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Hello and welcome to this month's Gynecologic Oncology Journal Podcast.
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I'm David Cohn, the editor-in-chief.
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And today you'll hear our podcasters that are featuring our editor's choice article and the accompanying editorial.
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I hope you do enjoy this podcast.
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The article and editorial we'll discuss are available at our homepage, Gynecologic Oncology-online.net.
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Thank you for listening.
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Hello and welcome to the Gynecologic Oncology Journal Podcast.
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This is Greg Nelson, Associate Editor of the Journal.
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Today I'm joined by Dr.
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Sarabi Tawari and Dr.
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Alex Melamed from the Department of Epstetrics and Gynecology, Massachusetts General Hospital in Boston, Massachusetts.
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They are the first and senior authors, respectively, on the editor's choice article entitled Same-Day Discharge After Minimally Invasive Interval Debulking Surgery in Advanced Stage Ovarian Cancer.
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I'm also joined by Dr.
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Alejandro Raoin from the University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine in Houston, Texas, and senior author of the editorial entitled Same-Day Discharge in Advanced Ovarian Cancer as a Milestone of Surgical Evolution and Patient Selection.
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Thanks everyone for joining me today.
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Alex, let's get started.
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Can you briefly describe the landscape of same-day discharge in gynecologic oncology?
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And importantly, what was the motivation for conducting the study that we're discussing today?
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Sure.
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So, you know, as laparoscopy and minimally invasive approaches have gained traction across disease sites in gynecologic oncology, procedures that had previously required a hospitalization became feasible to conduct on an outpatient basis.
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And you know, there's a very broad literature about different operations after which people go home after the same day, you know, and especially as ERAS has become more widely accepted.
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I think this practice is very common for endometrial cancer.
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When we were doing more cervical cancer minimally invasively, I think a lot of patients were even going home after radical hysterectomy the same day.
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But the use of minimally invasive surgery for advanced ovarian cancer is fairly novel.
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You know, this has happened as new adjuvant chemotherapy has become increasingly more common and as interval debulking surgery has started to become more common than primary debulking surgery.
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And there are some key differences, we thought, about the population of folks who are having minimally invasive interval debulking surgery.
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These folks have gone through neoadjuvant chemotherapy.
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Many of these folks are frail, not only from the chemotherapy that they've had, but from the disease process that they've endured, which sometimes decreases appetite and makes folks malnourished.
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And so we were interested in seeing whether gynecologic oncologists in the US were adopting same-day discharge after this procedure.
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Great.
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Thank you so much for providing that context.
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So, Ravi, over to you.
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Now can you describe the main findings from your current study for our listeners?
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Yeah, definitely.
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So I think our main takeaway is that although rates of same-day discharge are only about 10% in our whole cohort, the rates have increased from 1.3% to 14.8% from 2010 to 2021, which was the duration of our study period.
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At the time of the study, we only had data up to 2021, but it may be that the real rates have continued to rise since then.
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Our second point is that when we look at factors that are associated with same-day discharge, those patients who are younger and had a complete resection were more likely to go home on the same day in comparison to those patients that were admitted.
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And lastly, and importantly, the short-term outcomes that we analyzed, including readmission rates and 90-day mortality, did not differ between the patients who had same-day discharge and those patients that were admitted.
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However, these results have to be interpreted in the context of our overall low event rates and also our wide confidence intervals.
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Excellent.
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Thank you.
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Back over to you, Alex.
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You know, I found it quite intriguing that there was between 43 and 51 patients in the study who had stage four disease.
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This kind of goes against uh what most people might think would be appropriate for minimally invasive surgery, patient selection.
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What are your thoughts regarding this?
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Yeah, so you know, I think patient selection for minimally invasive interval cytoreductive surgery is an active area of research still.
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You know, in the Lance trial, stage four patients are allowed, and they are allowed just as long as all of their extra abdominal disease has resolved in response to neoadjugemotherapy.
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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.
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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.
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Yeah, that's a good point.
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I guess it's just about kind of changing sort of how we think about things.
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Yeah.
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Thanks, thanks for providing that.
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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.
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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.
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So, what's going on?
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You know, what do you think are the main barriers in this group to achieving higher same-day discharge?
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Yeah, that's a good question.
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I think it's likely multifactorial.
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So, like Dr.
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Melaman mentioned, minimally invasive surgery for interval cider reduction in advanced ovarian cancer is relatively novel.
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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.
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This likely also makes it difficult to implement institutional pathways for same-day discharge.
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Also, we saw that patients who were older were less likely to go home on the same day.
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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.
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So, for example, in endometrial cancer, like Dr.
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Melliman mentioned, those patients undergoing staging surgery, they usually present like at their baseline state of health.
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They tend to go home on the same day of surgery.
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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.
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It might be that providers are a little hesitant to send these patients home.
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And these patients may also feel uncomfortable with the idea of a same-day discharge.
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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.
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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.
