Faculty Bibliography

Purpose/Objective(s): Intensity-modulated radiation therapy (IMRT) is an advanced radiotherapy technique that delivers conformal radiation to desired targets while minimizing dose to surrounding organs at risk. In the post-operative setting, IMRT is associated with reduced acute and late genitourinary and gastrointestinal side effects for patients with cervical cancer. However, no prospective randomized data exist for the use of IMRT in the setting of definitive treatment of intact cervical cancer. The objective of this study was to identify trends in IMRT use for this population. Materials/Methods: Patients with stage IB2-IVA cervical cancer diagnosed from 2004-2018 who were treated with curative intent chemoradiation were identified in the National Cancer Database. Patients who underwent primary surgical management, did not receive external beam radiation to the pelvis or received radiation outside the pelvis, or received an unspecified technique or target of radiation were excluded. The primary outcome of interest was utilization of IMRT vs 3D conformal radiotherapy (3D-CRT) over time. A Cochrane-Armitage test was performed to assess trends over time. T-tests, chi-square tests, and multivariable logistic regression with propensity score matching were used to identify factors associated with receipt of IMRT.
Result(s): Overall, 13,974 patients met inclusion criteria; 4,590 (33%) received IMRT, and 9,384 (67%) received 3DCRT. In this cohort, 65% were non-Hispanic White, 45% were early stage (I-II), 80% were squamous histology, 62% received brachytherapy, and 28% had lymph node involvement. The utilization of IMRT increased from 30% in 2004 to 71% in 2018 (p<0.001). After adjustment for clinical and demographic variables, factors associated with IMRT use were: Hispanic ethnicity (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.0-1.5), treatment in the Western U.S. (aOR 1.4, CI 1.2-1.7) and the Southern U.S. (aOR 1.3, CI 1.1-1.5), living more than 50 miles from the treatment facility (aOR 1.2, CI 1.0-1.5), stage III disease (aOR 1.3, CI 1.1-1.5), and lymph node involvement (aOR 1.4, CI 1.3-1.6). Compared to an academic medical center, patients receiving care at a comprehensive community cancer center were less likely to receive IMRT (aOR 0.66, CI 0.59-0.72). There were no differences in IMRT use by age, insurance, or medical comorbidities.
Conclusion(s): Despite the lack of prospective efficacy data supporting the use of IMRT in patients with intact cervical cancer, IMRT has dramatically increased over the last fifteen years especially for patients with advanced-stage disease or lymph node involvement. More data on the optimal use of IMRT, including appropriate target volume margins and on-board imaging, are needed.
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Introduction/UNASSIGNED:Elective surgical procedures were suspended during the coronavirus disease pandemic (COVID-19) in New York City (NYC) between March 16 and June 15, 2020. This study characterizes the impact of the ban on surgical delays for patients scheduled for surgery during this first wave of the COVID-19 outbreak. Methods/UNASSIGNED:Patients who were scheduled for surgical treatment of malignant or pre-invasive disease by gynecologic oncologists at three NYC hospitals during NYC's ban on elective surgery were included. Outcomes of interest were the percentage of patients experiencing surgical delay and the nature of delays. Kruskal-Wallis, chi-square, and logistic regression tests were performed with significance set at p < 0.05. Results/UNASSIGNED:Of the 145 patients with malignant or pre-invasive diseases scheduled for surgery during the ban on elective surgery, 40% of patients experienced one or more surgical delays, 10% experienced two or more and 1% experienced three surgical delays. Of patients experiencing an initial delay, 77% were hospital-initiated and 11% were due to known or suspected personal COVID-19. Overall, 81% of patients completed their planned treatment, and 93% of patients underwent their initially planned surgery. Among patients for whom adjuvant therapy was recommended, 67% completed their planned treatment, and the most common reasons for not completing treatment were medically indicated followed by concerns regarding COVID-19. Conclusion/UNASSIGNED:During the ban on elective surgery in NYC during the first outbreak of the COVID-19 pandemic, many patients experienced minor surgical delays, but most patients obtained appropriate, timely care with either surgery or alternative treatment.

