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To develop a machine learning (ML) algorithm to predict outcome of primary cytoreductive surgery (PCS) in patients with advanced ovarian cancer (AOC) METHODS: This retrospective cohort study included patients with AOC undergoing PCS between January 2017 and February 2021. Using radiologic criteria, patient factors (age, CA-125, performance status, BRCA) and surgical complexity scores, we trained a random forest model to predict the dichotomous outcome of optimal cytoreduction (1 cm) and no gross residual (RD = 0 mm) using JMP-Pro 15 (SAS). This model is available at https://ipm-ml.ccm.sickkids.ca.One hundred and fifty-one patients underwent PCS and randomly assigned to train (n = 92), validate (n = 30), or test (n = 29) the model. The median age was 58 (27-83). Patients with suboptimal cytoreduction were more likely to have an Eastern Cooperative Oncology Group 3-4 (11% vs. 0.75%, p = 0.004), lower albumin (38 vs. 41, p = 0.02), and higher CA125 (1126 vs. 388, p = 0.012) than patients with optimal cytoreduction (n = 133). There were no significant differences in age, histology, stage, or BRCA status between groups. The bootstrap random forest model had AUCs of 99.8% (training), 89.6%(validation), and 89.0% (test). The top five contributors were CA125, albumin, diaphragmatic disease, age, and ascites. For RD = 0 mm, the AUCs were 94.4%, 52%, and 84%, respectively.Our ML algorithm demonstrated high accuracy in predicting optimal cytoreduction in patients with AOC selected for PCS and may assist decision-making.

Objectives The optimal systemic therapy strategy for advanced epithelial ovarian cancer (EOC) remains unclear. We performed a systematic review and meta-analysis to assess oncologic outcomes and toxicity of bevacizumab combination treatment in advanced EOC. Methods We conducted an electronic search of all phase 2 and 3 clinical trials involving bevacizumab combination therapy in advanced-stage EOC between 2010 and March 2020, using Embase, Medline, Epub Ahead of Print, Cochrane for clinical trials, Cochrane Database of Systematic Reviews, Web of Science and clinicaltrials.gov databases. Progression-free survival (PFS), overall survival (OS), and their hazard ratios (HR) when available were extracted. Pooled HR were calculated for each efficacy endpoint in the meta-analysis using inverse variance weighted method. Bias was assessed using the Cochrane Collaboration Risk of Bias I (ROB1) tool for randomized controlled trials. Results Thirty-five studies were included in the qualitative analysis and eight studies in the quantitative synthesis. In the first-line setting, bevacizumab combined with chemotherapy revealed a significant improvement in PFS (pooled HR = 0.72, 95% CI 0.65–0.81) when compared to chemotherapy alone but no significant OS benefit (pooled HR = 0.88, 95% CI 0.72–1.06). In the recurrent setting, bevacizumab combinations showed significant PFS (pooled HR = 0.52, 95% CI 0.47–0.58) and OS benefits (pooled HR = 0.88, 95% CI 0.79–0.99) compared with non-bevacizumab regimens. Rate of bowel perforation was low at 1.24% (range 0–4.2%). Conclusions Bevacizumab-containing regimens are associated with significant PFS benefit in advanced and recurrent epithelial ovarian cancer. While the difference in OS did not reach statistical significance in the first-line setting, bevacizumab was associated with improved survival in the recurrent setting.

Most individuals with gestational trophoblastic neoplasia (GTN) are cured with chemotherapy; however, about 5% of them will develop chemotherapy-resistant disease and will die of disease progression. Most GTN tissues express programmed death ligand-1 (PDL-1), making immune checkpoint inhibitors (ICIs) targeting this pathway an attractive treatment option for individuals with GTN. There is increasing evidence to support the use of ICIs for individuals with recurrent or resistant GTN, but available data are derived from case reports and small single arm trials. As promising as it seems, not all individuals with GTN respond to ICIs, and there is lack of evidence toward which factors mediate the effect of ICIs on GTN. In addition, treatment-related adverse events and impact on future fertility are not negligible and should be considered before initiating this treatment. Therefore, additional research is needed to evaluate treatment outcome of ICIs in GTN compared to standard treatment, and to identify molecular and clinical predictors for treatment response, before this treatment is incorporated into the standard of care.

