The role and timing of palliative medicine consultation for women with gynecologic malignancies: association with end of life interventions and direct hospital costs

OBJECTIVE

Aggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies.

METHODS

A retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥ 30 days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission <3 days. Inpatient direct hospital costs were calculated for the last 30 days of life from accounting records. Data were analyzed using Fisher's Exact, Mann-Whitney U, Kaplan-Meier, and Student's T testing.

RESULTS

49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0-3) versus 2 (range 0-6) p=0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30 days of life were lower for patients with timely consultation, $0 (range 0-28,019) versus untimely, $7729 (0-52,720), p=0.01.

CONCLUSIONS

Timely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.

Assessment of palliative care training in gynecologic oncology: a gynecologic oncology fellow research network study

OBJECTIVE

Palliative care is recognized as an important component of oncologic care. We sought to assess the quality/quantity of palliative care education in gynecologic oncology fellowship.

METHODS

A self-administered on-line questionnaire was distributed to current gynecologic oncology fellow and candidate members during the 2013 academic year. Descriptive statistics, bivariate and multivariate analyses were performed.

RESULTS

Of 201 fellow and candidate members, 74.1% (n=149) responded. Respondents were primarily women (75%) and white (76%). Only 11% of respondents participated in a palliative care rotation. Respondents rated the overall quality of teaching received on management of ovarian cancer significantly higher than management of patients at end of life (EOL), independent of level of training (8.25 vs. 6.23; p<0.0005). Forty-six percent reported never being observed discussing transition of care from curative to palliative with a patient, and 56% never received feedback about technique regarding discussions on EOL care. When asked to recall their most recent patient who had died, 83% reported enrollment in hospice within 4 weeks of death. Fellows reporting higher quality EOL education were significantly more likely to feel prepared to care for patients at EOL (p<0.0005). Mean ranking of preparedness increased with the number of times a fellow reported discussing changing goals from curative to palliative and the number of times he/she received feedback from an attending (p<0.0005).

CONCLUSIONS

Gynecologic oncology fellow/candidate members reported insufficient palliative care education. Those respondents reporting higher quality EOL training felt more prepared to care for dying patients and to address complications commonly encountered in this setting.

Microinvasive adenocarcinoma of the cervix

OBJECTIVE

We compared the outcomes of microinvasive squamous cell carcinoma and adenocarcinoma of the cervix and examined the safety of fertility-conserving treatment.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results database was used to identify all women with stage IA1 and IA2 cervical carcinoma diagnosed from 1988 to 2005. The treatment and outcomes of women with adenocarcinomas were compared with squamous cell carcinomas.

RESULTS

A total of 3987 women including 988 with adenocarcinomas (24.8%) were identified. Women with adenocarcinoma were more often white and were younger (P < .05 for all). Survival for stage IA1 adenocarcinomas (hazard ratio, 0.79; 95% confidence interval, 0.21-2.94) was similar to that of women with squamous cell tumors. For stage IA2 tumors, survival was similar for squamous cell and adenocarcinomas (hazard ratio, 0.51; 95% confidence interval, 0.18-1.47). For stage IA1 and IA2 adenocarcinomas, survival was similar for conization and hysterectomy.

CONCLUSION

Survival is similar for microinvasive adenocarcinomas and squamous cell carcinomas. Conization appears to be adequate treatment for microinvasive adenocarcinoma.

Performance status and symptom scores of women with gynecologic cancer at the end of life

OBJECTIVE

The Palliative Performance Scale (PPS), which measures performance status (100 = best performance to 0 = dead), and the Edmonton Symptom Assessment System (ESAS), which measures severity of 9 symptoms, are routinely collected at ambulatory cancer visits in Ontario. This study describes the trajectory of scores in patients with gynecologic cancer in the last 6 months of life.

METHODS

An observational study was conducted between 2007 and 2010. Patients had ovarian/fallopian tube, uterine, and cervical cancer and required 1 or more PPS or ESAS assessment in the 6 months before death. Outcomes were the average PPS and ESAS scores per week before death. Using logistic regression, we analyzed the odds ratio of reporting a moderate to severe score for each symptom.

