Faculty Bibliography

BACKGROUND: Widespread disparities in care have been documented in women with gynecologic cancer in the United States. This study was designed to determine whether structural barriers to optimal care were present during the preoperative period for patients with gynecologic cancer. METHODS: A retrospective review was conducted for patients undergoing surgery for a gynecologic malignancy at a public hospital or a private hospital staffed by the same team of gynecologic oncologists between July 1, 2013 and July 1, 2014. RESULTS: Two hundred fifty-seven cases were included for analysis (public hospital, 69; private hospital, 188). Patients treated at the private hospital were older (58 vs 52 years; P = .004) and had similar medical comorbidities (median Charlson comorbidity index at both hospitals, 6) but required fewer hospital visits in preparation for surgery (2 vs 4; P < .001). Public hospital patients had a longer wait time from the diagnosis of disease to surgery (63 vs 34 days; P < .001). According to a multiple linear regression model, the public hospital setting was associated with a longer interval from diagnosis to surgery with adjustments for the insurance status, age at diagnosis, cancer stage, and number of preoperative hospital visits (P < .001). CONCLUSIONS: Patients at the public hospital were subject to a greater number of preoperative visits and had to wait longer for surgery than patients at the private hospital. Attempts to reduce health care disparities should focus on improving efficiency in health care delivery systems once contact has been established. Cancer 2016;122:859-67. (c) 2016 American Cancer Society.

OBJECTIVE: We aimed to compare access to gynecologic oncology care at a private and a city hospital, both of which closed for a period of time because of Hurricane Sandy. METHODS: This was a cross-sectional study of gynecologic oncology chemotherapy, radiotherapy, and surgical patients from October 29, 2012 (the eve of the storm), to February 7, 2013 (the reopening of the city hospital). New referrals during this time were excluded. Delays in chemotherapy, radiotherapy, and surgery were compared. RESULTS: Analysis included 113 patients: 59 private patients (52.2%) and 54 city patients (47.8%). Of the private patients, 33/59 received chemotherapy (55.9%), 1/59 received radiotherapy (1.7%), and 28/59 had planned surgery (47.5%). Of the city patients, 40/54 received chemotherapy (74.1%), 7/54 received radiotherapy (12.3%), and 18/54 had planned surgery (33.3%). The mean delay in chemotherapy was 7.6 days at the private hospital and 21.7 days at the city hospital (P=0.0004). The mean delay in scheduled surgery was 14.2 days at the private hospital and 22.7 days at the city hospital (P=0.3979). The mean delay in radiotherapy was 0.0 days at the private hospital and 25.0 days at the city hospital (P=0.0046). Loss to follow-up rates were 3/59 of the private patients (5.1%) and 3/54 of the city patients (5.6%). CONCLUSIONS: Gynecologic oncology care was maintained during a natural disaster despite temporary closure and relocation of services. Disparity in care was in access to chemotherapy. (Disaster Med Public Health Preparedness. 2015;0:1-4).

Objectives: Widespread disparities in care have been documented in women with gynecologic cancer in the United States. Prior studies have focused on inequality in access and quality of care. We sought to determine if structural barriers to optimal care were present during the preoperative period for gynecologic cancer patients. Methods: We performed a retrospective review of patients undergoing surgery for a gynecologic malignancy at a public and private hospital staffed by the same gynecologic oncology team between 7/ 1/13 and 7/1/14. Statistical analyses included chi square, Student's ttest, Pearson correlation, and multivariable linear regression. Results: A total of 372 cases were identified, of which 257 were included for analysis (public 69, private 188). Patients treated at the private hospital were older (58 vs. 52 years, P= 0.003) and more likely to have medical comorbidities (71% vs. 46%, P < 0.001) but required fewer median hospital appointments in preparation for surgery (2 vs. 4, P < 0.001). Patients treated at the public hospital had a longer time interval from diagnosis to surgery (65 vs. 34 days, P < 0.001) and from surgical booking appointment to surgery (26 vs. 19 days, P =0.049). The number of contacts with the hospital system during the preoperative period was correlated with interval from diagnosis to surgery (Pearson correlation 0.324, P < 0.001) and surgical booking to surgery (Pearson correlation 0.312, P < 0.001). On a linear regression analysis model that included age, hospital setting, cancer type, disease stage, medical comorbidities and number of hospital contacts, both the public hospital setting (P =0.011) and hospital contact number (P < 0.001) were associated with a longer interval from diagnosis to surgery. Conclusions: Despite being treated by the same team of gynecologic oncologists, patients at a public hospital, who were younger and had fewer medical comorbidities, were subject to a greater number of preoperative visits and less coordination of care than patients at a private hospital. Furthermore, patients at the public hospital had to wait longer from time of diagnosis to surgery and surgical booking appointment to surgery. Attempts to reduce health care disparities should focus not just on access and quality but also on improving efficiency in health care delivery systems once contact has been established

