.399 So yeah, thanks again for a very interesting editorial. 00:11:18.480 --> 00:11:20.639 You know, you brought up several important issues. 00:11:20.799 --> 00:11:25.440 You know, only about one in 10 patients had same-day discharge even by 2021. 00:11:25.519 --> 00:11:30.960 And, you know, these were disproportionately younger, higher-income metropolitan patients treated in certain U.S. 00:11:31.039 --> 00:11:31.360 regions. 00:11:31.519 --> 00:11:33.440 This was highlighted by uh Dr. 00:11:33.600 --> 00:11:34.080 Tawari. 00:11:34.480 --> 00:11:38.480 Are we seeing the emergence of a fast-track elite in ovarian cancer care? 00:11:38.559 --> 00:11:40.960 And what are the ethical implications of that? 00:11:41.440 --> 00:11:44.080 Hi, first of all, thank you so much for

inviting me to be here. 00:11:44.159 --> 00:11:47.120 I'm very excited to be with colleagues and friends. 00:11:47.360 --> 00:11:51.840 And Greg, to your point, I do I think that is, I think, a valid concern. 00:11:52.000 --> 00:12:04.080 And the data do suggest that early adoption was concentrated in younger, healthier, and more resourced populations treated at high volume centers. 00:12:04.320 --> 00:12:12.799 However, I will frame this less as a fast-track elite and more as a typical pattern of innovation diffusion in surgical oncology. 00:12:13.039 --> 00:12:26.799 New pathways, particularly those requiring multidisciplinary coordination, enhanced recovery protocols, and care for patient selection, tend to be implemented first in centers with the proper infrastructure to support them. 00:12:27.120 --> 00:12:30.720 And I think we've seen that in many other scenarios. 00:12:30.799 --> 00:12:36.720 And you know, I think you know, you as the expert of ERAS probably witnessed that kind of scenario. 00:12:36.960 --> 00:12:49.120 In perhaps initially, those protocols were implemented in healthier, younger populations and in academic centers, and eventually they were translated into different types of populations. 00:12:49.440 --> 00:12:56.080 I would say that the ethical issue arises if this truly remains confined to those settings. 00:12:56.320 --> 00:13:08.399 So to me, same-day discharge, when appropriately applied, has the potential to reduce patient burden, certainly improve recovery, and you know, we'll see whether it truly reduces cost to the system. 00:13:08.639 --> 00:13:19.279 But, you know, what we've seen at least in other settings and some analysis in other settings, same-day discharge apparently does reduce cost to the healthcare system. 00:13:19.519 --> 00:13:24.000 So you would imagine that the same would happen in this particular scenario. 00:13:24.240 --> 00:13:37.919 But I think to me, the priority should always be to ensure that these pathways are rigorously standardized with proper patient selection and, you know, again, following safety protocols to make sure that it's they're properly applied. 00:13:38.159 --> 00:13:47.679 And the other part that I think was raised that I it is important is that you know, this is it seems at this point that it's for particular patient selection. 00:13:47.759 --> 00:13:58.000 So we should not forget that this, if there is an advantage to this, uh it should apply to patients for medically underserved communities as well. 00:13:58.559 --> 00:13:59.360 Yeah, thank you. 00:13:59.440 --> 00:14:00.320 I I fully agree. 00:14:00.399 --> 00:14:09.759 You know, when we see other surgical quality initiatives such as sort of ERAS, uh globally, there's you know, huge differences uh in in uptake. 00:14:10.000 --> 00:14:30.080 Another question, Alejandro, you know, minimally invasive interval debulking surgery, uh, I don't have to tell you, of course, as the lead for the Lance trial is still under oncologic scrutiny, you know, should we even be talking about same-day discharge pathways for minimally invasive interval debulking surgeries, but you know, before the cancer control question is definitively settled? 00:14:30.480 --> 00:14:33.840 Yeah, I think this is such a good question, an important question. 00:14:34.000 --> 00:14:52.080 I mean, I think the reality in the United States, at least in the United States, is that when you look at the data, right now, the last time we looked at the national cancer database, I think almost a third of the patients that were having an interval debulking surgery were having the procedure done through a minimally invasive approach. 