C. Lefkowits

Symptom management in women with recurrent ovarian cancer: Do patients and clinicians agree on what symptoms are most important?

OBJECTIVE We sought to compare symptoms identified as a priority by patients with recurrent ovarian cancer to symptoms most frequently documented by their clinicians, and examine the association between clinician documentation of symptoms and subsequent clinical intervention. METHODS Single-institution, retrospective chart review of patients enrolled in WRITE Symptoms Study (GOG 259), a randomized controlled trial of internet-based recurrent ovarian cancer symptom management. As part of the trial, women completed the Symptom Representation Questionnaire for 28 symptoms and selected 3 priority symptoms (PS). We compared patient-reported PS to clinician documentation of symptoms and interventions over the time period corresponding to study enrollment. RESULTS At least one PS was documented in 92% of patients. Of 150 PS reported by patients, 53% were never documented by clinicians; these symptoms tended to be less directly related to disease or treatment status. Symptoms not identified by patients as PS were frequently documented by clinicians; these symptoms tended to relate to physiologic effects of disease and treatment toxicity. 58% of patients had at least one PS intervention. PS intervened for were documented at 2.58 visits vs 0.50 visits for PS not receiving intervention (p≤0.0001). CONCLUSIONS Discordance was identified between symptoms reported by patients as important and symptoms documented by clinicians. Symptoms more frequently documented were also more frequently intervened for. Our study illustrates the need to improve identification of symptoms important to patients, and suggests that improving communication between patients and clinicians could increase intervention rates to enhance quality of life in women with recurrent ovarian cancer.

Prospective screening with the validated Opioid Risk Tool demonstrates gynecologic oncology patients are at low risk for opioid misuse

OBJECTIVE To characterize risk for opioid misuse among gynecologic oncology patients. METHODS The Opioid Risk Tool (ORT), a validated screen for opioid misuse risk, was administered to a convenience sample of patients with gynecologic cancer receiving opioid prescriptions in gynecologic oncology or palliative care clinics from January 2012-June 2016. Demographic and clinical information was abstracted on chart review. The primary outcome was ORT risk level (low vs. moderate or high). Chi-square tests were performed for categorical variables. RESULTS A total of 118 women were screened. Most women were Caucasian (79%) with a median age of 57years. Ovarian cancer patients comprised 46% of the cohort with fewer endometrial (25%), cervical (23%), vulvar (4%), and vaginal (2%) cancer patients. The median ORT score was 1.0 (range, 0-10) out of a possible 26. Overall, 87% of patients were categorized as low-risk for opioid misuse, 7% as moderate-risk, and 6% as high-risk. Patients who were at moderate or high-risk of opioid misuse were significantly younger (47 vs. 58years, p=0.02), more likely to have cervical cancer (p=0.02), be smokers (p=0.01) and be uninsured or on Medicare (p=0.03). CONCLUSIONS Most gynecologic oncology patients in our cohort were low-risk for opioid misuse (87%). Cervical cancer patients were more likely to be moderate to high-risk for misuse. Future screening efforts for opioid misuse may have the highest utility in this subset of patients.

Opioid use in gynecologic oncology in the age of the opioid epidemic: Part I - Effective opioid use across clinical settings, a society of gynecologic oncology evidence-based review

As the only oncologists that provide both medical and surgical oncologic care, gynecologic oncologists encounter an exceptionally broad range of indications for prescribing opioids, from management of acute post-operative pain to chronic cancer-related pain to end-of-life care. If we are to balance opioid efficacy, safety and accessibility for our patients, we must be intimately familiar with appropriate clinical use of opioids in a range of settings, and engage in the national conversation around opioid misuse and how associated regulations and legislation may impact us and our patients. This article examines the appropriate use of opioids across the range of clinical settings encountered in gynecologic oncology.

Opioid use in gynecologic oncology in the age of the opioid epidemic: Part II – Balancing safety & accessibility

As the only oncologists that provide both medical and surgical care, gynecologic oncologists encounter an exceptionally broad range of indications for prescribing opioids in clinical situations ranging from management of acute post-operative pain to chronic cancer-related pain to end-of-life care. While opioids are essential to the practice of gynecologic oncology, they can also have significant side effects and can be misused. Due to the explosive growth of opioid prescriptions and opioid-related overdoses and deaths during the first decade of the 21st century, there has been a recent concerted public health effort to prevent and treat opioid misuse through both legislation and education [1]. The first article in this two part series focused on appropriate use of opioids across clinical settings. This article addresses both the clinical and regulatory aspects of balancing opioid safety and accessibility for patients with gynecologic cancer.

Incontinence, Voiding Dysfunction, and Other Urologic Complications After Radiotherapy for Gynecologic Malignancies

Women with newly diagnosed gynecologic cancer will undergo treatment with surgery, radiation, or combination therapy. A considerable proportion of these women will develop urologic complications including urinary incontinence, urinary retention, radiation cystitis, ureteral stricture, or genitourinary fistula. Diagnosis is typically made with a careful history, physical exam, endoscopy, urodynamics, and imaging. Non-surgical and surgical management of urologic complications following radiotherapy is complicated by local tissue damage resulting in inferior success rates when compared to the general population. It is imperative that the patient and physician understand the complexity of treatment and manage expectations accordingly.