OBJECTIVE: We sought to compare robotic versus laparoscopic surgery in regards to patient reported post-operative pain and quality of life. STUDY DESIGN: This was a prospective study of patients who presented for treatment of a new gynecologic disease requiring minimally invasive surgical intervention. All subjects were asked to take the validated Brief Pain Inventory-Short Form (BPI-SF) at 3 time points to assess pain and its effect on quality of life. Statistical analyses were performed using Pearson x2 and Student's t test. RESULTS: One hundred eleven were included in the analysis of which 56 patients underwent robotic assisted surgery and 55 patients underwent laparoscopic surgery. There was no difference in post-operative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. There was a statistically significant difference found at the delayed postoperative period when evaluating interference of sleep, favoring laparoscopy (ROB 2.0 v LSC 1.0; p 0.03). There were no differences found between the robotic and laparoscopic groups of patients receiving narcotics (56 vs 53, p=0.24, respectively), route of administration of narcotics (47 vs 45, p=1.0, respectively), or administration of non-steroidal anti-inflammatory medications (27 vs 21, P=0.33, respectively). CONCLUSIONS: Our results demonstrate no difference in post-operative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. Furthermore, pain did not appear to interfere consistently with any daily activity of living. Interference of sleep needs to be further evaluated after controlling for BSO.

Objective: Risk-reducing BSO (RRBSO), or prophylactic removal of the adnexae in women at increased genetic risk of ovarian cancer, diminishes ovarian cancer risk. While many general gynecologists (GG) perform these procedures, some argue that they should be performed exclusively by gynecologic oncologists (GO). Crucial aspects of the procedure include attention to removing all adnexal tissue, systematic methods and processing to detect occult disease, and communication between surgeon and pathologist. After compiling a "best practices" protocol for performing RRBSO, we sought to identify how often these practices were followed and whether surgeons' training affected implementation. Methods: All cases of RRBSO from 2006 to 2010 at a single institution were identified.We abstracted data from the medical record, including type of surgeon and year of procedure. We reviewed operative reports to determine if pelvic washings were obtained; whether the upper abdomen, and peritoneal surfaces were inspected; and whether a retroperitoneal approach was used to skeletonize the infundibulopelvic (IP) ligament and maximize length of this pedicle. The pathology report was used to determine if the applicable preoperative diagnosis was noted and whether the entirety of the fallopian tubes and ovaries was sectioned or if only representative sections were reviewed. Fisher's exact test and chi-square were used as appropriate to compare differences between groups (InStat, LaJolla, CA). Results: Among 290 RRBSOs, 26 were performed by GGs and 264 by GOs. When performed by GOs, the ovaries and fallopian tubes were more likely to be completely sectioned compared with GG cases: 231/264 (88%) vs. 17/26 (65%) (P =0.003). GOs were more likely to perform pelvic washings 228/264 (86%) when compared to GGs 13/ 26 (50%) (P < 0.0001). GOs were more likely to use a retroperitoneal approach to skeletonize the IP ligaments 172/264 (65%) when compared to GGs 6/26 (23%) (P < 0.0001). GOs were more likely to include a description of t!

