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Wilke RN, Iniesta MD, Fellman B, Jazaeri AA, Meyer LA, Fleming ND, Schmeler KM, Taylor JS. A colostomy for large bowel obstruction at the end of life: What do patients gain from palliative surgery? Gynecol Oncol 2024; 188:120-124. [PMID: 38945019 DOI: 10.1016/j.ygyno.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/15/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES Malignant large bowel obstruction (LBO) is a frequent complication affecting women with gynecologic cancers and is an indication for emergent surgery. However, the life expectancy and subsequent medical care utilization are unknown. We sought to estimate overall survival (OS) following colostomy and describe subsequent healthcare utilization among patients with advanced gynecologic malignancies. METHODS We conducted a retrospective analysis of patients with advanced gynecologic cancers who underwent colostomy with palliative intent due to LBO at our institution between March 2014 and January 2023. Summary statistics were used to describe the clinical and demographic characteristics of the study population. OS was estimated using the Kaplan-Meier method, and we defined healthcare utilization at the end-of-life using criteria published by the National Quality Forum. RESULTS A total of 78 patients were included. The median age at the time of surgery was 61 (range: 34-83), and most patients had recurrent ovarian, fallopian tube, or primary peritoneal cancer (n = 51, 65.4%), followed by cervical cancer (n = 16, 20.5%), and uterine cancer (n = 10, 12.8%). The median Charlson comorbidity index was 3 and median postoperative length of stay was five days (range: 1-26). The median follow-up for all patients was 4.5 months (range: 0.07-46.2), and the median OS was 4.5 months (95% CI: 2.9-6.0), including 12 patients (15.4%) with <30-day OS and 21 (26.9%) with <60-day OS. In the last 30 days of life, 62.7% of patients were re-admitted to the hospital, 53.0% were seen in the emergency department, and 18.5% were admitted to an intensive care unit. CONCLUSIONS A significant proportion of patients died within 60 days of surgery, and many had high healthcare utilization at the end of life.
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Affiliation(s)
- Roni Nitecki Wilke
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Maria D Iniesta
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Bryan Fellman
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Amir A Jazaeri
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Larissa A Meyer
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicole D Fleming
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kathleen M Schmeler
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jolyn S Taylor
- The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Promoting timely goals of care conversations between gynecologic cancer patients at high-risk of death and their providers. Gynecol Oncol 2022; 164:288-294. [PMID: 34922770 PMCID: PMC8799508 DOI: 10.1016/j.ygyno.2021.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/29/2021] [Accepted: 12/05/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We designed a multi-faceted intervention to increase the rate of outpatient goals of care (GOC) conversations in women with gynecologic cancers who are at high-risk of death. METHODS AND MATERIALS A multidisciplinary team developed an educational program around GOC conversations at end-of-life and chose criteria to prospectively identify patients at high-risk of death who might benefit from timely GOC conversations: recurrent or metastatic endometrial, cervical or vulvar cancer or platinum-resistant ovarian cancer. Gynecologic oncology provider consensus was built regarding the need to improve the quality and timing of GOC conversations. Eligible outpatients were prospectively identified and providers alerted pre-encounter; timely GOC documentation within 3 visits of high-risk identification was tracked. Our institution concurrently and subsequently tracked GOC documentation during the last 6 months of life among all established oncology patients. RESULTS Of 220 pilot period high-risk patients (96 pre- and 124 during pilot period 2017-2018), timely GOC discussion documentation increased from 30.2% to 88.7% (p < 0.001) and this increase was sustained over time. In the post-pilot period (2019-2020), among patients seen by oncologists during last 6 months of life, compared to other cancer types, gynecologic cancer patients had a higher rate of GOC documentation (81% versus 9%; p < 0.001), a lower rate of receiving chemotherapy during the last 14 days of life (2% vs 5%; p = 0.051), and no difference in end-of-life admissions (29% vs 31%; p = NS). CONCLUSIONS Implementation of systematic outpatient identification of high-risk gynecologic oncology patients is feasible, sustainable, and increases the timely conduct of GOC conversations.
