July 10th, 2020

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Timing of Referral to the New England Trophoblastic Disease Center: Decentralized Treatment for Postmolar Gestational Trophoblastic Neoplasia is Associated with Increased Lines of Chemotherapy and Longer Time to Remission
Authors:  Elisabeth J. Diver, M.D., Neil S. Horowitz, M.D., Kevin M. Elias, M.D., Donald P. Goldstein, M.D., Ross S. Berkowitz, M.D., and Whitfield B. Growdon, M.D.
  OBJECTIVE: To assess if referral before or after primary chemotherapy treatment for postmolar gestational trophoblastic neoplasia (PMGTN) affected subsequent clinical outcomes.

STUDY DESIGN: Records were queried retrospectively at the New England Trophoblastic Disease Center (NETDC) for all patients with PMGTN from 1993–2013 requiring >1 line of chemotherapy to achieve remission.

RESULTS: From 1993–2013 173 women were treated for PMGTN, and 65 required >1 line of chemotherapy and formed the study population. An increase in the need for >2 lines of chemotherapy was noted in the cohort referred after initial chemotherapy as compared to the cohort with treatment beginning at NETDC (9/18 [50%] vs. 7/40 [18%]; p=0.003); this difference remains significant when controlling for age, hCG at persistence, and WHO risk score (p=0.04). This translated into prolonged time to remission (78 vs. 107 days, p=0.01) on univariate analysis. Treatment at an outside institution was the variable most strongly associated with prolonged time to remission in a multivariate model (HR 0.54, 95% CI 0.27–1.07; p=0.08).

CONCLUSION: Primary chemotherapy for PMGTN prior to referral to our specialty center was associated with increased need for additional lines of chemotherapy, resulting in a significantly prolonged time to remission.
Keywords:  gestational trophoblastic disease, gestational trophoblastic neoplasia, hydatidiform mole, HCG (human chorionic gonadotropin), uterine neoplasms
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