To determine the 30-day incidence of venous thromboembolism (VTE) after gynecologic oncologic surgery and identify perioperative factors associated with postoperative VTE.The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify all gynecologic oncology cases from 2013 to 2019. Clinical and surgical characteristics, VTE events and 30-day postoperative complications were retrieved. Chi-square analysis and logistic regression models were performed to compare characteristics and postoperative outcomes of patients with and without VTE.A total of 63,198 gynecologic oncology patients were included. The incidence of 30-day postoperative VTE was 1.2% (n = 781). On multivariable analysis, postoperative VTE was significantly associated with ascites (odds ratio (OR) 1.8), disseminated cancer (OR 1.7), pre-operative albumin30 g/L (OR 1.9), laparotomy (OR 2.8), operative time 180 min (OR 2.0), and increased surgical complexity (OR 2.2) (all p 0.001). The incidence of VTE was higher after laparotomy compared to minimally invasive surgery (MIS) (2.3% v. 0.6%, p 0.001). When stratified by type of gynecologic malignancy undergoing laparotomy, incidence of VTE was higher in patients with ovarian (2.4%) and uterine (2.4%) malignancies, compared to cervical cancer (1.1%) (p 0.001). The 30-day incidence of VTE was 1.7% in 2013 compared to 0.9% in 2019 (laparotomy: 2.6% in 2013 to 1.6% in 2019 and MIS: 0.8% in 2013 to 0.4% in 2019).Postoperative VTE is a potentially preventable complication of gynecologic oncology surgery. Our findings indicate that laparotomy, ascites, disseminated cancer, longer operative time, and low pre-operative albumin are risk factors for VTE.

5546 Background: In advanced ovarian cancer, the decision for primary cytoreductive surgery(PCS) or neoadjuvant chemotherapy(NACT) remains a challenge and may impact survival. We previously developed the integrated prediction model(IPM) using a 4-step algorithm of unresectable stage IVb, patient factors, surgical resectability and surgical complexity to predict outcome of optimal cytoreduction in advanced epithelial ovarian cancer(AEOC) and triage patients to NACT or PCS. The objective of the current study was to validate this model on a retrospective historical cohort of patients. Methods: This is a retrospective cohort study of 107 patients with AEOC treated at the Princess Margaret Cancer Centre between January 2017 and September 2018 undergoing PCS or NACT. All diagnostic imaging was retrospectively reviewed to assign surgical resectability score (SRS) for sites of disease and the surgical complexity score (SCS) for procedures anticipated to be required to achieve optimal cytoreduction based on pre-operative imaging. Those scores were modified from previously validated tools. Patient factors (PF) included age, ECOG and albumin. We previously developed an IPM algorithm to achieve outcome of optimal cytoreduction and determined cut-offs using the Youden index J. Triaging patients to PCS without stage IVb unresectable disease, PF≤ 2, SRS≤5 and SCS≤ 9 led to an 85% specificity and 75% accuracy for outcome of optimal cytoreduction < 1 cm. The current validation study was performed reporting sensitivity, specificity, negative (NPV) and positive predictive value (PPV) on an external cohort. Results: Among 107 patients, 61 had PCS and 46 had NACT followed by ICS. Patients treated with NACT were significantly older (63.5 vs 61 years, p = 0.037), more likely stage IV (52% vs 18%, p < 0.001), had a higher proportion of ECOG > 1 (30% vs 11%, 0.045), a lower pre-operative album (37 vs 40, p < 0.001) and higher CA-125 (970 vs 227.5, p < 0.001) compared to PCS. They also had higher PF (2 vs 0, p = 0.013), SRS (4 vs 1, p < 0.001) and SCS (8 vs 5, p = < 0.001). There was no significant difference in outcome of cytoreduction; the optimal cytoreduction rate was 85% vs 87%, p = 0.12 between PCS and ICS patients. In this validation cohort, triaging patients without unresectable stage IVb disease, PF≤ 2, SRS≤ 5 and SCS≤ 9 to PCS had a sensitivity of 91% to correctly identify patients who will have optimal cytoreduction of < 1 cm at PCS and a specificity of 81%. The PPV was 83%, NPV was 90% and accuracy was 86%. Application of the IPM would have prevented 5 suboptimal patients and correctly triaged them to NACT. Conclusions: We validated a triage algorithm integrating patient factors, surgical complexity and surgical resectability for patients with AEOC to achieve optimal cytoreduction at PCS with high sensitivity and specificity. This may therefore be used in a clinical setting to decide between PCS and NACT.