Objective/UNASSIGNED:Patients with advanced or recurrent gynecologic malignancies occasionally take breaks from systemic treatment colloquially referred to as "treatment holidays" or "chemotherapy holidays." There are no data from the patient perspective that help describe this experience. Methods/UNASSIGNED:Patients with recurrent or advanced primary gynecologic malignancies who had decided to enter a treatment holiday were recruited and interviewed. A treatment holiday was defined as a planned temporary break or delay in treatment for a patient with recurrent or advanced primary gynecologic malignancy for reasons other than pursuit of hospice or best supportive care, research protocol violation or unacceptable toxicity. Interviews were audiotaped, transcribed and then analyzed using an inductive thematic analysis. Results/UNASSIGNED:Of 6 total patients identified for participation, 5 completed interviews with ages ranging from 57 to 80 years. Two participants returned to their previous treatment regimen after their holiday therapy, two switched therapies, and one remained on an extended break from systemic treatment. Treatment holidays were experienced as a break from the physical and psychological routine of being a cancer patient, but also brought about feelings of a lack of structure, uncertainty, and led to a confrontation with mortality issues. Overall, participants had favorable experiences which were initiated by their providers in whom they had a deep sense of trust. Conclusion/UNASSIGNED:Patients experience treatment holidays as a positive and valuable break from the physical and psychosocial routine of cancer treatment and illness. These experiences produce distinct emotional needs that clinicians should address to best support patients electing treatment holidays.

Objective: To analyze physician opinions of, and experiences with patients who take a temporary break from treatment in the setting of metastatic primary or recurrent gynecologic cancer.
Method(s): An electronic survey was sent to the members of the Society of Gynecologic Oncology (SGO). A treatment holiday was defined as a planned temporary break from systemic treatment in a patient with recurrent or metastatic gynecologic malignancy. Descriptive statistics were calculated using Microsoft Excel, and continuous variables were compared using the Wilcoxon Rank Sum test. Free text responses were qualitatively analyzed.
Result(s): Of the 1314 individuals invited to participate, 74 responded (5.6% response rate). Ninety-six percent of respondents had a patient take a treatment holiday. Ninety-five percent of respondents would offer a treatment holiday for ovarian cancer, 90% for endometrial cancer, 70% for cervical cancer, 57% for vulvar cancer, 52% for vaginal cancer, and 49% for sarcoma. Using a Likert scale, respondents identified life events (86.6%), fatigue from side effects (77.9%), schedule fatigue (67.6%) and desire for ''life off treatment'' (64.7%) as ''very important'' reasons for offering a treatment holiday. Patients resumed treatment for return of symptoms (62.9%), progression of disease (60.0%), end of pre-specified break (50%), patient anxiety (45.7%) and recommendation of the physician (11%). 6.8% of physicians experienced regret after a patient underwent a treatment holiday. Ninety-eight percent of respondents agreed that a treatment holiday can be valuable.
Conclusion(s): The gynecologic and medical oncologists who responded to this survey almost uniformly offered their patients treatment holidays, were more likely to offer treatment holidays for ovarian and endometrial cancer, and were unlikely to express regret after the experience.
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Objective/UNASSIGNED:To compare perioperative outcomes of the elderly versus non-elderly patients on ERPs undergoing laparotomy for gynecologic surgery. Methods/UNASSIGNED:-test or Wilcoxon rank-sum tests for continuous variables, with p < 0.05 for significance. Results/UNASSIGNED:One hundred eighty-nine patients were enrolled in the study, including 16 patients ≥ 70 years old. The median age was 75 years for the elderly and 45 years for the non-elderly. Elderly patients were more likely to have more complex surgery and longer operative times (absolute median difference of 39 min). Despite the increasing complexity of surgical procedures for elderly patients, there were no statistically significant differences in serious inpatient complications (Clavien-Dindo score 3A or greater), pain and nausea scores, 30-day complications and readmission rates. Elderly patients had a longer median length of stay compared to non-elderly patients by one day (p < 0.001), however, this was not statistically significant on multivariate analysis. Conclusion/UNASSIGNED:In our series, elderly patients on the ERP had similar rates of complications and readmission when compared to non-elderly patients, despite undergoing more complex surgeries. This suggests that ERP may be feasible and safe in the elderly population undergoing elective gynecologic laparotomy.