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Kajiyama H, Suzuki S, Shimbo A, Utsumi F, Yoshikawa N, Kikkawa F. Survival after Anticancer Treatment of Terminally Ill Patients with Ovarian Carcinoma. J Palliat Med 2020; 23:1060-1065. [PMID: 32293976 DOI: 10.1089/jpm.2019.0456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It remains unclear whether the end-of-life (EOL) treatment/environment impacts on survival after anticancer treatment in terminally ill women with ovarian carcinoma (OC). Objective: The aim of this investigation was to clarify how long those women actually survived after their last anticancer treatments and their hallmarks. Setting, Design, and Measurements: Between 2003 and 2011, 79 terminally ill women with OC were retrospectively analyzed as a single institutional study. Postcancer treatment survival (PCS), defined as the duration between the last date of the abovementioned "cancer treatment" and that of death from any cause, was analyzed on stratification by type of supportive care or where patients spend their EOL. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were employed to compare PCS between the two groups. Results: The median PCS of patients was 10.8 weeks. In the multivariable analysis, the performance status and EOL place retained their significance as independent prognostic factors of poorer PCS (performance status [2-3/0-1]: hazard ratio [HR] = 3.279 [95% confidence interval; CI 1.967-5.586; p < 0.0001], EOL place [hospital/home hospice]: HR = 0.574 [95% CI 0.355-0.913; p = 0.0188]). In the IPTW-adjusted cohort, the median PCS rates were 15.0 and 9.7 weeks in patients of home/hospice and hospital groups, respectively (p = 0.04). Also in the IPTW cohort, the EOL place retained its significance (IPTW-adjusted: HR [95% CI]: 1.548 [1.009-2.374], p = 0.045, multivariable adjusted with IPTW: HR [95% CI]: 1.670 [1.077-2.588], p = 0.022). Conclusion: Our current data may be hypothesis generating; it is possible that the EOL environment is a crucial prognostic factor for survival after anticancer treatment.
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Affiliation(s)
- Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Shimbo
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumi Utsumi
- Department of Obstetrics and Gynecology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Nobuhisa Yoshikawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Green DS, Nunes AT, David-Ocampo V, Ekwede IB, Houston ND, Highfill SL, Khuu H, Stroncek DF, Steinberg SM, Zoon KC, Annunziata CM. A Phase 1 trial of autologous monocytes stimulated ex vivo with Sylatron ® (Peginterferon alfa-2b) and Actimmune ® (Interferon gamma-1b) for intra-peritoneal administration in recurrent ovarian cancer. J Transl Med 2018; 16:196. [PMID: 30012146 PMCID: PMC6048715 DOI: 10.1186/s12967-018-1569-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Ovarian cancer has no definitive second line therapeutic options, and largely recurs in the peritoneal cavity. Locoregional immune therapy using both interferons and monocytes can be used as a novel approach. Interferons have both cytostatic and cytotoxic properties, while monocytes stimulated with interferons have potent cytotoxic properties. Due to the highly immune suppressive properties of ovarian cancer, ex vivo stimulation of autologous patient monocytes with interferons and infusion of all three agents intraperitoneally (IP) can provide a strong pro-inflammatory environment at the site of disease to kill malignant cells. METHODS Patient monocytes are isolated through counterflow elutriation and stimulated ex vivo with interferons and infused IP through a semi-permanent catheter. We have designed a standard 3 + 3 dose escalation study to explore the highest tolerated dose of interferons and monocytes infused IP in patients with chemotherapy resistant ovarian cancer. Secondary outcome measurements of changes in the peripheral blood immune compartment and plasma cytokines will be studied for correlations of response. DISCUSSION We have developed a novel immunotherapy focused on the innate immune system for the treatment of ovarian cancer. We have combined the use of autologous monocytes and interferons alpha and gamma for local-regional administration directly into the peritoneal cavity. This therapy is highly unique in that it is the first study of its type using only components of the innate immune system for the locoregional delivery consisting of autologous monocytes and dual interferons alpha and gamma. Trial Registration ClinicalTrials.gov Identifier: NCT02948426, registered on October 28, 2016. https://clinicaltrials.gov/ct2/show/NCT02948426.