Objective A sentinel lymph node biopsy is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer, but its value in high-grade endometrial cancer remains controversial. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of sentinel lymph node biopsy in patients with endometrial cancer with high-grade histology (registered in the International Prospective Register of Systematic Reviews with identifying number CRD42020160280). Data Sources We systematically searched the MEDLINE, Epub Ahead of Print, MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase databases all through the OvidSP platform. The search was performed between January 1, 2000, and January 26, 2021. ClinicalTrials.gov was searched to identify ongoing registered clinical trials. Study Eligibility Criteria We included prospective cohort studies in which sentinel lymph node biopsy were evaluated in clinical stage I patients with high-grade endometrial cancer (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated or dedifferentiated, and high-grade not otherwise specified) with a cervical injection of indocyanine green for sentinel lymph node detection and at least a bilateral pelvic lymphadenectomy as a reference standard. If the data were not reported specifically for patients with high-grade histology, the authors were contacted for aggregate data. Methods We pooled the detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Results We identified 16 eligible studies of which the authors for 9 of the studies provided data on 429 patients with high-grade endometrial cancer specifically. The study-level median age was 66 years (range, 44–82.5 years) and the study-level median body mass index was 28.6 kg/m2 (range, 19.4–43.7 kg/m2). The pooled detection rates were 91% per patient (95% confidence interval, 85%–95%; I2=59%) and 64% bilaterally (95% confidence interval, 53%–73%; I2=69%). The overall node positivity rate was 26% (95% confidence interval, 19%–34%; I2=44%). Of the 87 patients with positive node results, a sentinel lymph node biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% confidence interval, 84%–96%; I2=0%), a false negative rate of 8% (95% confidence interval, 4%–16%; I2=0%), and a negative predictive value of 97% (95% confidence interval, 95%–99%; I2=0%). Conclusion Sentinel lymph node biopsy accurately detect lymph node metastases in patients with high-grade endometrial cancer with a false negative rate comparable with that observed in low-grade endometrial cancer, melanoma, vulvar cancer, and breast cancer. These findings suggest that sentinel lymph node biopsy can replace complete lymphadenectomies as the standard of care for surgical staging in patients with high-grade endometrial cancer.

Objectives: Optimally caring for oncology patients of culturally and linguistically diverse (CALD) backgrounds poses a unique set of challenges. We aimed to describe CALD gynecologic oncology patient characteristics and distress screening completion in a large, multicultural academic cancer center. Methods: This was a retrospective study of patients with a primary gynecologic malignancy treated in the medical, surgical, or radiation oncology and palliative care clinics at Princess Margaret Cancer Centre (PM), Toronto, Canada, from January 1 to December 31, 2019. Data was generated from electronic health records and other databases. Non-English patients were defined as those who listed a primary language on Electronic Patient Records other than English on initial registration. Edmonton Symptom Assessment System-revised (ESAS-r) was available in various languages, and completion rates were assessed and descriptive statistics performed. Results: In 2019, there were 19,343 patient visits recorded in gynecologic oncology clinics, and 4684 unique patients (mean visits per patient = 4.13). 1656 (8.6%) patient visits were registered as non-English speakers (376 [8.6%] out of 4684 unique patients) comprising more than 40 languages (Figure 1). Most common spoken languages were Mandarin (15.5%), Portuguese (11.6%), Cantonese (10.9%), Spanish (7.8%) and Italian (7.3%). ESAS-r completion rates in the gynecologic oncology clinics were lower in non-English (18.4%) than English (36%; p Download : Download high-res image (80KB) Download : Download full-size image Conclusions: The PM gynecology clinic sees a significant proportion of patients of CALD backgrounds. Completion rates of ESAS-r are significantly lower amongst patients of CALD backgrounds. These results suggest that linguistic sensitivity in assessing and treating gynecologic cancer patients is paramount. Further research focusing on optimizing care in CALD populations should be considered.

Objectives: The rate of perioperative adverse events, postoperative outcomes and survival between patients aged 60-69 yo versus those ≥70 yo undergoing surgery for the primary treatment of advanced ovarian cancer (OC). Methods: We retrospectively identified all patients ≥60 years old treated surgically for primary advanced high-grade OC at our institution between January 2016 and December 2018. Institutional National Surgical Quality Improvement Program data were obtained for post-operative complications. Additional data were abstracted from medical records. Results are stratified based on the treatment approach: primary debulking surgery (PDS) or neo-adjuvant chemotherapy followed by interval debulking surgery (NACT/IDS). Appropriate statistical tests were performed. Results: A total of 77 patients were analyzed; 45 were between 60-69 years and 32 were ≥70 years. There were no differences in preoperative BMI, ECOG, ASA, CCI, polypharmacy, baseline bloodwork and stage (Table 1). Only 2 patients ≥70 years (0.6%) saw a geriatric oncology specialist prior to treatment. A total of 32 patients underwent PDS (60-69yo: n=18, ≥70yo: n=14), and 45 patients had NACT/IDS (60-69yo: n=27, ≥70yo: n=18). In both PDS and NACT/IDS groups, there were no differences in the post-operative adverse events between the two age groups. Older patients in the NACT/IDS group received less total platinum and taxane chemotherapy before and after surgery compared to NACT/IDS patients aged 60-69 years (p Download : Download high-res image (144KB) Download : Download full-size image Download : Download high-res image (263KB) Download : Download full-size image Conclusions: Although baseline characteristics were comparable between younger and older OC patients, reasons for PDS versus NACT/IDS were difficult to extrapolate from the medical record. Age was not a factor influencing perioperative outcomes of advanced ovarian cancer patients and the main predictor of outcomes was treatment approach. Since PDS is the main predictor of survival, a standardized, multi-disciplinary approach to optimize the management of older patients with ovarian cancer is necessary. Use of a formal assessment tool and consultation with a geriatric specialist may facilitate more patients undergoing PDS.