RESULTS

Seven hundred ninety-five (PPS) and 1299 (ESAS) patients were included. The average PPS score started at 70 and ended at 30, rapidly declining in the last 2 months. For ESAS symptoms, drowsiness, decreased well-being, lack of appetite, and tiredness increased in severity closer to death and were prevalent in more than 70% of patients in the last week of life. Patients with cervical cancer had increased odds of moderate to severe pain (1.74; 95% confidence interval, 1.30-2.32) compared with ovarian cancer.

CONCLUSIONS

Trajectories of mean performance status had not reached the "end-of-life" phase until 1 week before death. A large proportion of the gynecologic cancer patients reported moderate to severe symptom scores as death approached. Pain was uniquely elevated in the cervical cancer cohort as death approached. Adequately managing the symptom burden appears to be a significant issue in end-of-life gynecologic care.

The impact of skeletal muscle abnormalities on tolerance to adjuvant chemotherapy and radiation and outcome in patients with endometrial cancer

INTRODUCTION

Skeletal muscle abnormalities, such as low skeletal muscle mass, measured by skeletal muscle index (SMI), and low skeletal muscle quality, measured by skeletal muscle density (SMD), are associated with poor prognosis in cancer. There has been little investigation of their impact on tolerance to radiation therapy and overall outcome in gynaecologic cancers. We examined the effect of low SMI and SMD on treatment tolerance and survival outcomes in patients with endometrial cancer receiving pelvic radiation.

METHODS

Stage IB-IVA patients with endometrial cancer treated at one institution between 2007 and 2017 were reviewed. All patients received hysterectomy and pelvic radiation. SMI was based on the cross-sectional area of skeletal muscle at the L3 vertebral body. SMD was expressed as the mean radiation attenuation in Hounsfield units (HUs) at the same vertebral level.

RESULTS

Sixty-four patients met criteria for analysis. Forty-four per cent had low SMI (<41 cm² /m² ), 80% had low SMD (mean < 33 HU if BMI> 25 and mean < 41 HU if BMI < 25), and 33% had both. Patients with both features were less likely to complete planned chemotherapy (p = 0.01); this was consistent on multivariate analysis. Radiation treatments were well-tolerated regardless of SMI or SMD. On survival analysis, having both low SMI and low SMD was associated with poorer outcomes compared with having either individual factor (p = 0.04).

CONCLUSION

Large percentages of patients with endometrial cancer have low skeletal muscle mass and density. Low skeletal muscle measures predict for poor tolerance to chemotherapy in this patient population. Compliance with adjuvant radiation is high, regardless of SMI and SMD.

Undergoing active treatment for gynecologic cancer during COVID-19: A qualitative study of the impact on healthcare and social support

•

COVID-19 challenges mechanisms of gynecologic cancer care delivery.

•

COVID-19 complicates social support for cancer patients undergoing active treatment.

•

Patient narratives of COVID-19 may offer targeted solutions to improve care delivery.

The COVID-19 pandemic poses unique challenges for oncology patients and clinicians. While guidelines for oncology care delivery during the pandemic have been established, there is a paucity of data examining patient experiences of cancer care during the COVID pandemic. This qualitative study captured the perspectives of women undergoing active treatment for gynecologic malignancy at an academic medical center. Hour-long semi-structured interviews were conducted via video-conference and transcribed verbatim. Focused coding was conducted to identify all data related to COVID-19. These data were then categorized into themes that emerged inductively. Seven women (N = 7) were interviewed. Several themes arose under two main categories: 1) Impact of COVID-19 on cancer care delivery and interactions and 2) Intersection of cancer and COVID-19 outside of the healthcare setting. Under category 1, themes included: going to treatment alone; variable access to care and information. Under category 2, themes included: unavailability of cancer-specific social support; mask wearing; COVID-19 & life outlook; adapting coping strategies. Participants’ perceptions of having cancer during the COVID-19 pandemic varied and were not always negative. Healthcare systems can draw on our findings to inform interventions to ensure optimal patient care. Additionally, given our finding that noncompliance with mask wearing and physical distancing can be uniquely distressing to cancer patients, healthcare systems should prioritize clear messaging around COVID-19 precautions and ensure compliance of staff and patrons. Due to the rapidly changing nature of the pandemic, outcomes for these patients should be monitored and care guidelines should incorporate first-hand patient narratives.