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Affiliation(s)
- Daniel S. Green
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive RM 3B43C, Bethesda, MD 20892 USA
| | - Ana T. Nunes
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive RM 3B43C, Bethesda, MD 20892 USA
| | - Virginia David-Ocampo
- Cell Processing Section, Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, USA
- Present Address: Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, FDA, Silver Spring, MD USA
| | - Irene B. Ekwede
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive RM 3B43C, Bethesda, MD 20892 USA
| | - Nicole D. Houston
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive RM 3B43C, Bethesda, MD 20892 USA
| | - Steven L. Highfill
- Cell Processing Section, Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, USA
| | - Hanh Khuu
- Cell Processing Section, Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, USA
- Present Address: Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, FDA, Silver Spring, MD USA
| | - David F. Stroncek
- Cell Processing Section, Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, USA
| | - Seth M. Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, MD USA
| | - Kathryn C. Zoon
- Laboratory of Infectious Diseases, National Institutes of Allergy and Infectious Diseases, National Institutes of Health Bethesda, Bethesda, MD USA
| | - Christina M. Annunziata
- Women’s Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive RM 3B43C, Bethesda, MD 20892 USA
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Faraz SB, Salem SB, Schattner M, Mendelsohn R, Markowitz A, Ludwig E, Zheng J, Gerdes H, Shah P. Predictors of clinical outcome of colonic stents in patients with malignant large-bowel obstruction because of extracolonic malignancy. Gastrointest Endosc 2018; 87:1310-1317. [PMID: 29307474 PMCID: PMC8439169 DOI: 10.1016/j.gie.2017.12.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 12/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Colonic stent placement in patients with large-bowel obstruction (LBO) secondary to extracolonic malignancy (ECM) has been evaluated in small series with heterogeneous results. Our aim is to better characterize the technical and clinical success of colonic stent placement and to identify factors that affect this success in ECM patients. METHODS All patients at a single high-volume center who presented for colonic stent placement for LBO because of ECM between 2001 and 2012 were retrospectively identified. The outcomes of interest were technical success, clinical success, stent occlusion rate, and overall survival. RESULTS A total of 187 patients were identified. Mean age was 61.9 years (range, 23-89), and 150 (80.2%) were women. The most common malignancy type was urogynecologic (n = 104) and most common location sigmoid colon (n = 128). Overall, 142 patients (75.9%) achieved technical success and 102 patients (54.5%) clinical success. Radiographic presence of peritoneal carcinomatosis (P < .001) and multifocal disease (P < .001) were associated with both decreased technical and clinical success. Procedure-related adverse events were seen in 12 patients (6.4%). In patients with clinical success, the incidence of stent occlusion at 3 months was 14.7% (95% confidence interval, 7.8%-21.6%) and was higher in patients with prior radiation therapy (P = .011). The median overall survival for all patients from time of attempted stent placement was 3.3 months (95% confidence interval, 3.0-4.1). CONCLUSIONS This study represents the largest retrospective series of colonic stent placement for LBO in ECM patients in the literature. Our technical success rate of 75.9%, clinical success rate of 54.5%, and 3-month stent occlusion rate of 14.7% suggest that stent placement is a viable palliative option for patients with advanced disease because of ECM. Patients with peritoneal carcinomatosis and multifocal disease have reduced technical and clinical success. However, these factors should not dissuade an attempt at stent placement, if risk-to-benefit analysis is favorable.