292 Background: Initial treatment of epithelial ovarian cancer (EOC) consists of combination of cytoreductive surgery (CSR) and/or chemotherapy. Targeted therapies such as bevacizumab have shown to improve outcomes in a subset population with high-risk features. Real-world patterns of systemic therapy delivery in EOC in the modern era are not well understood. Our objective is to evaluate the patterns of first-line systemic treatment of advanced EOC in Ontario, focusing on adoption of bevacizumab, which was approved for use in 2016. Methods: We conducted a retrospective, population cohort study using administrative databases held at the ICES in Ontario, Canada. Patients diagnosed with non-mucinous EOC between 2014 and 2018 were identified from the Ontario Cancer Registry; early-stage disease was excluded. Information on systemic therapy was obtained from Activity Level Reporting and New Drug Funding Program databases. Provider of care (gynecologic oncologist vs medical oncologist) information was obtained from billing codes. Academic cancer centers were identified using validated systemic facility codes from Cancer Care Ontario. Statistical analyses include descriptive statistics, t-tests, and multivariable logistic regression using SAS. Results: Out of 4,680 cases diagnosed with EOC during the study period, 3,632 (77.6%) were considered advanced stage. Median age of cohort was between 65-70, and the majority had Charlson score of 1-2 (97%) and are urban (91.8%). A total of 3,181 (87.6%) patients underwent CRS and 2,722(74.9%) patients underwent chemotherapy. Of those who received chemotherapy, 1,259 (46.2%) received neoadjuvant chemotherapy, 1,012 (37.2%) received upfront CRS, and 451(16.5%) received chemotherapy only. The majority of chemotherapy was delivered by gynecologic oncologists (60.6%) and in academic cancer centres (61.7%). There was no significant difference in use of neoadjuvant chemotherapy between medical oncologists and gynecologic oncologists (p = 0.67). Only 53 chemotherapy patients (1.9%) received bevacizumab containing-regimen in the first-line setting. Medical oncologists were 4 times more likely to administer bevacizumab-containing regimen compared to gynecologic oncologists (OR 4.03, 95% CI.29 – 7.36) after adjusting for age, stage, Charlson score and rurality score on logistic regression. Delivery of bevacizumab is relatively higher in non-academic cancer centres (OR 2.61, 95% CI 2.32- 2.94) while 83% of intraperitoneal chemotherapy is delivered in academic cancer centres. Conclusions: Patterns of care of EOC in Ontario remain heterogenous between care providers and institutions, while uptake of bevacizumab for first-line treatment of EOC remains low. Factors leading to low uptake and real-world outcomes should be explored.

Objectives: Urinary retention after pelvic surgery is common and contributes to postoperative catheter-associated urinary tract infection (UTI). The aim of our quality improvement study was to reduce the rate of UTI by 50% during the study period. Methods: A standardized voiding protocol was designed and implemented in patients undergoing minimally invasive hysterectomy for gynecologic malignancy between January to September 2020. The protocol included: 1) aseptic indwelling catheter insertion technique, 2) use of a new catheter for every insertion attempt, 3) proper positioning of the catheter bag below the patient's bladder on the side of the table during surgery, 4) catheter removal immediately after surgery prior to transfer to recovery room, 5) bladder scan after void, 6) and limiting repeat catheterizations for retention (Figure 1). We compared the demographics, time to first void, rate of urinary retention, and UTI rates between the pre- and post-protocol cohorts. Data for the historical cohort was obtained using the National Surgical Quality Improvement Program (NSQIP) database. Chi-square and Fisher's exact tests were used for comparison of categorical variables and Wilcoxon Rank-Sum tests for continuous variables. Results: A total of 79 post-protocol patients were compared to 124 patients in a historical cohort. The post-implementation cohort was younger (59 vs 65; p=0.04) but clinical and surgical characteristics were not statistically different between the two cohorts. The voiding protocol led to a significant decrease in the interval to first void (289 vs 526 minutes; p Conclusions: Implementation of a standardized voiding protocol was associated with a significant reduction in time to first void, and 50% decreased catheter-associated UTI.

