Faculty Bibliography

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.

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.
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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.
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Introduction: We have achieved greater than 6-month survivals in baboons that received vascularized thymus plus kidney xenotransplants (VT+KTx). We assessed the thymic function and recipient immune responses >4 months post-transplant.
Method(s): Six baboon recipients that survived >4 months after VT+KTx were studied. All animals underwent thymectomy and bilateral nephrectomy prior to Tx. Two received anti-CD154 mAb-based (129 and 193 days survivals) and the other four received anti-CD40 mAb-based immunosuppression (126, 154, 174 and 187 survivals). Three of the animals received grafts from GalTKO donors, without other transgenes, and three received grafts from hCD47+GalTKO pigs Tg for additional human complement +/-coagulation regulatory proteins. In vitro T cell responses as well as anti-donor antibodies were assessed using recipient PBMCs and kidney grafts. Graft cell infiltrates were examined with anti-CD3 and anti-FoxP3 Abs. Newly developed baboon T cells in peripheral blood were determined using anti-human CD3/ CD4/CD31/CD45RA mAbs.
Result(s): All animals had stable renal function for the first 4 months. Some exhibited eventual increased serum creatinine (Cre) due to organ growth. No grafts showed signs of acute or chronic rejection histologically. All animals showed pig-specific hyporesponsiveness at all time points tested, including the day of euthanasia. Only one baboon, which was euthanized at POD187 due to SVC syndrome associated with MMF toxicity, developed anti-donor IgG after POD60 (PODs 90, 120 and 187), with no rise in Cre (0.6-0.9mg/ dL) and no histologic evidence of rejection (Figure), suggesting accommodation. The remaining five did not develop anti-pig Abs. One kidney displayed cell infiltrates around vessels without tubulitis or endothelialitis (biopsy at POD144) that were FoxP3+, consistent with Treg-rich organized lymphoid structures (TOLs). Three baboons (174, 187 and 193 day survivors), all of whose native thymi had been removed prior to VT+K Tx, showed peripheral naive recipient T cells, which gradually increased after POD60 post-VT+KTx, suggesting recipient thymopoiesis in the donor pig thymus.
Conclusion(s): Life-supporting porcine VT+KTx in thymectomized baboon recipients led to new host T cell development and specific hyporesponsiveness to pig antigens, accompanied by development of FoxP3+ TOLs in the donor kidneys, without evidence of acute rejection

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.

Objectives: The use of power morcellation has been restricted in many centers due to concerns for inadvertent spread of an undiagnosed leiomyosarcoma. Our institution implemented a preoperative protocol to avoid power morcellation in high risk cases. In this retrospective cohort study, we report the impact of this protocol on institutional surgical practice patterns, and the influence of MRI and LDH results on surgical route.
Material(s) and Method(s): An institutional protocol requiring preoperative MRI with diffusion-weighted imaging and serum LDH levels was implemented on 4/23/2014 at a single academic hospital. A retrospective chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. Statistical analyses included univariate comparisons between the cohorts pre- and post-protocol, as well as overall adherence to protocol, trends in surgical patterns, and incidence of uterine pathology.
Result(s): A total of 1085 patients were included, 479 before and 606 after implementation of the MRI/LDH 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 minimally invasive surgery (MIS) for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (81% vs. 84% and 90% vs. 91%, respectively). 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 when specimens were removed abdominally (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of patients who had abnormal MRI and LDH results, abnormal MRI results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal MRI and LDH tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal LDH results alone did not influence route.
Conclusion(s): Though earlier studies have suggested an overall decrease in minimally invasive hysterectomies in response to the FDA warning on power morcellation, there was no change in rates of minimally invasive hysterectomies and myomectomies at our institution during a similar time period. Changes in surgical techniques, such as decreased use of power morcellation and increased use of contained tissue extraction, were seen. Decreased rates of MIS were seen for patients with abnormal preoperative MRI.
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