Disparities in ovarian cancer survival at the only NCI-designated cancer center in Kansas

BACKGROUND

This study examined the impact of geographic distance on survival outcomes for patients receiving treatment for ovarian cancer at the only NCI-designated cancer center (NCI-CC) in Kansas.

METHODS

We identified ovarian cancer patients treated at the University of Kansas Cancer Center between 2010 and 2015. Demographic factors and clinical characteristics were abstracted. The main outcome measure was overall survival according to geographic distance from the institution. Kaplan Meier survival curves and Cox proportional hazard models were generated using SAS v9.4.

RESULTS

220 patients were identified. Survival analysis based on distance from the institution demonstrated that patients who lived ≤10 miles from the institution had worse overall survival (p = 0.0207) and were more likely to have suboptimal cytoreductive surgery (p = 0.0276). Lower estimated median income was also associated with a 1.54 increased risk of death, 95% CI (1.031-2.292), p = 0.0347.

CONCLUSIONS

We determined that ovarian cancer survival disparities exist in our patient population. Lower rates of optimal cytoreductive surgery has been identified as a possible driver of poor prognosis for patients who lived in proximity to our institution.

Hospice and Palliative Medicine Fellowship after Surgical Training: A Roadmap to the Future of Surgical Palliative Care

OBJECTIVE

Surgeons comprise only 2% of Hospice and Palliative Medicine (HPM) board-certified physicians. Little is known about the motivations of individuals who pursue this combined training or the perceived benefits of this pathway. This study aimed to capture the pathways and experiences of HPM fellowship trained surgeons and to establish recommendations for surgical trainees who may benefit from HPM fellowship training.

DESIGN

A qualitative study was designed using semi-structured zoom interviews that elicited experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis.

SETTING

Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings.

PARTICIPANTS

Eligibility included completion of a 1-year HPM fellowship and training in general surgery, general obstetrics and gynecology, or affiliated subspecialties.

RESULTS

Seventeen interviews were conducted. All participants expressed satisfaction with their HPM fellowship training. Four themes emerged as recommendations for surgeons to pursue HPM fellowship training: 1) a commitment to joining the HPM workforce, 2) becoming ambassadors for HPM and surgical culture change, 3) desire for advanced communication and symptom management skills at the specialist level, and 4) specialist level HPM skills may enhance surgical career.

CONCLUSIONS

HPM fellowship training is achievable through multiple pathways for surgeons from a variety of training backgrounds.

Case Report: Uterine Didelphys and Cervical Agenesis in an 18 Year-Old Woman Presenting with a Pelvic Mass

BACKGROUND

Although Müllerian anomalies are relatively common they can be easily misdiagnosed as other gynecologic conditions leading to inappropriate treatment.

CASE

An 18-year-old woman presented to the hospital with abdominal pain and was found to have a 17-cm pelvic mass and absence of the cervix. Because of concern for recurrent endometrioma formation in the setting of a Müllerian anomaly, she underwent a hysterectomy. During surgery, she was noted to have complete uterine didelphys with cervical agenesis and a normal vagina.

SUMMARY AND CONCLUSION

This extremely rare Müllerian anomaly represents one of the only descriptions to date of uterine didelphys with cervical agenesis and normal vaginal development. Appropriate identification and management of Müllerian anomalies is essential for guiding the care of these young, complex patients.

Higher baseline BMI and lower estimated median income associated with increasing BMI after endometrial cancer diagnosis

Introduction

Endometrial cancer is often directly related to obesity and interventions for weight loss have mixed results. Risk factors for continued weight gain after diagnosis are not clearly defined in the literature. The objective of this study is to describe risk factors associated with increased body mass index (BMI) trajectory among endometrial cancer patients.

Methods

Patients who were surgically treated for endometrial cancer at a single institution between 2010 and 2015 were identified. Demographics including age, race/ethnicity and estimated median income at diagnosis were obtained. BMI at five time points after diagnosis were calculated. BMI trajectories were estimated by latent class growth modeling using the PROC TRAJ procedure in SAS. Chi-squared tests and ANOVA were used to assess differences between trajectory groups. Statistical significance was set to a p-value < 0.05.