Objectives: The major shift in health-care resource utilization during the COVID-19 pandemic to support patients requiring mechanical ventilation and intensive care monitoring has led to unprecedented cancellations of elective surgeries and reductions of ambulatory clinic visits worldwide. The primary objective of this study is to determine whether the response to the pandemic resulted in modifications, cancellations or delays to the standard therapeutic algorithms for patients with gynecologic malignancies at tertiary, large-volume publicly funded Canadian cancer centers as compared to a privately funded American cancer center. Methods: This is a retrospective cohort study of all surgical oncology and gynecologic oncology cases performed in the province of Ontario and at the University Health Network/Princess Margaret Cancer Center (UHN/PMH) as a surrogate for treatment delays, compared to all gynecologic oncology patients treated at the Dana Farber Cancer Institute, Boston, MA, USA, between March 3, 2020-June 30, 2020. Descriptive statistics and treatment times were analysed using SPSS 25.0 Results: In the province of Ontario, between March 15, 2020-October 25, 2020, there was a 19% overall decrease in surgical oncology volumes compared to the same time period the previous year (March 17, 2019-Oct 17, 2019). There was an increase of 96% in high priority surgical oncology cases and a 43% decrease in low priority cancer cases. Surgeries for gynecologic malignancies decreased by 8% in the province of Ontario as compared to the previous year. At UHN/PMH, a publicly funded tertiary cancer center in Ontario, there was a 59.8% reduction in surgical oncology volumes between March 09, 2020-May 04 2020, as compared to the previous year (March 04, 2019-April 29 2019). In comparison, at the Dana Farber Cancer Institute, a privately funded tertiary cancer center, there were 202 new gynecologic oncology patient referrals and 66 returning patients between March 3, 2020-June 30, 2020. The median time from referral to first consultation for new patients was 11 days (range 1-21) and the time to primary treatment was 31 days (range 5-157). New patients with ovarian malignancies had the shortest time to treatment of 22 days (range 5-157). There were no modifications made to the standard of care treatment plans for any patients and 5.7% of the patients had treatment delays. Conclusions: During the COVID-19 pandemic, the public Canadian healthcare system in the province of Ontario was subjected to a 19% reduction in surgical oncology volumes and 8% specifically for gynecologic oncology surgeries, while there was a 5.7% treatment delay for gynecologic oncology surgeries for a similar patient cohort treated at a tertiary cancer center in a privately funded health care system in the United States.

Objectives: Timely treatment of primary epithelial ovarian cancer (EOC) by gynecologic oncologists (GOs) with a combination of surgery and/or platinum/taxane-based chemotherapy at expert centers has been advocated. Nonetheless, some patients have their oncologic surgery by non-GOs or are not assessed by GOs prior to starting their initial cancer treatment. The aim of the study was to evaluate the impact of care by gynecologic oncologists on the survival of primary non-mucinous EOC in Ontario. Methods: In this population-based retrospective cohort study, patients diagnosed with non-mucinous EOC between 2007-2018 were identified using province-wide administrative databases. Assessment by GOs was defined as any consultation 6 months prior to diagnosis date and up to first treatment (surgery or chemotherapy). Type of surgeon performing surgeries related to ovarian cancer were identified (general gynecologists, general surgeons, or GOs). Multivariate cox proportional hazards regression models were used to evaluate the impact of GO consultations prior to initiating treatment or having surgery done by a GO on the survival of ovarian cancer. Age, socioeconomic status (SES), year of diagnosis, comorbidity score and days from diagnosis to surgery were covariates in the models. FIGO stage was available in 70% of our cohort. Sensitivity analysis was performed adjusting for stage and the other covariates. Results: A total of 10,086 EOC patients were included between 2007-2018 with a median age of 63 years (range 53-72). Primary treatment included surgery alone in 26% of patients (2,593/10,086), while 63% (6,397/10,086) had neoadjuvant chemotherapy and/or adjuvant chemotherapy and 11% (1,096/10,086) had chemotherapy alone. A total of 8,990 ovarian cancer patients underwent surgery as part of their primary treatment. During the study period, there was an increase in GO consultations (79% in 2007 to 87% in 2018-19) and surgeries performed by GOs (69% in 2007 to 88% in 2018-19). On multivariate analysis, there was an increase in all-cause mortality for patients not assessed by GOs before first treatment (Hazard ratio (HR): 2.18; 95% CI 1.98-2.41). There was also an increase in all-cause mortality if ovarian cancer surgery was performed by non-GOs (HR 2.37; 95% CI 2.11- 2.67) after adjusting for age, SES, year of diagnosis, comorbidity score and days from diagnosis to surgery. In a sensitivity analysis where FIGO stage was added to the models, there remained a significant increase in all-cause mortality for patients not assessed by GOs before first treatment (HR 1.44; 95% CI 1.26-1.66) and an increase in all-cause mortality if ovarian cancer surgery was performed by non-GOs (HR 2.23; 95% CI 1.88-2.65). Conclusions: Assessment by GO before starting initial treatment (chemotherapy or surgery) was associated with improved survival in women with non-mucinous EOC. Type of surgeons performing primary ovarian cancer surgery had a significant impact on survival.