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Affiliation(s)
- Shahdabul B.S. Faraz
- Weill Cornell Medical College, New York, NY, USA,Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | - Emmy Ludwig
- Weill Cornell Medical College, New York, NY, USA
| | | | - Hans Gerdes
- Weill Cornell Medical College, New York, NY, USA
| | - Pari Shah
- Weill Cornell Medical College, New York, NY, USA
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Utsumi F, Kajiyama H, Niimi K, Sekiya R, Sakata J, Suzuki S, Shibata K, Mizuno M, Kikkawa F. Clinical significance and predicting indicators of post-cancer-treatment survival in terminally ill patients with ovarian cancer. J Obstet Gynaecol Res 2017; 43:365-370. [PMID: 28150408 DOI: 10.1111/jog.13219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/26/2016] [Accepted: 09/23/2016] [Indexed: 11/29/2022]
Abstract
AIM Women with ovarian cancer (OC) often experience relapse and receive further repetitive chemotherapy. The objective of this study was to overview the remaining survival time after the final chemotherapy and to examine influential clinicopathologic indicators in those patients. METHODS The medical charts of deceased OC patients who had died of the disease between 2003 and 2012 were retrospectively reviewed. We investigated post-cancer-treatment survival (PCS) defined as the interval between the date of the final chemotherapy and death. RESULTS In all, 77 patients were enrolled. Three patients (3.9%) had received chemotherapy in the last 2 weeks. Eight (10.4%), 28 (36.4%), and 44 (57.2%) patients had received chemotherapy in the last 30, 60, and 90 days, respectively. There were no differences in either survival after recurrence or overall survival between the shorter (<75 days) and longer (≥75 days) PCS groups. On the other hand, patients in the shorter PCS group had significantly fewer chances of referral to a hospice or home-care than those in the latter group (P = 0.035). In multivariable analysis, a poorer performance status, an elevated white blood cell count, and a higher C-reactive protein value were significantly correlated with a shorter PCS (P = 0.004, 0.006 and 0.027, respectively). CONCLUSION Half of the patients received chemotherapy within 75 days of death and we did not identify any survival benefit in patients who received chemotherapy near the end of life. We should provide information to patients about their prognosis and discuss the timing of withdrawal from chemotherapy from the early stage of their recurrence.
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Affiliation(s)
- Fumi Utsumi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Center for Postgraduate Clinical Training and Career Development, Nagoya University Hospital, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuichiro Sekiya
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Sakata
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyosumi Shibata
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mika Mizuno
- Department of Gynecology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Changes in health-related quality of life and quality of care among terminally ill cancer patients and survival prediction: Multicenter prospective cohort study. Palliat Support Care 2014; 13:1103-11. [DOI: 10.1017/s1478951514000960] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:This study examined changes in health-related quality of life (HRQoL) and quality of care (QoC) as perceived by terminally ill cancer patients and a stratified set of HRQoL or QoC factors that are most likely to influence survival at the end of life (EoL).Method:We administered questionnaires to 619 consecutive patients immediately after they were diagnosed with terminal cancer by physicians at 11 university hospitals and at the National Cancer Center in Korea. Subjects were followed up over 161.2 person-years until their deaths. We measured HRQoL using the core 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and QoC using the Quality Care Questionnaire–End of Life (QCQ–EoL). We evaluated changes in HRQoL and QoC issues during the first three months after enrollment, performing sensitivity analysis by using data generated via four methods (complete case analysis, available case analysis, the last observation carried forward, and multiple imputation).Results:Emotional and cognitive functioning decreased significantly over time, while dyspnea, constipation, and pain increased significantly. Dignity-conserving care, care by healthcare professionals, family relationships, and QCQ–EoL total score decreased significantly. Global QoL, appetite loss, and Eastern Cooperative Oncology Group Performance Status (ECOG–PS) scores were significantly associated with survival.Significance of results:Future standardization of palliative care should be focused on assessment of these deteriorated types of quality. Accurate estimates of the length of life remaining for terminally ill cancer patients by such EoL-enhancing factors as global QoL, appetite loss, and ECOG–PS are needed to help patients experience a dignified and comfortable death.