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And national disparities in practice patterns, as well as differential access to care, likely impacted the rate of same-day discharge.
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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.
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Great.
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Thanks.
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Yeah, those are all uh really interesting points that we need to be paying attention to uh moving forward.
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Okay, another question for you, Alex.
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Same-day discharge is often framed as you know, patient-centered and evidence of high value care.
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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?
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Yeah, I think that is such an important question.
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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.
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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.
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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.
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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.
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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.
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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.
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Uh, the things I'm thinking of is sleeping in one's own bed.
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You know, hospital beds are not comfortable.
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I know patients sleep better when they go home.
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Another patient-centered thing that I think of is access to your own pain medicine, right?
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Even when you're on oral pain medications in the hospital, you have to call the nurse.
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The nurse may have three patients, she may be dealing with something else.
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And so you're sort of at the mercy of what it is to be an inpatient.
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You're dependent on the system.
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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.
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And I have not had one patient, you know, compliment us on the food services.
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And, you know, people eat better and feel better if they go home.
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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.
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Yeah, those are great points.
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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.
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And so I think in many cases, oftentimes we're sort of, you know, not really taking that into account.
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Okay, well, we've heard uh some really excellent points from our study authors.
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We're now gonna hand it over to our editorialist, Alejandro.
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So yeah, thanks again for a very interesting editorial.
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You know, you brought up several important issues.
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You know, only about one in 10 patients had same-day discharge even by 2021.
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And, you know, these were disproportionately younger, higher-income metropolitan patients treated in certain U.S.
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regions.
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This was highlighted by uh Dr.
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Tawari.
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Are we seeing the emergence of a fast-track elite in ovarian cancer care?
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And what are the ethical implications of that?
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Hi, first of all, thank you so much for inviting me to be here.
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I'm very excited to be with colleagues and friends.
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And Greg, to your point, I do I think that is, I think, a valid concern.
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And the data do suggest that early adoption was concentrated in younger, healthier, and more resourced populations treated at high volume centers.
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However, I will frame this less as a fast-track elite and more as a typical pattern of innovation diffusion in surgical oncology.
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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.
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And I think we've seen that in many other scenarios.
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And you know, I think you know, you as the expert of ERAS probably witnessed that kind of scenario.
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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.
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I would say that the ethical issue arises if this truly remains confined to those settings.
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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.
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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.
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So you would imagine that the same would happen in this particular scenario.
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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.
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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.
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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.
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Yeah, thank you.
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I I fully agree.
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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.
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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?
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Yeah, I think this is such a good question, an important question.
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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.
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So the reality is that in the United States, despite the lack of prospective data, these procedures are already happening.
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I'm not encouraging anyone to go ahead and do it, and that's why we're conducting the Lance trial.
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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.
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And I 100% agree that oncological safety must remain the primary consideration.
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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?
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I mean, we still are trying to figure out what are the right candidates.
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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.
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With all of that said, I view this as related for distinct question.
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You know, same-discharge is a pre-operative pathway that applies to surgical approach.
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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.
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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.
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Great.
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Thank you so much.
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Yeah, it's uh we're all uh anxiously awaiting that data.
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Uh okay, just in the last couple of minutes, uh maybe back to our study authors, Saravi, Alex.
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Uh, any final comments uh you'd like to make, particularly uh with respect to Dr.
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uh Raoin's uh editorial.
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Well, uh I would definitely just I would underscore what what Dr.
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Rauhein said about the fact that we do not have randomized data for this surgery yet.
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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.
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I mean, it is already standard of care because people are treating it like it's standard of care.
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But I guess we're not trying to give encouragement to folks to adopt this procedure prior to the completion of the trial.
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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.
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Or conversely, if it's not safe, we can prevent harm to patients.
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Right.
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And just echoing Dr.
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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.
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Great.
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So, you know, I've really enjoyed speaking with you all today.
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I I've certainly learned a lot, and uh, so hopefully so too have our listeners.
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My thanks to our podcasters and all of our guests for joining us today.
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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.
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Thank you for listening and be well.
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Hello and welcome to this month's Gynecologic Oncology Journal Podcast.
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I'm David Cohn, the editor-in-chief.
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And today you'll hear our podcasters that are featuring our editor's choice article and the accompanying editorial.
00:00:18.640 --> 00:00:20.640
I hope you do enjoy this podcast.
00:00:20.800 --> 00:00:28.559
The article and editorial we'll discuss are available at our homepage, Gynecologic Oncology-online.net.
00:00:29.039 --> 00:00:30.640
Thank you for listening.
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Hello and welcome to the Gynecologic Oncology Journal Podcast.
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This is Greg Nelson, Associate Editor of the Journal.
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Today I'm joined by Dr.
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Sarabi Tawari and Dr.
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Alex Melamed from the Department of Epstetrics and Gynecology, Massachusetts General Hospital in Boston, Massachusetts.