Objective: Data regarding conservative treatment of endometrial neoplasia (EN) consist of case series and nonstandardized treatments. Prospective trial design for this regimen has been fraught with incongruity. We sought to design and implement a protocol for the conservative management of EN using a consistent treatment regimen, assessment of response, and endpoints. Methods: Women with atypical endometrial hyperplasia (AEH) or grade 1 and 2 endometrioid endometrial carcinoma (EC) with gynecologic pathologist- confirmed diagnoses, no evidence of myometrial invasion or extrauterine disease on imaging, and no contraindication to megestrol acetatewho desired conservative management of EN were enrolled on this phase 2 study. Women received 160 mg of megestrol daily. After 12 weeks of treatment, office endometrial biopsy (EMB) was performed. If EMB did not reveal negative endometrium or progression, patients could continue treatment. Those with negative EMB underwent dilation and curettage (D&C) to confirm response, and endpointwas described as pathologic complete response (pCR) on D&C. Patientswithout pCR orwith progression continued onmegestrol for an additional 12 weeks, after which they were similarly reassessed. There were no dose escalations or modifications. Treatment could continue if necessary for as long as 24 months. After pCR, patients were instructed to pursue fertility or start a lower-dose progestin-based maintenance agent. Under this 1-stage design, a sample size of 30 patients achieved 80% power to detect a difference of 0.25 between the H0 of 0.4 and the H1 of 0.65 using a 2-sided Z test. Results: Among 31 patients enrolled in the study, 30 underwent protocol-defined treatment. Ages ranged from 27 to 49 years, with a median age of 37.5 years. 42% of patients were not Caucasian. Median time on study was 210 days (range, 50-768 days). To date, 13/30 (43%) experienced pCR, 3/30 (10%) a partial response, 5/30 (17%) an unconfirmed complete response, 7/30 (23%) stable disease with 3 sti!

Objective: Irinotecan and bevacizumab have single-agent activity in both platinum- sensitive and -resistant recurrent ovarian cancer. We sought to evaluate the efficacy and safety of irinotecan in combination with bevacizumab in these patients. The primary end point of the study was to estimate the progression-free survival (PFS) rate at 6 months. Secondary objectives included overall survival, observed response rate, duration of response, and toxicity. Methods: Patients with recurrent ovarian cancerwho had received any number of prior regimens were eligible. Irinotecan 250 mg/m2 (amended to 175 mg/m2 after treatment-related toxicities in the first 6 patients) and bevacizumab 15 mg/kg every 3 weeks were administered until disease progression or toxicity. Response was assessed by Response Evaluation Criteria in Solid Tumors (RECIST) every 2 cycles and by CA-125 criteria for those patients without measurable disease. Results: Thus far, 25 of the planned 35 patients have been enrolled in the study. Themedian age was 61 years (range, 45-78 years). Seven patients were platinum-sensitive and 18 patients were platinum-resistant. The median number of prior regimens was 5 (range, 1-12), with 10 patients having received prior bevacizumab-containing therapies and 9 patients prior topotecan-containing therapies. The median number of study treatments received was 6 cycles (range, 1-25 cycles); 4 patients withdrew after only 1 cycle (3 due to toxicity and 1 due to physician discretion). Of the 19 patients assessable for response at this time, 5 patients experienced partial response (PR), 11 patientsmaintained stable disease (SD), and 3 patients had progressive disease. Eleven of the patients with PR/SD were platinum-resistant. The observed clinical benefit rate (PR+SD) was 68% (95% CI: 50%, 86%) for the 25 enrolled patients (intention to treat). Durable responses were observed, with 9 patients having longer than 24 weeks of sustained response. Themedian PFS was 8.1 months, and the median overall survival was!

Background Suppression of neoangiogenesis and pegylated liposomal doxorubicin (PLD) each contribute to the management of platinum-resistant/refractory ovarian cancer. The aim of this study is to test the combination of bevacizumab and PLD in women with resistant or refractory ovarian cancer. Methods Eligibility criteria were no more than two prior treatments with platinum-containing regimens and one additional regimen, without anthracyclines. Treatment was administered every 3 weeks (bevacizumab 15 mg/kg beginning on cycle 2 and PLD 30 mg/m(2)). The primary end point was progression-free survival (PFS) at 6 months; the secondary end points included side-effects, overall response rates (ORR) and survival (OS). Results Forty-six patients were enrolled. The average number of courses administered was 7. The median PFS was 6.6 months (range 1-24.6 months) according to Gynecologic Cancer Intergroup Committee (GCIC) criteria and 7.8 months (range 2-13.3 months) according to Response Evaluation Criteria in Solid Tumors (RECIST). The median OS was 33.2 months (range 3-37.5+ months). The ORR was 30.2% [95% confidence interval (CI) 17.2-46.1] and the clinical benefit rate (CBR) was 86.1% (95% CI 72.1-94.7). Adverse events included mucosal and dermal erosions (30% grade 3) and asymptomatic cardiac dysfunction. Additional toxic effects included hypertension, headache, renal dysfunction and proteinuria, wound healing delay, and one episode each of central nervous system (CNS) ischemia and hemolytic uremic syndrome. Conclusion PLD with bevacizumab has improved activity in recurrent ovarian cancer with increased toxicity.