Objectives: Same-day discharge (SDD) after minimally invasive hysterectomy for benign or malignant gynecologic conditions has been shown to be safe and feasible, but remains challenging to implement. We designed and implemented a quality improvement perioperative program for minimally invasive gynecologic oncology surgery (MIGOS). Our aim was to improve SDD rate from 30% to 75% over the study period, while maintaining acceptable 30-day perioperative outcomes and patient experience. Methods: Consecutive patients undergoing minimally invasive hysterectomy at a single cancer centre were included during the 9-month project period and a historical cohort of 100 consecutive patients was identified for comparison. A team of gynecologic oncologists, anesthesiologists, and nurses developed a comprehensive perioperative care program and met bi-weekly to revise interventions through plan-do-study-act (PDSA) cycles. Patients were followed for 30 days after discharge. We conducted a descriptive analysis of the characteristics of pre-MIGOS and MIGOS patient cohorts using Wilcoxon rank-sum or Fisher exact tests. We used a run chart to monitor effects of interventions on outcomes and a pre-post analysis to evaluate for statistical significance of change in SDD and perioperative outcomes. Results: We assessed 100 consecutive pre-MIGOS and 79 consecutive MIGOS patients. Overall SDD rates increased from 31% (31/100) to 71% (56/79) after implementation (p Download : Download high-res image (130KB) Download : Download full-size image Conclusions: Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, a multidisciplinary team significantly improved SDD rates while maintaining low 30-day perioperative complications and excellent patient experience.

Objectives: Sentinel lymph node (SLN) biopsy is widely accepted as the standard of care for surgical staging in low grade endometrial cancer, but its value in high grade endometrial cancer remains unclear. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of SLN biopsy compared with pelvic lymphadenectomy in endometrial cancer patients with high-grade histology (PROSPERO ID: CRD42020160280). Methods: We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Ovid MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (January 1, 2000 to February 4, 2020) for prospective observational studies evaluating SLN biopsy in clinical stage I high grade endometrial cancer patients (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated/dedifferentiated, high grade not otherwise specified). Studies in which patients underwent cervical injection of indocyanine green for SLN detection, and at least a bilateral pelvic lymphadenectomy as a reference standard, were eligible for inclusion. If data was not reported specifically for patients with high grade histology, authors were contacted for aggregate data. We pooled detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit link, and assessed risk of bias using the QUADAS-II tool. Results: We identified 20 eligible studies, of which the authors for 8 provided data on 427 high grade patients specifically. The study-level median age was 66.9 years (range 44-82.8) and the study-level median BMI was 28.8 kg/m2 (range 18.9-45.2). The pooled detection rates were 91% per patient (95% CI 85-95; I2=62%) and 64% bilaterally (95% CI 53-73, I 2=72%). The overall node-positivity rate was 26% (95% CI 20-34; I 2=47%). Of 87 node positive patients, SLN biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% CI 84-96; I2=0%) (Figure 1), false negative rate of 8% (95% CI 4-16; I2=0%), and negative predictive value of 97% (95% CI 95-99; I 2=0%). Download : Download high-res image (94KB) Download : Download full-size image Conclusions: SLN biopsy accurately detects lymph node metastases in high grade endometrial cancer, with a false negative rate comparable to that observed in melanoma and breast cancer. Diagnostic accuracy would be even higher if a strict SLN algorithm was followed in all included studies. SLN biopsy can replace complete lymphadenectomy in patients with high grade endometrial cancer.

Objective To report three cases of embryonal rhabdomyosarcoma (ERMS) of the cervix in young women successfully treated with fertility-sparing surgery and chemotherapy. Methods Between January 2014 and December 2015, three cases of ERMS of the cervix were confirmed in young women at a single tertiary cancer center. All cases were managed by a pediatric oncologist and a gynecologic oncologist with a combination of surgery and chemotherapy. Fertility-sparing surgeries (cervical conization or robotic-assisted radical trachelectomy) were offered to patients depending on the tumor size. Results All patients were nulliparous and aged 14, 20 and 21 years and all presented with abnormal uterine bleeding. The first patient was managed with radical trachelectomy followed by adjuvant chemotherapy. The second patient underwent primary hysteroscopic resection of the tumor followed by completion cervical conization and adjuvant chemotherapy. The third patient received neoadjuvant chemotherapy followed by loop electrosurgical excision procedure (LEEP) with positive residual margins. She then underwent completion radical trachelectomy. None of the patients experienced perioperative complications. None of the women received radiation. All patients are alive with no evidence of disease. Conclusion Fertility-sparing surgery and chemotherapy in well-selected patients with ERMS of the cervix result in low complication rates and excellent oncologic outcomes. This treatment option may be considered in young patients who wish to preserve fertility by avoiding hysterectomy. A collaborative effort between pediatric oncologists and gynecologic oncologists is imperative to facilitate innovative approaches to these rare tumors in young adults., Highlights • Embryonal RMS of the cervix has an excellent prognosis when treated adequately. • Embryonal RMS of the cervix is treated with surgery and multi-agent chemotherapy. • Fertility-sparing surgery can be offered in young patients with early cervical RMS.