Results

Of 695 patients included in the study, the average age at diagnosis was 62 years and over 70% of patients were obese at baseline. Patients experienced increasing, stable, or decreasing BMI over 2 years following diagnosis. Patients with younger age and lower estimated median income were most likely to be in the increasing BMI group. Among obese patients, those with Class I obesity (BMI 30 to 34.9 kg/m²) were most likely to experience decreasing BMI and those with Class III obesity (BMI > 40 kg/m²) were most likely to experience increasing BMI, p < 0.0001.

Conclusion

A third of endometrial cancer survivors experience increasing BMI. Severity of obesity at diagnosis matters, patients with severe obesity (Class III) were most likely to experience weight gain.

Functional Analysis of RE1 Silencing Transcription Factor as a Putative Tumor Suppressor in Human Endometrial Cancer

Uterine cancer is the most common gynecologic malignancy in the United States, with endometrioid endometrial adenocarcinoma (EC) being the most common histologic sub-type. Considering the molecular classifications of EC, efforts have been made to identify additional biomarkers that can assist in diagnosis, prognosis, and individualized therapy. We sought to explore the relationship of Repressor Element 1 (RE1) silencing transcription factor (REST), which downregulates neuronal genes in non-neuronal tissue, along with matrix metalloproteinase-24 (MMP24) and EC. We analyzed the expression of REST and MMP24 in 31 cases of endometrial cancer and 16 controls. We then explored the baseline expression of REST and MMP24 in two EC cell lines (Ishikawa and HEC-1-A) compared to a benign cell line (t-HESC) and subsequently evaluated proliferation, migration, and invasion in the setting of loss of REST gene expression. REST and MMP24 expression were significantly lower in human EC samples compared to control samples. REST was highly expressed in EC cell lines, but decreasing REST gene expression increased proliferation (FC: 1.13X, p < 0.0001), migration (1.72X, p < 0.0001), and invasion (FC: 7.77X, p < 0.05) in Ishikawa cells, which are hallmarks of cancer progression and metastasis. These findings elicit a potential role for REST as a putative tumor suppressor in EC.

Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer: A Multisite Randomized Clinical Trial

Importance

Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care.

Objective

To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers.

Intervention

Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits.

Main Outcomes and Measures

Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48.

Results

By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P < .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions.

Conclusions and Relevance

The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03375489.

Utilization and outcomes of serial cervical cancer screening in a National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in a non-Medicaid expansion state

PURPOSE

Since 1990, the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has offered free cervical cancer screening to low-income, uninsured patients, increasing single time point screening and early detection rates. Little is known about NBCCEDP's longitudinal effectiveness. The objective of this study was to assess utilization of Kansas's NBCCEDP, early detection works (EDW) for one-time versus serial screening and compare rates of cervical dysplasia between groups.

METHODS

A retrospective cohort study was conducted among patients who received cervical cancer screening through EDW from 2001 to 2021. Demographic factors, Papanicolaou (Pap) test, and human papillomavirus (HPV) results were compared between patients with one screening versus multiple. Descriptive statistics were performed.

RESULTS

From 2014 to 2021, 3.71-7.06% of eligible patients completed screening through EDW annually. 17.4% of 58,582 eligible patients were up-to-date with screening in 2020. Rural patients and those under age forty were less likely to have EDW screening. Of 43,916 ever-screened patients, 14,638 (33.3%) received multiple screenings. 77% of patients did not have HPV testing; rates were lower in serially screened patients. Cervical dysplasia rates differed minimally between groups.

CONCLUSION

Despite screening 24,017 patients over 7 years, EDW maintains up-to-date screening for under one-fourth of eligible Kansans. Young and rural patients less frequently access EDW. HPV testing is underutilized, which limits the negative predictive value of screening. Serial screening is largely used by low-risk patients currently. Identification and prioritization of serial screening in high risk could increase program impact.

