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In memoriam: Franco M Muggia [Letter]

Pothuri, Bhavana; Curtin, John P
PMID: 35058333
ISSN: 1525-1438
CID: 5131842

Opioid-free gynecologic surgery: A prospective quality improvement initiative [Meeting Abstract]

Margolis, B; Andriani, L; Baumann, K E; Hirsch, A; Lutz, K; Curtin, J P; Pothuri, B
Objective: Surplus postoperative opiate pills can lead to misuse and dependence for patients and household contacts. We aimed to omit or reduce opiate prescriptions after gynecologic surgery with a prospective quality improvement initiative.
Method(s): Patients undergoing scheduled surgery by a gynecologic oncologist at an academic hospital were included. Procedures performed vaginally were excluded. Patients received preoperative counseling, including setting expectations and pain management strategies. Preoperative gabapentin and acetaminophen and postoperative acetaminophen, ibuprofen, and gabapentin were prescribed. Ambulatory patients were not prescribed opiates, and minimally invasive (MIS) 23-hour observation patients were prescribed only 4 pills of oxycodone if they used >5 opiate doses prior to discharge. Laparotomy patients were provided oxycodone opiate prescriptions according to their usage 24 hours prior to discharge: no opiate prescriptions if 0-1 dose used, 4 pills if 2-5 doses used, and 12 pills if >5 doses used. Baseline characteristics, postoperative opiate prescriptions, opiate refills, and pain scores were collected 60 days pre- and post-intervention. Pre- and post-intervention variables were compared using t tests, Wilcoxon rank sum tests, Pearson X2, and Fischer exact tests.
Result(s): A total of 193 procedures (103 pre- and 90 post-intervention) were analyzed. The mean number of opiate pills prescribed decreased from 5.63 to 1.96 (P < 0.001); mean oral morphine equivalent decreased from 29 to 12 (P < 0.001), and the percentage of patients sent home with an opiate prescription was reduced from 69% to 23% (P < 0.001). MIS hysterectomy patients who received an opiate prescription decreased from 81% to 18% (P < 0.001), and laparotomy patients who received an opiate prescription decreased from 64% to 50% (P = 0.400). There was no significant change in postoperative opiate prescription refills (6% vs 11%, P = 0.184) or postoperative pain calls (9% to 14%, P = 0.137). Ninety-five percent of patients agreed to the statement "my pain was well controlled after surgery" at their postoperative visit. See Table 1.
Conclusion(s): Opiate prescriptions were significantly reduced or omitted with excellent patient satisfaction and without increasing refills. More than 80% of MIS hysterectomy and 50% of laparotomy patients were discharged without an opiate prescription. Curtailing or omitting opiate prescriptions is a very important step in reducing the opioid epidemic by surgeons.
Copyright
EMBASE:2008347134
ISSN: 0090-8258
CID: 4638412

Factors associated with delay in treatment initiation of locally advanced cervical cancer [Meeting Abstract]

Lee, S S; Berger, A A; Ishaq, O; Curtin, J P; Salame, G M; Pothuri, B; Schiff, P B; Boyd, L R; Lymberis, S
Objective: We aimed to explore the disparities associated with the delay of initiating chemoradiation therapy (CRT) and brachytherapy (BT) beyond the recommended 8 weeks for patients with cervical cancer and the effect on outcomes.
Method(s): Patients with FIGO stage IB2-IVA cervical cancer treated at an academic medical center and an urban public hospital by the same team of gynecologic and radiation oncologists with definitive CRT and BT from July 2009 to September 2017 were included. Patients received CRT followed by BT (7 Gy x 4 fractions) delivered via 2 insertions 1 week apart with image-guided CT/MR delineation. Patients who initiated CRT within 8 weeks from diagnosis as recommended (rCRT) were compared across demographic and cancer outcomes to patients who received delayed CRT after 8 weeks (dCRT). Disease-free survival (DFS) and overall survival (OS) were analyzed using adjusted Cox regression analysis (P < 0.05).
Result(s): In our cohort of 97 patients, 72 (75.0%) had rCRT and 24 (25.0%) had dCRT. At a median follow-up of 31.5 months, overall local control was achieved in 94.8% of patients. Patients with dCRT were more likely to be African-American (37.5% vs 17.8%, P = 0.046) and be uninsured or on Medicaid (87.5% vs 61.6%, P = 0.023). There were no differences in stage and grade. Patients with dCRT were more likely to recur or progress (OR = 2.65, 95% CI 1.02-6.86). Of those who recurred, 35.0% of rCRT patients had locoregional recurrence versus 66.7% of dCRT patients (P = 0.144). When controlling for age, race, insurance, referring hospital, and stage, patients with dCRT had lower DFS than patients with rCRT (50.6 vs 63.2 months, aHR = 6.11, 95% CI 2.00-18.62). However, there were no differences in OS.
Conclusion(s): Patients receiving delayed CRT tended to have worse recurrence and DFS than those initiating CRT by 8 weeks from diagnosis. African-American and uninsured patients were more likely to experience a delay in care. Navigator and social work services may help improve access to treatments for these patients.
Copyright
EMBASE:2008347033
ISSN: 0090-8258
CID: 4638422