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They are the first and senior authors, respectively, on the editor's choice article entitled Same-Day Discharge After Minimally Invasive Interval Debulking Surgery in Advanced Stage Ovarian Cancer.
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I'm also joined by Dr.
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Alejandro Raoin from the University of Texas MD Anderson Cancer Center, Department of Gynecologic Oncology and Reproductive Medicine in Houston, Texas, and senior author of the editorial entitled Same-Day Discharge in Advanced Ovarian Cancer as a Milestone of Surgical Evolution and Patient Selection.
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Thanks everyone for joining me today.
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Alex, let's get started.
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Can you briefly describe the landscape of same-day discharge in gynecologic oncology?
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And importantly, what was the motivation for conducting the study that we're discussing today?
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Sure.
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So, you know, as laparoscopy and minimally invasive approaches have gained traction across disease sites in gynecologic oncology, procedures that had previously required a hospitalization became feasible to conduct on an outpatient basis.
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And you know, there's a very broad literature about different operations after which people go home after the same day, you know, and especially as ERAS has become more widely accepted.
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I think this practice is very common for endometrial cancer.
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When we were doing more cervical cancer minimally invasively, I think a lot of patients were even going home after radical hysterectomy the same day.
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But the use of minimally invasive surgery for advanced ovarian cancer is fairly novel.
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You know, this has happened as new adjuvant chemotherapy has become increasingly more common and as interval debulking surgery has started to become more common than primary debulking surgery.
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And there are some key differences, we thought, about the population of folks who are having minimally invasive interval debulking surgery.
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These folks have gone through neoadjuvant chemotherapy.
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Many of these folks are frail, not only from the chemotherapy that they've had, but from the disease process that they've endured, which sometimes decreases appetite and makes folks malnourished.
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And so we were interested in seeing whether gynecologic oncologists in the US were adopting same-day discharge after this procedure.
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Great.
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Thank you so much for providing that context.
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So, Ravi, over to you.
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Now can you describe the main findings from your current study for our listeners?
00:03:16.479 --> 00:03:17.599
Yeah, definitely.
00:03:17.919 --> 00:03:35.759
So I think our main takeaway is that although rates of same-day discharge are only about 10% in our whole cohort, the rates have increased from 1.3% to 14.8% from 2010 to 2021, which was the duration of our study period.
00:03:36.000 --> 00:03:44.080
At the time of the study, we only had data up to 2021, but it may be that the real rates have continued to rise since then.
00:03:44.479 --> 00:03:58.719
Our second point is that when we look at factors that are associated with same-day discharge, those patients who are younger and had a complete resection were more likely to go home on the same day in comparison to those patients that were admitted.
00:03:58.960 --> 00:04:12.319
And lastly, and importantly, the short-term outcomes that we analyzed, including readmission rates and 90-day mortality, did not differ between the patients who had same-day discharge and those patients that were admitted.
00:04:12.560 --> 00:04:20.720
However, these results have to be interpreted in the context of our overall low event rates and also our wide confidence intervals.
00:04:21.439 --> 00:04:21.920
Excellent.
00:04:22.000 --> 00:04:22.399
Thank you.
00:04:22.560 --> 00:04:23.600
Back over to you, Alex.
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You know, I found it quite intriguing that there was between 43 and 51 patients in the study who had stage four disease.
00:04:32.399 --> 00:04:38.800
This kind of goes against uh what most people might think would be appropriate for minimally invasive surgery, patient selection.
00:04:38.959 --> 00:04:40.639
What are your thoughts regarding this?
00:04:41.040 --> 00:04:51.279
Yeah, so you know, I think patient selection for minimally invasive interval cytoreductive surgery is an active area of research still.
00:04:51.439 --> 00:05:06.160
You know, in the Lance trial, stage four patients are allowed, and they are allowed just as 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.
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Yeah.
00:05:48.639 --> 00:05:50.079
Thanks, thanks for providing that.
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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?
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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.
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I think it's likely multifactorial.
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So, like Dr.
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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.
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Melliman mentioned, those patients undergoing staging surgery, they usually present like at their baseline state of health.
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They tend to go home on the same day of surgery.
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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.
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It might be that providers are a little hesitant to send these patients home.
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And these patients may also feel uncomfortable with the idea of a same-day discharge.
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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.
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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.
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And national disparities in practice patterns, as well as differential access to care, likely impacted the rate of same-day discharge.
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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.
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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.
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Okay, another question for you, Alex.
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Same-day discharge is often framed as you know, patient-centered and evidence of high value care.
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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.
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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.
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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.
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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.
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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.
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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.
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Uh, the things I'm thinking of is sleeping in one's own bed.
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You know, hospital beds are not comfortable.
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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?
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Even when you're on oral pain medications in the hospital, you have to call the nurse.
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The nurse may have three patients, she may be dealing with something else.
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And so you're sort of at the mercy of what it is to be an inpatient.
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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.
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And, you know, people eat better and feel better if they go home.
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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.
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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.
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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.
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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.
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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.