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The role of palliative colorectal stents in gynaecologic malignancy. Gynecol Oncol 2014; 134:566-9. [DOI: 10.1016/j.ygyno.2014.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/15/2014] [Accepted: 06/23/2014] [Indexed: 11/21/2022]
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Price MA, Bell ML, Sommeijer DW, Friedlander M, Stockler MR, Defazio A, Webb PM, Butow PN. Physical symptoms, coping styles and quality of life in recurrent ovarian cancer: a prospective population-based study over the last year of life. Gynecol Oncol 2013; 130:162-8. [PMID: 23578538 DOI: 10.1016/j.ygyno.2013.03.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 03/24/2013] [Accepted: 03/28/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of this study was to describe the trajectory of physical symptoms, coping styles and quality of life (QoL) and the relationship between coping and QoL over the last year of life in women with recurrent ovarian cancer. METHODS The patient cohort were women recruited to the Australian Ovarian Cancer Study who subsequently experienced recurrent, invasive ovarian cancer and completed at least one psychosocial assessment (optimism, minimisation, hopelessness/helplessness, QoL) during the last year of life (n=217). RESULTS QoL declined sharply from six months before death. Lack of energy was the most prevalent symptom over three measurement periods (67-92%) and also the most severe. Anorexia (36-55%), abdominal swelling (33-58%), nausea (26-47%) and pain (26-43%) all increased in prevalence and severity towards the end of life. Higher optimism (p=0.009), higher minimisation (p=0.003) and lower helplessness/hopelessness (p=0.03) at baseline were significant predictors of subsequent higher QoL. CONCLUSIONS Progressive deterioration in quality of life may be an indicator of death within about six months and therefore should be an important consideration in decisions about subsequent treatment. Coping styles which independently predicted subsequent changes in QoL could potentially be targeted by interventions to minimise worsening QoL.
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Affiliation(s)
- M A Price
- Centre for Medical Psychology and Evidence-based Decision-making, School of Psychology, The University of Sydney, Sydney, Australia.
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Jatoi A, Nieva JJ, Qin R, Loprinzi CL, Wos EJ, Novotny PJ, Moore DF, Mowat RB, Bechar N, Pajon ER, Hartmann LC. A pilot study of long-acting octreotide for symptomatic malignant ascites. Oncology 2012; 82:315-20. [PMID: 22572824 DOI: 10.1159/000337246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/02/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective, non-invasive, palliative strategies for symptomatic malignant ascites are unavailable. This trial explored whether octreotide, an inhibitor of vascular endothelial growth factor, a putative mediator of ascites, prolongs the interval to next paracentesis. METHODS After a baseline paracentesis and a test of short-acting agent, patients with symptomatic ascites were randomly assigned to long-acting octreotide (Sandostatin LAR®) depot 30 mg intramuscularly every month versus 0.9% sodium chloride administered similarly. Patients were then monitored for recurrent, symptomatic ascites. RESULTS Thirty-three patients were enrolled: 16 assigned to the octreotide and 17 to the control arm. The median time to next paracentesis was 28 and 14 days in the octreotide and placebo arm, respectively (p = 0.17). After adjustment for extracted ascites volume and abdominal girth change, no statistically significant difference between the groups was observed (hazard ratio = 0.52, with a 95% confidence interval of 0.21-1.28; p = 0.15, per Cox model). Octreotide-treated patients described less of abdominal bloating (p = 0.01), abdominal discomfort (p = 0.02), and shortness of breath (p = 0.007) at one month, although other quality of life symptoms were comparable between the arms. Long-acting octreotide was reasonably well tolerated. CONCLUSION As prescribed in this trial, octreotide did not seem effective in prolonging the time to next paracentesis, although improvements in symptoms suggest that vascular endothelial growth factor inhibition merits further investigation.
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Affiliation(s)
- Aminah Jatoi
- Mayo Clinic Rochester, Rochester, MN 55905, USA.
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Schorge JO, Eisenhauer EE, Chi DS. Current surgical management of ovarian cancer. Hematol Oncol Clin North Am 2011; 26:93-109. [PMID: 22244664 DOI: 10.1016/j.hoc.2011.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Surgical management of ovarian cancer requires excellent judgment and mastery of a wide array of procedures. Involvement of a gynecologic oncologist improves outcomes. Staging of apparent stage I disease is important. Minimally invasive techniques provide advantages. Primary debulking surgery provides the best long-term survival of any strategy in advanced ovarian cancer. Aggressive surgical paradigms have the greatest success. Further cytoreductive surgery may be appropriate. Most relapsed patients require management of bowel obstruction at some point. Palliative intervention can enhance quality of life. Surgical correction may extend survival. For end-stage patients with progressive disease, the treating gynecologic oncologist must manage expectations.
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Affiliation(s)
- John O Schorge
- Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA.
