Search

PURPOSE: Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease. MATERIALS AND METHODS: We conducted a retrospective chart review of consecutive gynecology oncology outpatients. RESULTS: Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% v 67.5%; P =.001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups. CONCLUSION: Current processes fail to engage patients in selecting and preparing an MDM. [ABSTRACT FROM AUTHOR]

Background: The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined. Methods: A case-control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence. Results: The cases ( n = 75) were significantly older than the AV ( n = 203) and PV ( n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m2, p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge. Conclusions: Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation. [ABSTRACT FROM AUTHOR]

Abstract: Background: The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons. Methods: A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared. Results: Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p <0.001), BSO 7% to 75% (p =0.005), right PLND 4% to 44% (p <0.001), left PLND 0% to 56% (p <0.001), and VCC 59% to 82% (p =0.024). Console times (min) were similar for SH (60 vs. 63, p =0.73), BSO (48 vs. 43, p =0.55), and VCC (20 vs. 22, p =0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p =0.04, left 23 vs. 27, p =0.02). Nodal counts were not significantly different (right 7 vs. 8, p =0.17 or left 7 vs. 7, p =0.87). Conclusions: Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons. [Copyright &y& Elsevier]

BACKGROUND: Failure to detect metastasis to para-aortic nodes in patients with locally advanced cervical cancer leads to suboptimal treatment. No previous studies have prospectively compared positron emission tomography (PET)/computed tomography (CT) with laparoscopic extraperitoneal staging in the evaluation of para-aortic lymph nodes. METHODS: Sixty-five patients were enrolled; 60 were available for analysis. Patients with stage IB2-IVA cervical cancer without evidence of para-aortic lymphadenopathy on preoperative CT or magnetic resonance imaging (MRI) were prospectively enrolled. All patients underwent preoperative PET/CT. Laparoscopic extraperitoneal lymphadenectomy was performed from the common iliac vessels to the left renal vein. RESULTS: The median age at diagnosis was 48 years (range, 23-84). The median operative time was 140 minutes (range, 89-252). The median blood loss was 22.5 mL (range, 5-150). The median length of hospital stay was 1 day (range, 0-4). The median number of lymph nodes retrieved was 11 (range, 1-39). Fourteen (23%) patients had histopathologically positive para-aortic nodes. Of the 26 patients with negative pelvic and para-aortic nodes on PET/CT, 3 (12%) had histopathologically positive para-aortic nodes. Of the 27 patients with positive pelvic but negative para-aortic nodes on PET/CT, 6 (22%) had histopathologically positive para-aortic nodes. The sensitivity and specificity of PET/CT in detecting positive para-aortic nodes when nodes were negative on CT or MRI were 36% and 96%, respectively. Eleven (18.3%) patients had a treatment modification based on surgical findings. CONCLUSIONS: Laparoscopic extraperitoneal para-aortic lymphadenectomy is safe and feasible. Surgical staging of patients with locally advanced cervical cancer should be considered before planned radiation and chemotherapy. [ABSTRACT FROM AUTHOR]

Cervical cancer continues to be a major worldwide health concern, particularly in developing countries. In the past few decades, great strides have been made in understanding the molecular basis of the development of this disease. Human papillomavirus (HPV) has become recognized as the major factor in the genetic abnormalities associated with both pre-invasive and invasive cervical cancer. As a result, multiple therapies for the prevention and treatment of cervical cancer have been developed to target HPV. [Copyright &y& Elsevier]

Abstract: Background : Phlegmasia cerulea dolens is an extremely rare condition caused by complete venous occlusion and often results in tissue necrosis, limb amputation, or death. Treatment options include systemic anticoagulation, systemic thrombolytic therapy, fasciotomy, or surgical thrombectomy. Rare case reports have described the use of catheter-directed thrombolysis in the treatment of this condition. Prompt diagnosis and treatment initiation are important to prevent gangrene, amputation, and ultimately death. Case : We report two unusual cases of phlegmasia cerulea dolens that presented in patients with aggressive gynecologic malignancies and who were successfully treated with catheter-directed thrombolytic therapy. Conclusion : To maximize the opportunity for limb salvage, catheter-directed venous thrombolytic therapy should be considered in the treatment of phlegmasia cerulea dolens that presents in the gynecologic oncology patient. [Copyright &y& Elsevier]