Does race impact time to presentation in patients with endometrial cancer? [Meeting Abstract]

Saleh, M; Curtin, J P; Boyd, L R
Objective: Prior studies have investigated how long women cope with the symptoms of endometrial cancer prior to presentation to a physician. Most studies utilized patient surveys following cancer diagnosis, which are subject to recall bias. Black women are known to present with more advanced stages of endometrial cancer and more aggressive subtypes. We sought to investigate whether race has an impact on time to presentation to a physician with symptoms of endometrial cancer and whether this may account for later stage at diagnosis.
Method(s): This was a retrospective chart review of endometrial cancer patients at an urban academic center from October 22, 2010, to October 22, 2018. Demographic and cancer-related data were abstracted. Time to presentation was determined by review of clinical documentation. Student t and chi2 tests were utilized to compare groups. Statistics were performed with Stata v15.
Result(s): A total of 885 patients were identified for inclusion. There were 625 white women and 108 black women. Most patients presented with postmenopausal bleeding (65% of white women vs 61% of black women). White women experienced symptoms for 97 days prior to presentation to care, whereas black women experienced symptoms for 242 days (P = 0.0015). There was no significant difference in proportion of black women or white women who had public insurance. Black women were on average younger than white women (61.9 years vs 63.9 years, P = 0.04) and had higher BMI at diagnosis (34.7 kg/m2 vs 30.7 kg/m2, P < 0.00001). White women had lower parity than black women (P < 0.001) and were more likely to be nulliparous than black women (P = 0.000389). The average time between the first visit with gynecologic oncology and date of first treatment was 34 days, which was equivalent among both groups. Black women were more likely to present at stage II or later than white women (P = 0.000003).
Conclusion(s): Black women experienced symptoms of endometrial cancer for significantly longer than white women and were more likely to present at stage II or greater. This occurred despite no differences in insurance status. Although white women presented earlier, both groups exhibited a waiting period of more than 3 months prior to presentation. Increased efforts at education and outreach are warranted by these results.
Copyright
EMBASE:2008346820
ISSN: 0090-8258
CID: 4638432

Facilitated referral pathway for genetic testing at the time of ovarian cancer diagnosis: uptake of genetic counseling and testing and impact on patient-reported stress, anxiety and depression

Frey, Melissa K; Lee, Sarah S; Gerber, Deanna; Schwartz, Zachary P; Martineau, Jessica; Lutz, Kathleen; Reese, Erin; Dalton, Emily; Olsen, Annie; Girdler, Julia; Pothuri, Bhavana; Boyd, Leslie; Curtin, John P; Levine, Douglas A; Blank, Stephanie V
BACKGROUND:Timely genetic testing at ovarian cancer diagnosis is essential as results impact front line treatment decisions. Our objective was to determine rates of genetic counseling and testing with an expedited genetics referral pathway wherein women with newly-diagnosed ovarian cancer are contacted by a genetics navigator to facilitate genetic counseling. METHODS:Patients were referred for genetic counseling by their gynecologic oncologist, contacted by a genetics navigator and offered appointments for genetic counseling. Patients completed quality of life (QoL) surveys immediately pre- and post-genetic assessment and 6 months later. The primary outcome was feasibility of this pathway defined by presentation for genetic counseling. RESULTS:From 2015 to 2018, 100 patients were enrolled. Seventy-eight had genetic counseling and 73 testing. Median time from diagnosis to genetic counseling was 34 days (range 10-189). Among patients who underwent testing, 12 (16%) had pathogenic germline mutations (BRCA1-7, BRCA2-4, MSH2-1). Sixty-five patients completed QoL assessments demonstrating stress and anxiety at time of testing, however, scores improved at 6 months. Despite the pathway leveling financial and logistical barriers, patients receiving care at a public hospital were less likely to present for genetic counseling compared to private hospital patients (56% versus 84%, P = 0.021). CONCLUSIONS:Facilitated referral to genetic counselors at time of ovarian cancer diagnosis is effective, resulting in high uptake of genetic counseling and testing, and does not demonstrate a long term psychologic toll. Concern about causing additional emotional distress should not deter clinicians from early genetics referral as genetic testing can yield important prognostic and therapeutic information.
PMID: 32057464
ISSN: 1095-6859
CID: 4304652