Objective Gynecologic Oncology patients are traditionally admitted for 2–3 days following ileostomy closure. Our aim was to assess feasibility and safety of same-day discharge (SDD), by comparing 30-day clinical outcomes after SDD and standard admission. Methods Retrospective study of patients who underwent ileostomy closure at two academic tertiary centres in Toronto, Canada, between January 2010 and October 2017. Results In total 117 patients underwent ileostomy closure: 23 had SDD and 94 were admitted for a median of 3 days. There were no significant differences between groups in terms of age, body mass index, comorbidities, primary malignancy, tumor stage, indication for ileostomy, previous radiation therapy, chemotherapy, interval between ileostomy formation and closure, and intraoperative complications. Median operative time was shorter (47 versus 60 min, p = 0.0001) and there was a longer median interval between last chemotherapy cycle to ileostomy closure (145 versus 106 days, p = 0.01) in the SDD group. SDD was not associated with an increased risk of adverse events (13% versus 24.5%, p= 0.24), as assessed by a composite outcome which included small bowel obstruction, anastomotic leak, surgical site infection, clostridium difficile infection, sepsis, and thromboembolic events, when compared to standard admission. Moreover, SDD did not lead to more emergency room visits (17.4% versus 16%, p = 0.87) or readmissions within 30 days of surgery (17.4% versus 8.5%, p= 0.21). Conclusions SDD is a safe alternative to routine hospitalization that has the potential to improve healthcare resource utilization, without increasing readmissions or emergency room visits. Careful patient selection is warranted.

224 Background: Adverse drug events are common in ambulatory oncology where care spans multiple providers and medication documentation is often poor. We undertook a QI project with the aim of having 30% of patients have a best possible medication history (BPMH) or medication reconciliation (MedRec) documented within 30 days of starting systemic therapy. Methods: An Electronic Medical record-Integrated Tool (EMITT) was developed to facilitate documentation. 2 Plan-Do-Study-Act (PDSA) cycles have been completed to date; PDSA 1 consisted of piloting EMITT in 3 clinics run by physician champions. PDSA 2 which consisted of expanding pharmacy support and addition of a 4th clinic was impacted by care changes related to COVID. The proportion of patients with BPMH/MedRec documented in EMITT was calculated monthly for each period (PDSA 1, PDSA 2 pre-COVID and PDSA 2 post-COVID). The balancing measure of time to complete an entry was evaluated through a time motion study. Results: Between 9/9/2019 and 31/5/2020, 9.4% (233/2488) of patients had BPMH/MedRec completed; Table shows proportion of patients by month. BPMH and MedRec were most frequently performed by pharmacists followed by pharmacy students and nurses. On average, it took 5.5 minutes to complete an entry (n = 10; median number of medications per patient = 12.3). Conclusions: BPMH was documented more often than MedRec. While some usage was sustained, the changes to care as a result of COVID-19 negatively impacted ambulatory medication reconciliation. Future PDSA cycles will involve engaging patients in MedRec and extending EMITT to all ambulatory cancer clinics where medication management is a major component of care. [Table: see text]

21 Background: Cancer prevalence is rising and there is a corresponding increase in hospitalizations across the cancer continuum. However, little is known about the patterns of care and outcomes of cancer inpatients as administrative data may not capture in-hospital details including investigations and medications required for characterization. Understanding how cancer inpatients are managed and their outcomes can help to optimize care delivery. Methods: We conducted a multicenter study of all patients admitted to GIM at seven hospitals (Toronto, Canada) from 2010 to 2017 where we deterministically linked administrative data with each hospital’s electronic information (pharmacy, orders, notes, laboratory/imaging and results) at the patient level. Multivariable regression models compared characteristics and outcomes between cancer and non-cancer patients for the top 5 non-cancer patient discharge diagnoses. Results: Among 230,040 hospitalizations, 15% had cancer listed as an ICD-10 comorbidity. The most common cancer disease sites were gastrointestinal (20%), lung (13%) and leukemia (11%). The most common discharge diagnoses for cancer patients were disease progression (9%), palliative care (6%), pneumonia (4%), leukemia (4%) and lung cancer (4%), while for non-cancer patients were: heart failure (5%), pneumonia (5%), stroke (5%), COPD (5%) and urinary tract infections (5%). In general, compared to non-cancer patients, cancer patients were younger (70 vs 72), had greater length of stay (LOS; 6.4 vs 4.6 days), in-hospital mortality (16% vs 5%), ICU use (12% vs 11%), 30 day re-admission rate (17% vs 10%) and were more likely to receive CTs (64% vs 52%), MRIs (14% vs 12%) and interventional procedures (22% vs 8%) (p < 0.001, all comparisons). When evaluating the top 5 non-cancer patient discharge diagnoses, results (adjusted for age, gender, Charlson comorbidity score and hospital) were similar wherein cancer patients had a higher in-hospital mortality (aOR = 2.02 p < 0.001), 30 day re-admission rate (aOR = 1.09 p = 0.08) and were more likely to receive CTs (aOR = 1.88 p < 0.001), MRIs (aOR = 1.66 p < 0.001) or interventional procedures (aOR = 1.78 p < 0.001), despite similar mean LOS (5.7 vs 5.1 days p = 0.35). Results were similar across discharge diagnoses. Conclusions: Cancer patients represent a unique population on GIM and have higher resource use, mortality and LOS compared to non-cancer patients, with similar trends even for the same non-cancer diagnoses. Specialized models of care for hospitalized cancer patients may be warranted.