The objective of this study was to assess differences in long-term sexual and menopausal side effects after uterine cancer treatment among treatment modalities. This is a cross-sectional study that examined women treated for uterine cancer from 2006–2018. Eligible women included those who underwent a hysterectomy/bilateral salpino-oophorectemy alone (HS), with brachytherapy (BT), or with external beam radiation therapy (EBRT). A noncancer cohort of women who underwent a hysterectomy/BSO for benign indications were also identified (non-CA). To compare outcomes, we utilized a shortened form of the female sexual function index (FSFI) and the menopause survey, which consists of 3 subscales: hot flashes, vaginal symptoms, and urinary symptoms. Demographic, comorbidity, and other treatment variables were collected. Survey totals were compared across cohorts using ANOVA tests and logistic regression. A total of 284 women completed the Menopause Survey (Non-CA 64, HS 60, BT 69, EBRT 91); 116 women reported sexual activity in the last 4 weeks and completed the FSFI (NC 32, HS 21, BT 31, EBRT 32). The mean FSFI score for the entire cohort was 11.4 (SD 4.16), which indicates poor sexual function. There was no significant difference between any cohort in the overall FSFI score (p = 0.708) or in any of the FSFI subscales (all p > 0.05). On univariate analysis, BT was associated with fewer menopausal hot flashes and vaginal symptoms compared to the non-CA cohort (p < 0.05), which did not persist on multivariable analysis. There was no significant difference in sexual dysfunction or menopausal symptoms in those treated for uterine cancer with or without adjuvant radiation. Most patients reported poor sexual function. [ABSTRACT FROM AUTHOR]

Objective: To assess efficacy of the levonorgestrel-releasing intrauterine device (LNG-IUD) for treatment of complex atypical hyperplasia or low-grade endometrial cancer.Methods: This retrospective case series included all patients treated with the LNG-IUD for complex atypical hyperplasia or early-grade endometrial cancer from January 2003 to June 2013. Response rates were calculated and the association of response with clinicopathologic factors, including age, body mass index, and uterine size, was determined.Results: Forty-six patients diagnosed with complex atypical hyperplasia or early-grade endometrial cancer were treated with the LNG-IUD. Of 32 evaluable patients at the 6-month time point, 15 had complex atypical hyperplasia (47%), nine had G1 endometrial cancer (28%), and eight had grade 2 endometrial cancer (25%). Overall response rate was 75% (95% CI 57-89) at 6 months; 80% (95% CI 52-96) in complex atypical hyperplasia, 67% (95% CI 30-93) in grade 1 endometrial cancer, and 75% (CI 35-97) in grade 2 endometrial cancer. Of the clinicopathologic features evaluated, there was a trend toward the association of lack of exogenous progesterone effect in the pathology specimen with nonresponse to the IUD (P=.05). Median uterine diameter was 1.3 cm larger in women who did not respond to the IUD (P=.04).Conclusion: Levonorgestrel-releasing IUD therapy for the conservative treatment of complex atypical hyperplasia or early-grade endometrial cancer resulted in return to normal histology in a majority of patients. [ABSTRACT FROM AUTHOR]