Neoadjuvant chemotherapy in patients with advanced endometrial cancer

Khouri, Olivia R; Frey, Melissa K; Musa, Fernanda; Muggia, Franco; Lee, Jessica; Boyd, Leslie; Curtin, John P; Pothuri, Bhavana
OBJECTIVES/OBJECTIVE:Neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) is a treatment strategy for ovarian cancer patients with unresectable disease or poor performance status (PS). This strategy has been used in the treatment of advanced endometrial cancer and a survival benefit has been shown in patients who are subsequently able to undergo interval cytoreduction. This study sought to review our single institution experience with NACT for advanced endometrial cancer. METHODS:We conducted a retrospective review of all patients who received NACT for advanced endometrial cancer at two institutions in New York City between 2002 and 2016. RESULTS:We identified 39 patients (median age 61, range 35-89). The histologic subtype distribution was: serous (44%), endometrioid (28%), carcinosarcoma (10%), clear cell (8%), mixed (8%), neuroendocrine (3%). Contraindications to primary surgery included: unresectable disease (72%), poor PS (15%), unresectable disease and poor PS (13%). Twenty-three patients (59%) did not undergo IDS due to: progression of disease (70%), medical ineligibility (4%), unresectable disease (17%), lost to follow-up (4%), death (4%). Sixteen patients (41%) underwent IDS, 81% had an optimal cytoreduction. Disease status at NACT completion was: partial response (56%), stable disease (3%) and progression of disease (41%). There were no complete responses. Patients who responded to NACT had a significantly longer overall survival than those who did not (15 vs. 5 months. P = 0.015). IDS was also associated with an improvement in overall survival versus no surgery (16 vs. 6 months, P = 0.04). CONCLUSIONS:Unlike ovarian cancer, less than half of the patients undergoing NACT for endometrial cancer underwent IDS, none had a complete response, and 41% had disease progression during NACT. However, endometrial cancer patients who underwent IDS had a high rate of optimal cytoreduction. Both response to NACT and IDS were associated with improved survival.
PMID: 30980132
ISSN: 1432-0843
CID: 3809502

A phase II feasibility study of nab-paclitaxel and carboplatin in chemotherapy naive epithelial neoplasms of the uterus [Meeting Abstract]

Pothuri, B; Sawaged, Z; Lee, J; Musa, F; Lutz, K; Reese, E; Blank, S V; Boyd, L R; Curtin, J P; Li, X; Goldberg, J D; Muggia, F M
Objective: Few effective treatment options exist for women with advanced or recurrent endometrial cancer (EC). To explore a modification of the standard systemic treatment for advanced or recurrent EC, we sought to determine the feasibility of completing 6 cycles of nab-paclitaxel (Nab-P) and carboplatin. Unlike paclitaxel, Nab-P does not require any steroid or other premedication, an important consideration for patients with diabetes mellitus and in the investigation of combinations with immunotherapy. We prospectively evaluated safety and efficacy of a day 1, 8-dose schedule of Nab-P in combination with carboplatin day 1 q3weeks in patients with chemotherapy naive EC.
Method(s): Patients with early-stage and high-risk, advanced primary, or recurrent EC with no prior platinum and taxane exposure were enrolled at a single institution. Patients received 6 cycles of day 1 Nab-P 100 mg/m2 IV with carboplatin AUC 6 IV and day 8 Nab-P 100 mg/m2 IV q21days. We evaluated percentage completion of 6 cycles with standard dose reductions, as well as toxicity per CTCAE v.4. Measurable disease was not required, and efficacy was assessed by PFS rate at 6 months.
Result(s): From 2016 to 2018, 23 subjects were enrolled; median age was 65 (43-73) years. Nineteen (82%) completed 6 cycles of the doublet therapy. Eight subjects (35%) were dose-reduced 1 level, and 5 (22%) were reduced 2 levels; only 1 subject withdrew due to toxicity. Twelve subjects (52%) had at least 1 grade 3/4 treatment-related adverse event, the most common being anemia, 6 (26%); neutropenia, 4 (17%); and diarrhea, 2 (9%). Pre-existing neuropathy was an exclusion criteria, and 13 (57%) reported at least grade 1 neuropathy with treatment. After treatment, 3 (13%) deaths occurred with 2 due to disease progression and 1 to pulmonary embolism. At 6 months after treatment initiation, 19 (83%) had no evidence of disease or its progression; 4 (17%) had progressed. Kaplan-Meier analysis revealed a 6-month PFS rate of 80.5% (95% CI 65.1%-99.7%) (Figure 1).
Conclusion(s): The Nab-P/carboplatin day 1, 8 regimen met the prespecified criteria of feasibility with acceptable toxicity and efficacy. Use of Nab-P obviates steroid premedications, ideal for immune checkpoint inhibitors that target mismatch repair deficient advanced EC. A future phase II feasibility trial combining an anti-PD-1 agent with Nab-P and carboplatin is planned. [Figure presented]
Copyright
EMBASE:2002078181
ISSN: 1095-6859
CID: 4004742

