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

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.