Uterine cancer is the most common gynecologic malignancy in the United States; however, little is understood of long-term sequelae of adjuvant radiotherapy treatment. The purpose of this study was to compare quality of life (QoL) in patients who have undergone surgery with or without adjuvant radiotherapy for uterine cancer. This is a cross-sectional cohort study that examined women treated for uterine cancer at a tertiary cancer center from 2006-2018. Participants included those who underwent hysterectomy/bilateral salpino-oophorectemy alone (BSO), with brachytherapy (BT), or with external bean radiation therapy (EBRT). A non-cancer cohort of women who underwent a hysterectomy/BSO for benign indications was also identified (NC). To compare QoL we utilized the FACT-En, a validated 27-question survey used to assess QoL in endometrial cancer patients. The survey consists of 5 well-being subscales: physical, social, emotional, functional, and an endometrial-cancer specific subscale. Responses are on a 5-point Likert scale, with a higher score indicating a better quality of life. Maximum score is 172 for the entire survey. Demographic and other treatment variables were obtained from medical records. Subscales and survey totals were compared across cohorts using ANOVA tests. 282 women completed the FACT-En survey (BSO 59, BT 70, EBRT 93, NC 65). Median time from surgery to completion of survey was 6.7 years. Women in the NC cohort were significantly younger at survey completion compared to the other cohorts (mean age 63 [std 8.2] NC, 66 [9.6] HS, 68 [8.4] BT, 67 [10.8] EBRT; p<0.001). Mean total FACT-En score for the entire cohort was 114.2 [22.1]. Overall QoL was significantly different between cohorts, with patients in the EBRT cohort reporting the lowest QoL (mean 139.4 [21.6]), followed by the NC cohort (142.1 [26.5]), BSO cohort (146.1 [20.1]), and the BT cohort reporting highest total score (150.6 [18.2], p=0.006). All subscales were significantly different (all p<0.05) across cohorts aside from social well-being subscale. In the physical domain, the EBRT cohort had the lowest average score (23.3 [5.0]), followed by the NC cohort (25.3 [4.2]), the BT cohort (25.0 [3.8]), with the BSO group reporting the highest scores (25.4 [3.9], p=0.001). The NC cohort reported the lowest scores in the endometrial symptom-specific subscale, with a mean score of 53.3 [10.5]. Among patients who had undergone cancer treatment, the EBRT cohort reported the worst average endometrial-specific QoL (53.5 [8.6]), while again the BT group reported the highest score (57.5 [6.1], p=0.007). QoL differences between treatment modalities for uterine cancer remain years after treatment. In women with endometrial cancer who require adjuvant therapy, vaginal brachytherapy does not appear to have any long-term effects of reported QOL. [ABSTRACT FROM AUTHOR]

Objectives The study objective was to analyze the impact of prognostic factors, including treatment modality, on outcome in patients with advanced-stage uterine serous carcinoma (USC). Methods A retrospective review of patients diagnosed with stage III or IV USC between 1993 and 2012 was performed. Summary statistics were used to describe demographic and clinical characteristics. Overall survival (OS) and recurrence free survival (RFS) were estimated by Kaplan-Meier analysis. Cox proportional hazards regression was used to model the association of potential prognostic factors with OS and RFS. Results The study included 260 patients with median follow-up of 26.6 months (range 1–172.8). Median age was 63 years (range 30–88) and 52.3% had stage III disease. In all, 60% were treated with surgery followed by chemotherapy, 18.1% received surgery, chemotherapy, and radiotherapy, 11.5% had surgery and radiotherapy, and 10.4% had neoadjuvant chemotherapy. The overall complete response rate was 68.9%, and the cumulative incidence of recurrence was 82.7%. Treatment that included surgery, chemotherapy, and radiation and stage III disease were associated with improved RFS on multivariate analysis. For OS, therapy with surgery, chemotherapy, and radiation, mixed histology, and stage III disease were associated with better OS on multivariate analysis. Conclusions Patients with advanced-stage USC have a poor prognosis, regardless of clinical factors or treatment received. However, combination therapy that includes chemotherapy and radiation appears to be associated with improved survival in these women. [ABSTRACT FROM AUTHOR]

Objective. Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. Methods. We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. Results. From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. Conclusions. This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted. [ABSTRACT FROM AUTHOR]