Gastrointestinal fistula formation in cervical cancer patients who received bevacizumab [Meeting Abstract]

Gerber, D; Curtin, J P; Saleh, M; Boyd, L R; Lymberis, S; Schiff, P B; Pothuri, B; Lee, J
Objective: The Gynecologic Oncology Group (GOG) study 240 demonstrated a 3.5-month improvement in overall survival when bevacizumab (bev) was added to a combination chemotherapy regimen. This study established a bev-containing regimen as standard therapy for women with recurrent, persistent, or metastatic cervical cancer (CC). Gastrointestinal fistula (GIF) formation is a known complication of bev, and the long-term data of GOG 240 reported that a GIF rate of 15% in women who were treated with bev compared to 1% in the control group women. We sought to evaluate our experience with women treated with bev for CC and to identify associated risk factors for GIF formation.
Method(s): All patients who have received bev for CC from 2012 to 2018 at two academic institutions were identified, and their records were reviewed. Standard two-sided statistical analyses were performed.
Result(s): A total of 43 women were treated with a bev-containing chemotherapy regimen; among them, 34 (79.1%) were treated for CC recurrence, and the remaining were treated for metastatic disease at initial presentation or persistent disease following primary treatment. Thirty-three women (76.6%) received prior radiation therapy (RT); of these, 10 (32.3%) received external beam radiation therapy (EBRT), and 21 (67.7%) had prior EBRT and brachytherapy (BT). The median dose of bev was 15 mg/kg for both EBRT only and EBRT and BT groups. Eleven women developed GIF after bev treatment (11/43, 25.6%). All 11 (100%) had been previously treated with RT, and six (54.5%) had received EBRT plus BT. This resulted in rates of 33.3% (11/33) for GIF formation among women who received EBRT, and 28.6% (6/21) for GIF formation among women who received EBRT plus BT. The median number of bev cycles prior to GIF development was 8 (1-29), and 7 (7/11, 63.6%) received the dose of bev (15 mg/kg) as prescribed in GOG 240. See Table 1.
Conclusion(s): In our cohort of women with CC who were treated with bev, over 25% developed GIF. This is more than expected based on the 15% seen in GOG 240. Notably almost all who developed GIF had recurrent disease and were treated with prior RT. A third of women treated with RT followed by bev formed GIF, representing a considerable proportion of the cohort. GIF development and the possibility of requiring a colostomy should be a part of counseling prior to bev initiation especially in those who have had prior RT. [Figure presented]
Copyright
EMBASE:2002077900
ISSN: 1095-6859
CID: 4005042

How Old Is Too Old? Safety of Minimally Invasive Gynecologic Surgery and Early Hospital Discharge in Elderly Women

Kim, Sarah H.; Frey, Melissa K.; Madden, Nigel; Musselman, Kelsey; Chern, Jing-Yi; Lee, Jessica; Boyd, Leslie R.; Blank, Stephanie, V; Pothuri, Bhavana; Curtin, John P.
Objective: With the increasing age of the population, more elderly women undergo gynecologic surgery. While multiple studies have demonstrated the advantages of minimally invasive surgery (MIS), there is a paucity of data regarding MIS in elderly women. This study was performed to evaluate outcomes among elderly women undergoing gynecologic MIS. Materials and Methods: For this retrospective cohort study, medical records were reviewed for patients >= 65 years old who underwent MIS performed by gynecologic oncologists at a single institution between 2009 and 2016. Outcomes among "younger-elderly" (ages 65-79) and "older elderly" (>= age 80) patients were compared. Results: Two-hundred and ninety-eight patients, age >= 65, underwent MIS (younger-elderly = 268; older-elderly = 29). The median age in the younger-elderly was 69 (range: 65-79) and, in the older-elderly patients, 83 (range: 80-93). The older-elderly had more medical comorbidities than the younger-elderly patients (median Charlson index: 7 versus 5; p < 0.001). There was no significant difference between the 2 groups with respect to surgical approach, underlying malignancy, conversion to laparotomy, and hospital stay. There was also no significant difference between the younger- and older-elderly patients in rates of complications, or in 30- and 90-day readmissions. Conclusions: MIS with early discharge is a safe approach in elderly patients undergoing surgery performed by gynecologic oncologists. Elderly age should not prohibit consideration of MIS with early hospital discharge.
ISI:000462793700002
ISSN: 1042-4067
CID: 3803682

Effect of Insurance Status and Public versus Private Hospital on Cervical Cancer Outcomes [Meeting Abstract]

Berger, A. A.; Ishaq, O., Jr.; Curtin, J. P.; Pothuri, B.; Kehoe, S.; Schiff, P. B.; Boyd, L.; Lymberis, S. C.
ISI:000485671501042
ISSN: 0360-3016
CID: 4111362