"A Mission and Purpose to Make Some Sense out of Everything That Was Happening to Me": A Qualitative Assessment of Mentorship in a Peer-to-Peer Gynecologic Cancer Program

This study aimed to elucidate the relationship between mentorship, survivorship, and identity construction in people who have had gynecologic cancer and participated as mentors in a peer mentorship program. A qualitative descriptive study was designed, and hour-long semi-structured interviews with peer mentors were conducted. Interviews investigated how serving as a peer mentor influenced understanding of mentors' own cancer experiences. Thematic analysis was then conducted. All authors open-coded a subset of interviews to develop a codebook, which was then used to code the remaining transcripts. This qualitative inductive analysis of over 7 h of data was managed with NVivo 12. Seven peer mentor participants (N = 7) were interviewed. Four main themes emerged: serving in the social role of mentor gave participants (i) a sense of daily direction in their lives, (ii) an opportunity to give back to others in the cancer community, (iii) an explanatory reason for their cancer journey, and (iv) the ability to reify their own status as survivor. Providing support through a peer mentorship program helped our participants make meaning in their own cancer experience.

Higher baseline BMI and lower estimated median income is associated with increasing BMI after endometrial cancer diagnosis

Introduction

Endometrial cancer is often directly related to obesity and interventions for weight loss have mixed results. Risk factors for continued weight gain after diagnosis are not clearly defined in the literature. The objective of this study is to describe risk factors associated with increased body mass index (BMI) trajectory among endometrial cancer patients.

Methods

Patients who were surgically treated for endometrial cancer at a single institution between 2010 and 2015 were identified. Demographics including age, race/ethnicity and estimated median income at diagnosis were obtained. BMI at five time points after diagnosis were calculated. BMI trajectories were estimated by latent class growth modeling using the PROC TRAJ procedure in SAS. Chi-squared tests and ANOVA were used to assess differences between trajectory groups. Statistical significance was set to a p-value < 0.05.

Results

Of 695 patients included in the study, the average age at diagnosis was 62 years and over 70% of patients were obese at baseline. Patients experienced increasing, stable, or decreasing BMI over 2 years following diagnosis. Patients with younger age and lower estimated median income were most likely to be in the increasing BMI group. Among obese patients, those with Class I obesity (BMI 30 to 34.9 kg/m²) were most likely to experience decreasing BMI and those with Class III obesity (BMI > 40 kg/m²) were most likely to experience increasing BMI, p < 0.0001.

Conclusion

A third of endometrial cancer survivors experience increasing BMI. Severity of obesity at diagnosis matters, patients with severe obesity (Class III) were most likely to experience weight gain.

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Facilitators and Barriers to Recruiting Surgeons into Hospice and Palliative Medicine Training

CONTEXT

Few individuals have fellowship training in both hospice and palliative medicine (HPM) and a surgical specialty including general surgery, general obstetrics and gynecology, or affiliated subspecialties. There is a paucity of data to explain why some surgeons choose to pursue HPM fellowship training.

OBJECTIVE

Identify facilitators and barriers to palliative medicine fellowship training among physicians from a surgical specialty.

METHODS

We conducted individual semistructured interviews with 17 surgeons who were also fellowship-trained in HPM. Interviews were recorded, transcribed, and thematic analysis was conducted to identify themes.

RESULTS

Participants reported pivotal experiences-either positive exposure to palliative care or suboptimal surgical care experiences-as a key motivator for pursuing specialty palliative care training. Additionally, participants chose HPM training because they felt that practicing from a HPM perspective aligned with their personal care philosophy, and in some cases, offered professional opportunities to help achieve career goals. Participants reported encountering bias from both HPM and surgical faculty, and also found that some HPM fellowship programs did not accept surgical trainees. Surgeons also reported logistical concerns related to coordinating a one-year fellowship as a barrier to formal HPM training.

CONCLUSIONS

Understanding the motivations of surgeons who pursue HPM training and identifying challenges to completing fellowship may inform solutions to expand surgeon representation in palliative care. Both HPM and surgical faculty should be educated on the benefits of specialty HPM training for surgical trainees and practicing surgeons. Further research should explore HPM fellowship best practices for welcoming and training surgeons and other underrepresented specialties.