00:14:52.320 --> 00:15:00.720 So the reality is that in the United States, despite the lack of prospective data, these procedures are already happening. 00:15:00.879 --> 00:15:05.840 I'm not encouraging anyone to go ahead and do it, and that's why we're conducting the Lance trial. 00:15:06.000 --> 00:15:15.519 But I think I do think that we just have to acknowledge that this is already happening, and you know, and we'll see what the land trial shows. 00:15:15.759 --> 00:15:21.120 And I 100% agree that oncological safety must remain the primary consideration. 00:15:21.360 --> 00:15:34.639 You know, the question whether minimal invasive interval debulking is still being addressed in the Lance trial, and until the data is mature, you know, careful patient selection, as Alex said initially, is essential, right? 00:15:34.799 --> 00:15:38.320 I mean, we still are trying to figure out what are the right candidates. 00:15:38.480 --> 00:15:52.879 And I think at some degree, Lance would answer, first of all, whether it's safe, but also would give us an idea of who are, at least per the trial inclusion criteria, who are the right candidates for minimal invasive Vulcan surgery. 00:15:53.120 --> 00:15:57.679 With all of that said, I view this as related for distinct question. 00:15:57.759 --> 00:16:02.960 You know, same-discharge is a pre-operative pathway that applies to surgical approach. 00:16:03.360 --> 00:16:14.000 And and I think, you know, I think in that sense, this particular study is trying to answer that question that in this population, same-discharge is feasible or safe. 00:16:14.240 --> 00:16:23.840 And I don't, you know, it's not probably really trying to answer the oncological question that I do think that, you know, hopefully in a couple of years we'll have an answer from the Lance Trell. 00:16:24.720 --> 00:16:24.960 Great. 00:16:25.039 --> 00:16:25.519 Thank you so much. 00:16:25.600 --> 00:16:29.200 Yeah, it's uh we're all uh anxiously awaiting that data. 00:16:29.360 --> 00:16:34.000 Uh okay, just in the last couple of minutes, uh maybe back to our study authors, Saravi, Alex. 00:16:34.080 --> 00:16:38.320 Uh, any final comments uh you'd like to make, particularly uh with respect to Dr. 00:16:38.480 --> 00:16:40.559 uh Raoin's uh editorial. 00:16:41.120 --> 00:16:45.440 Well, uh I would definitely just I would underscore what what Dr. 00:16:45.600 --> 00:16:52.080 Rauhein said about the fact that we do not have randomized data for this surgery yet. 00:16:52.240 --> 00:17:01.200 And to underscore that the fact that our study looks at the same day discharge, we're not trying to say, oh, this is already standard of care. 00:17:01.360 --> 00:17:05.200 I mean, it is already standard of care because people are treating it like it's standard of care. 00:17:05.279 --> 00:17:11.680 But I guess we're not trying to give encouragement to folks to adopt this procedure prior to the completion of the trial. 00:17:11.839 --> 00:17:26.160 And if anything, we'd probably like to encourage more people to be putting patients on this trial so that when we do broadly adopt this operation, we can have uh evidence of its safety. 00:17:26.319 --> 00:17:30.400 Or conversely, if it's not safe, we can prevent harm to patients. 00:17:31.039 --> 00:17:31.359 Right. 00:17:31.519 --> 00:17:32.880 And just echoing Dr. 00:17:32.960 --> 00:17:46.720 Raoin and as he highlights in the editorial, just really careful patient selection for same-day discharge as we're still awaiting the results of the Lance trial to make sure that we're picking good candidates for this approach. 00:17:47.200 --> 00:17:47.519 Great. 00:17:47.599 --> 00:17:50.319 So, you know, I've really enjoyed speaking with you all today. 00:17:50.400 --> 00:17:55.279 I I've certainly learned a lot, and uh, so hopefully so too have our listeners. 00:17:56.160 --> 00:18:00.160 My thanks to our podcasters and all of our guests for joining us today. 00:18:00.400 --> 00:18:12.880 The article and editorial we've discussed are available at gynecologic oncology online.net, and you can access our podcast at the journal's homepage, Apple iTunes, Google Play, and Spotify. 00:18:13.039 --> 00:18:15.119 Thank you for listening and be well.