248 Background: Substantial work has been done to implement medication reconciliation (MedRec) in the inpatient setting to reduce medical errors and drug discrepancies. However, this work has not extended to the ambulatory cancer setting, where care spans multiple providers and responsibility remains unclear. We undertook an environmental scan to understand current MedRec practices in ambulatory cancer care across Canada. Methods: Semi-structured telephone interviews were conducted with stakeholders from institutions across Canada during a 2-month period in 2019. Questionnaires were pre-circulated to participants to guide discussions. Questions probed participants on processes, policies, roles and responsibilities, definitions of target populations, information sources, and barriers and facilitators. Results: 21 of the 23 stakeholders contacted were interviewed, representing 9 of 10 Provinces. Most institutions had a process in place for collecting best possible medication history (BPMH; 81%); however, considerable variation in practice was noted and full MedRec was uncommon. Of those institutions with a process, BPMH was most often undertaken by a pharmacist or pharmacy tech (53%) using a comprehensive Provincial drug information system (65%) as a starting point, and targeted patients initiating systemic therapy (59%). Few institutions (22%) routinely collected performance measures evaluating the process or outcomes. Lack of resources (physical, human and financial), high patient volumes, and access to medication records from external institutions and community pharmacies were identified as significant barriers to routinely collecting BPMH. Understanding the value added, clinician buy-in, and patient education regarding the importance of bringing medication to the clinic were identified as facilitators. Leveraging patients to more actively participate in collection and maintenance of their own medication records was identified as an area for future work. Conclusions: While most centres were doing BPMH in some patients, MedRec was uncommon in the ambulatory cancer setting. Results indicate a lack of consensus regarding best practices for medication management in ambulatory cancer care.

e17093 Background: Heated intraperitoneal chemotherapy (HIPEC) following cytoreductive surgery in the treatment of primary epithelial ovarian cancer (EOC) after neoadjuvant chemotherapy was associated with a significant 12 months improved overall survival (OS) in a well-designed randomized controlled trial. Nonetheless, there remains uncertainty about the benefit and safety of HIPEC in ovarian cancer. The aim of this review was to assess efficacy and safety of HIPEC in primary EOC. Methods: We conducted a systematic search in Medline, Embase, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, from inception to February 22nd 2018 for observational and randomized studies of patients with primary EOC undergoing HIPEC at cytoreductive surgery with no language restrictions . We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies. We determined the pooled proportion of 30-day grade 3-4 morbidity, reoperation, and postoperative death. Results: Thirty-five articles including 1937 patients with primary EOC met inclusion criteria. Timing of HIPEC and type of chemotherapy regimens were not consistent between studies. There was significant variation in the reported OS of patients treated with HIPEC at cytoreductive surgery for primary EOC (3-year OS:48-77%; 5-year OS:17-72%). Thirteen articles were including in a meta-analysis to determine to the safety of HIPEC. The pooled proportions for 30-day Grade 3-4 morbidity, 30-day reoperation, and 30-day postoperative death were 33.0% (95% CI 23.0-45.0), 9.0% (95% CI 5.0-17.0) and 3.0% (95% CI 1.0-5.0) respectively. Conclusions: The use of HIPEC in primary EOC is associated with significant morbidity. There is significant heterogeneity in current literature. Higher quality, large prospective randomized control trials are needed to further support the benefit of HIPEC at cytoreductive surgery in the first-line treatment of primary EOC.

TPS5611Background: ACT is based on the in vitro expansion of T cells with anti-tumor activity, followed by transfer of large numbers of T cells back to the patient. T cells for ACT can be obtained ...