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Jatoi A, Giordano KF, Nguyen PL, Sloan J, Hartmann LC. Targeting and palliating malignant ascites: an overview of an upcoming clinical trial from the north central cancer treatment group. ACTA ACUST UNITED AC 2011; 3:59-62. [PMID: 18632438 DOI: 10.3816/sct.2005.n.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, MN
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13
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Lentz SE. End-of-Life Decision Making. Gynecol Oncol 2011. [DOI: 10.1002/9781118003435.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rezk Y, Timmins PF, Smith HS. Review article: palliative care in gynecologic oncology. Am J Hosp Palliat Care 2010; 28:356-74. [PMID: 21187291 DOI: 10.1177/1049909110392204] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.
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Affiliation(s)
- Youssef Rezk
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Albany Medical College, Albany, NY 12208, USA
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Friedlander M, Butow P, Stockler M, Gainford C, Martyn J, Oza A, Donovan HS, Miller B, King M. Symptom control in patients with recurrent ovarian cancer: measuring the benefit of palliative chemotherapy in women with platinum refractory/resistant ovarian cancer. Int J Gynecol Cancer 2010; 19 Suppl 2:S44-8. [PMID: 19955914 DOI: 10.1111/igc.0b013e3181bf7fb8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Most women with advanced ovarian cancer will relapse and subsequently develop platinum-resistant/refractory ovarian cancer. The benefit of treatment is currently based on objective response rates, which are a crude measure of benefit. It would be clinically meaningful if we were better able to measure the benefit of palliative therapy and, in particular, ascertain whether cancer-related symptoms improve with treatment and how this impacts on quality of life. This paper reviews the management of patients with platinum-resistant/refractory ovarian cancer and highlights the gaps in our knowledge and shortcomings with the current approaches to measure the benefit of treatment. The ultimate objective is to describe and encourage recruitment to the Gynecologic Cancer Intergroup study that has recently opened. This study will recruit a large number of patients from around the world in an effort to develop more robust instruments to measure the benefit of chemotherapy and to understand the impact of chemotherapy on symptom control and quality of life. In addition, this study will give us an insight into how all patients are managed rather than a select minority who are treated in clinical trials.
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16
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Staging and surgical treatment. Cancer Treat Res 2009. [PMID: 19763430 DOI: 10.1007/978-0-387-98094-2_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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17
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Daniels MS, Urbauer DL, Stanley JL, Johnson KG, Lu KH. Timing of BRCA1/BRCA2 genetic testing in women with ovarian cancer. Genet Med 2009; 11:624-8. [DOI: 10.1097/gim.0b013e3181ab2295] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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18
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Abstract
Surgery is the cornerstone of treatment for patients with advanced ovarian cancer. The majority of patients with advanced ovarian cancer who experience a clinical remission after initial surgery will develop a recurrence. The optimal management for patients with recurrent ovarian cancer remains to be defined. Chemotherapy is frequently used with varying response rates. Repeat surgical cytoreduction appears to offer a survival benefit for select patients with recurrent ovarian cancer and should be considered. Surgery also plays a role in the palliation of certain patients. Continued investigations, especially randomized trials, are needed to further define the optimal treatment modalities for these patients.
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Affiliation(s)
- Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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von Gruenigen V, Daly B, Gibbons H, Hutchins J, Green A. Indicators of survival duration in ovarian cancer and implications for aggressiveness of care. Cancer 2008; 112:2221-7. [PMID: 18348300 DOI: 10.1002/cncr.23391] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ovarian cancer patients frequently receive chemotherapy near the end of life. The purpose of the current study was to develop indicators that characterize those ovarian cancer patients who have a short life span. METHODS The medical charts of deceased epithelial ovarian cancer patients were retrospectively reviewed from 2000 through 2006. All patients received primary debulking surgery and adjuvant chemotherapy. Aggressiveness of cancer care within the last month of life was measured by chemotherapy regimens, emergency room visits, and hospitalizations. Significant clinical events (SCE) were defined as ascites, bowel obstruction, and pleural effusion. Survival quartiles were compared using chi-square and Student t test statistics. Multiple regression analysis was performed using survival duration as a dependent variable. RESULTS In all, 113 patients with epithelial ovarian cancer were reviewed. Patients had increased hospitalizations (P < .001) and SCE (P < .001) as they approached the end of life. There was no difference in the pattern of hospitalizations and SCE between the top and bottom survival quartiles. Patients with a shorter survival time had a trend toward increased chemotherapy during their last 3 months of life (P = .057) and had increased overall aggressiveness of care (P = .013). In patients with a disease remission, the length of initial remission time was found to be significant in predicting survival (P < .01). Time to second disease recurrence was also significant in predicting survival time (P < 0.01). CONCLUSIONS Patients who received aggressive care did not have improvement in survival. Short disease remissions and increasing hospitalizations with SCE should be indicators of the appropriateness of reducing cure-oriented therapies and increasing palliative interventions.