Objectives: To characterize the effect that a ban on elective surgery had for patients who were scheduled for surgery with a gynecologic oncologist during the first coronavirus disease 19 (COVID-19) outbreak in New York City.
Method(s): Patients who were scheduled to undergo surgery by a gynecologic oncologist at one of three campuses of a New York City based academic hospital during the ban on elective surgery between March 16, 2020 and June 15, 2020 were included. Patients with benign disease were excluded. Data on patient demographics, perioperative characteristics, nature of surgical delay, and post-operative treatment were abstracted from patient charts. Standard of care was considered met if surgical procedures occurred for suspected malignant and pre-invasive disease, or if an appropriate treatment plan and follow up was documented for malignant cases. Kruskal-Wallis and chi-square test of independence were performed with significance set at p<0.05.
Result(s): A total of 196 patients were scheduled to undergo a surgical procedure during the ban on elective surgery, of which 146 were for malignant, suspected malignant or pre-invasive disease. The majority of cases (42.4%) occurred in patients with known malignancy, followed by suspected malignancy (37.7%) and pre-invasive disease (19.9%). Forty percent of patients experienced one or more surgical delay, 9.6% experienced 2 or more surgical delays and 1.4% experienced three or more surgical delays. Of patients who experienced surgical delays, 75.9% experienced hospital-initiated delays and 24.1% experienced patient-initiated delays. There were no differences between hospital versus patient initiated delays by White vs non-White race (p=0.167). Eight percent of delays were due to a patient with known or suspected COVID-19. The median time from surgical consultation to proposed date of surgery was 20 days for both known malignancy and suspected malignancy, and 34.5 days for pre-invasive disease (p=0.005). Similarly, the median time from surgical consultation to actual date surgery was 23 days for patients with known or suspected malignancy compared to 64 days for preinvasive disease (p=0.011). Of eight patients undergoing treatment for ovarian cancer, 50% underwent primary debulking and 50% underwent neoadjuvant chemotherapy. Among all scheduled cases, the standard of care was met in 89.7% of cases. Standard of care treatment was achieved with a documented alternative plan in 6.1% of cases and with a non-surgical plan in 3% of cases. [Formula presented]
Conclusion(s): During the ban on elective surgery in New York City during the first outbreak of the COVID-19 pandemic, many patients experienced minor surgical delays, but the majority of patients with known or suspected malignancies obtained appropriate, timely care. Ten percent of patients did not receive standard of care.
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There have long been noted significant health disparities related to cancer in populations comprised of low-income and minority individuals, including those with gynecologic cancers. Compliance with appointments related to cancer care is critical to ensuring timely diagnosis, treatment, and detection of disease progression. At a public safety net hospital in New York City, the rate of clinic absenteeism in gynecologic oncology clinic was noted to be nearly 20%. This prospective, survey-based study catalogued reasons for clinic absenteeism and noted that the most common reason an appointment was missed was the patient being unaware it existed. Next most common reasons were medical conflicts and family obligations. Patients at this clinic would benefit from a clinic navigator to assist with scheduling appointments, remind patients of upcoming appointments, and resolve conflicting medical appointments.

INTRODUCTION/BACKGROUND:Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. MATERIAL AND METHODS/METHODS:In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. RESULTS:A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. CONCLUSIONS:Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.