Objectives Uterine adenosarcoma is a rare malignancy with little data on optimal management. We aimed to clarify the impact of adjuvant therapy in patients with uterine adenosarcoma and identify risk factors for recurrence and death. Methods We performed a retrospective review of patients undergoing primary evaluation and treatment for uterine adenosarcoma at a single institution from July 1982 through December 2011. Univariate and multivariate analyses were used to identify prognostic factors for progression-free survival (PFS) and overall survival (OS). Results We identified 100 patients with uterine adenosarcoma, and 74 patients met the inclusion criteria. On multivariate analysis, sarcomatous overgrowth (SO) and lymphovascular space invasion (LVSI) were predictors of worse PFS and OS. Median PFS and OS were 29.4 and 55.4 months for patients with SO, compared to 105.9 and 112.4 months for patients without SO (PFS HR 2.58, 95% CI 1.37-4.84, p = 0.003; OS HR 2.45, 95% CI 1.26-4.76, p = 0.008). Among patients with stage I disease, 17 of 22 patients (77%) with SO and 8 of 37 patients (22%) without SO had a recurrence (p < 0.001). Among patients with stage I disease with SO, adjuvant therapy appeared to be associated with longer PFS and OS, but these differences were not statistically significant (PFS, 46.7 vs. 29.4 months, p = 0.28; OS, 97.3 vs. 55.4 months, p = 0.18). Conclusion In patients with uterine adenosarcoma, the presence of SO or LVSI confers a higher risk of recurrence. We did not identify an optimal treatment strategy for patients with SO, but adjuvant therapy may be associated with prolonged PFS. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the incidence of venous thromboembolism (VTE) before and after the implementation of standardized extended duration prophylaxis guidelines in women undergoing laparotomy for gynecologic cancer. Methods: In October 2009, departmental practice guidelines were implemented for VTE prevention. Patients undergoing laparotomy for gynecologic cancer were started on low molecular weight heparin (LMWH) within 24h of surgery and it was continued for a total of 28days postoperatively. The incidence of VTE diagnosed within 30 and 90days of surgery was determined and compared to a historic cohort of patients who underwent surgery prior to implementation of the guidelines. Results: The incidence of VTE within 30days of surgery decreased from 2.7% (8/300) to 0.6% (2/334) following implementation of VTE prevention guidelines (78% reduction, p=0.040). However, when the pre and post-guideline implementation groups were compared for the development of VTE within 90days of surgery, there was no significant difference (11/300 (3.7%) vs. 10/334 (3.0%) respectively, p=0.619). The median time between surgery and VTE diagnosis was 12days in the pre-guideline implementation group, compared with 57days in the post-guideline implementation group (p=0.012). Conclusion: Patients receiving extended duration LMWH were found to have significantly lower rates of VTE within 30days of surgery when compared with similar patients who did not receive extended duration LMWH. However, this effect was not sustained when the groups were compared for VTE diagnosis within 90days of surgery. Additional study is needed to further reduce long-term VTE rates in this high-risk population. [Copyright &y& Elsevier]

Abstract: Objective. : An HPV (human papillomavirus) vaccine will be available soon. Because vaccination for both boys and girls will be critical to reduce the incidence of this disease, we evaluated the willingness of women to accept the HPV vaccine and to consent to having their children vaccinated. Methods. : A 20-item questionnaire was distributed to women who had children between the ages of 8 and 14 years, the likely age range of the children who will be targeted to receive the vaccine. Results. : 200 women completed surveys. The median age for the respondents was 34.4 years (range, 23–53 years). 77% of the women surveyed would be willing to accept an HPV vaccine for themselves. 67% who had a daughter (n = 156) and 66% who had a son (n = 137) would consent to have their child vaccinated. Those not accepting the vaccine cited the risk of unknown adverse effects or their current lack of sexual activity. Women who would not consent to have their children vaccinated cited the risk of unknown adverse effects and their belief that their children are not sexually active. Male children not directly benefiting from the vaccine were also a reason for not considering the vaccine for sons. A history of an abnormal Papanicolaou smear was not associated with willingness to accept the vaccine. Conclusions. : This pilot study demonstrated a willingness of women to accept the HPV vaccine for themselves and their children. Gynecologists and gynecologic oncologists must focus not only on the diagnosis and treatment of cervical cancer but also on its prevention. [Copyright &y& Elsevier]