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Affiliation(s)
- Vivian von Gruenigen
- Department of Obstetrics and Gynecology, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.
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21
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Aletti GD, Gallenberg MM, Cliby WA, Jatoi A, Hartmann LC. Current management strategies for ovarian cancer. Mayo Clin Proc 2007; 82:751-70. [PMID: 17550756 DOI: 10.4065/82.6.751] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Epithelial ovarian cancer originates in the layer of cells that covers the surface of the ovaries. The disease spreads readily throughout the peritoneal cavity and to the lymphatics, often before causing symptoms. Of the cancers unique to women, ovarian cancer has the highest mortality rate. Most women are diagnosed as having advanced stage disease, and efforts to develop new screening approaches for ovarian cancer are a high priority. Optimal treatment of ovarian cancer begins with optimal cytoreductive surgery followed by combination chemotherapy. Ovarian cancer, even in advanced stages, is sensitive to a variety of chemotherapeutics. Although improved chemotherapy has increased 5-year survival rates, overall survival gains have been limited because of our inability to eradicate all disease. Technologic advances that allow us to examine the molecular machinery that drives ovarian cancer cells have helped to identify numerous therapeutic targets within these cells. In this review, we provide an overview of ovarian cancer with particular emphasis on recent advances in operative management and systemic therapies.
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Affiliation(s)
- Giovanni D Aletti
- Division of Gynecologic Surgery, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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22
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Ayhan A, Gultekin M, Taskiran C, Dursun P, Firat P, Bozdag G, Celik NY, Yuce K. Ascites and epithelial ovarian cancers: a reappraisal with respect to different aspects. Int J Gynecol Cancer 2007; 17:68-75. [PMID: 17291234 DOI: 10.1111/j.1525-1438.2006.00777.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Ascites is a common finding in patients with epithelial ovarian cancer (EOC). Clinico-pathologic correlations with respect to the presence of ascites, positive cytology and prognostic role of ascites, and the impact of ascitic volumes were not previously studied extensively. A total of 372 patients with EOC were retrospectively evaluated with respect to presence and amount of ascites, cytologic findings, and survival. Two groups were compared by using Chi-square, Student's t and Mann-Whitney U, binary logistic regression, Kaplan Meier and Cox-regression analysis tests, where appropriate. Omental metastasis (P < 0.001; OR: 3.21, 95% CI = 1.945-5.297) and mean number of metastatic lymph nodes (P= 0.008; OR: 1.063, 95% CI = 1.016-1.112) were significantly related with presence of ascites. Evaluation of ascitic volume at different thresholds revealed lymphatic-omental metastasis, and also the disease stage to be significantly different among patient groups at lower threshold values and the positive cytology and high-grade diseases at higher threshold values. In conclusion, presence of ascites correlates with both the intraperitoneal and also the retroperitoneal tumor spread. Amount of ascites has different correlations with the clinico-pathologic factors depending on the thresholds chosen. At lower volumes, lymphatic and omental metastasis seems to correlate with the development of ascites. Once ascites develops, tumor grade seems to be important for larger ascites volumes. Neither the presence of ascites or its volume nor the cytologic positivity was an independent predictor of survival.
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Affiliation(s)
- A Ayhan
- Departments of Obstetrics and Gynecology and Pathology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey
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Lewin SN, Buttin BM, Powell MA, Gibb RK, Rader JS, Mutch DG, Herzog TJ. Resource utilization for ovarian cancer patients at the end of life: How much is too much? Gynecol Oncol 2005; 99:261-6. [PMID: 16140364 DOI: 10.1016/j.ygyno.2005.07.102] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Revised: 07/20/2005] [Accepted: 07/25/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE End-of-life (EOL) medical care consumes 10-12% of national health care expenditures and 27% of Medicare dollars annually. Studies suggest that hospice services decrease EOL expenditures by 25-40%. The goal of this study was to compare the total cost of hospital-based resources utilized in ovarian cancer patients during their last 60 days of life for those enrolled in hospice versus those not on hospice. METHODS Study eligibility included patients who expired from ovarian cancer from 1999 to 2003. Medical records were reviewed for demographic data as well as treatment, response and recurrence rates, histologic type, grade and stage. Billing records were analyzed for costs of inpatient and outpatients visits, including radiologic, laboratory and pharmacy charges. Total cost of hospital resources was compared between patients managed on hospice for >10 days (hospice group) versus <10 days (non-hospice group) using the following methods: Mann-Whitney U, Kruskal-Wallis and Student's t tests. Overall survival was compared using Kaplan-Meier statistics. RESULTS Of the 84 patients analyzed, 67 (79.8%) were in the non-hospice group and 17 (20.2%) were in the hospice group. Demographic, histologic and staging characteristics as well as platinum sensitivity were similar between the two groups before the last 60 days of life. Mean number of chemotherapy cycles before the study period was also similar (20.4 and 21.0, respectively). However, during the study period, the mean total cost per patient in the non-hospice group was dollar 59,319 versus dollar 15,164 in the hospice group (P = 0.0001). A significant difference in cost was noted for mean inpatient days (dollar 6584 vs. dollar 1629, P = 0.0007), radiology (dollar 6063 vs. dollar 2343, P = 0.003), laboratory (dollar 12,281 vs. dollar 2026, P = 0.0004) and pharmacy charges (dollar 13,650 vs. dollar 4465, P = 0.0017) as well as for treating physician per patient (dollar 112,707 vs. dollar 34,677, P = 0.04). Overall survival for the two groups was the same. CONCLUSIONS Our findings demonstrate that there is a significant cost difference with no appreciable improvement in survival between ovarian cancer patients treated aggressively versus those enrolled in hospice at the EOL. These data suggest that earlier hospice enrollment is beneficial. Furthermore, cost variations between physicians and patients imply that education may be an important variable.
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Affiliation(s)
- Sharyn N Lewin
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA
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von Gruenigen VE, Daly BJ. Futility: clinical decisions at the end-of-life in women with ovarian cancer. Gynecol Oncol 2005; 97:638-44. [PMID: 15863171 DOI: 10.1016/j.ygyno.2005.01.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Revised: 01/24/2005] [Accepted: 01/24/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this article is to provide a review of the clinical meaning of futility, discuss current normative uses of futility assessments and propose guidelines for clinicians to use in dialogue regarding treatment decisions for patients with advanced ovarian cancers. METHODS We performed a MEDLINE literature search of relevant clinical articles for this review that discussed futility and the application to women with ovarian cancer. RESULTS Medical futility refers to treatments that serve no physiologic, quantitative or qualitative meaningful purpose. Despite the growth in options focused on symptom management rather than disease eradication, including hospice programs and the more recent development of palliative care programs, there is evidence that many patients continue to receive aggressive interventions, including chemotherapy, until days before their death. While the legal and moral acceptability of treatment limitation is well established, clarity in establishing goals of care, timing of the transition from cure to palliation and communication of specific decisions to withhold further aggressive interventions remain problematic for both patients and clinicians. CONCLUSIONS There continues to be a distinct need for both better understanding of the dynamics of patient choice and increased education of physicians in addressing end-of-life care planning. It is essential that we continue to test specific communication and supportive interventions that will improve our ability to help patients avoid the burden of futile therapy while maintaining hope.
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Affiliation(s)
- Vivian E von Gruenigen
- Department of Reproductive Biology, Division of Gynecologic Oncology, University MacDonald Women's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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