Jolyn S. Taylor

Perioperative blood transfusion in gynecologic oncology surgery: Analysis of the National Surgical Quality Improvement Program Database

OBJECTIVE To use a large-scale multi-institutional dataset to quantify the prevalence of packed red blood cell transfusions and examine the associations between transfusion and perioperative outcomes in gynecologic cancer surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant use file was queried for all gynecologic cancer cases between 2010 and 2012. Demographic, preoperative and intraoperative variables were compared between transfusion and non-transfusion groups using chi-squared, Fishers exact and Wilcoxon rank-sum tests. The primary endpoint was 30-day composite morbidity. Secondary endpoints included composite surgical site infections, mortality and length of stay. RESULTS A total of 8519 patients were analyzed, and 13.8% received a packed red blood cell transfusion. In the multivariate analysis, after adjusting for key clinical and perioperative factors, including preoperative anemia and case magnitude, transfusion was associated with higher composite morbidity (OR = 1.85, 95% CI 1.5-2.24), surgical site infections (OR 1.80, 95% CI 1.39-2.35), mortality (OR 3.38, 95% CI 1.80-6.36) and length of hospital stay (3.02 days v. 7.17 days, P < 0.001). CONCLUSIONS Blood transfusions are associated with increased surgical wound infections, composite morbidity and mortality. Based on our analysis of the NSQIP database, transfusion practices in gynecologic cancer should be scrutinized. Examination of institutional practices and creation of transfusion guidelines for gynecologic malignancies could potentially result in better utilization of blood bank resources and clinical outcomes among patients.

How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology

BACKGROUND Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.

Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients

OBJECTIVES To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life. METHODS Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007-2011 were identified. Statistical analyses included Wilcoxon-Mann-Whitney, Chi-square analysis, and multivariate analysis. RESULTS 183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer. Fifty percent had experienced at least one form of aggressive care during the last 30days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p=<0.001), with a median hospice stay of 18days before death. Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378days prior to death, respectively. CONCLUSIONS Many ovarian cancer patients underwent some form of aggressive medical care in the last 30days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.

Fighting cancer together: Development and implementation of shared medical appointments to standardize and improve chemotherapy education

OBJECTIVE Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. METHODS We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. RESULTS From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. CONCLUSIONS This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.

Dying well: How equal is end of life care among gynecologic oncology patients?

OBJECTIVE To identify disparities in utilization of end of life (EoL) resources by gynecologic oncology (GO) patients. METHODS This retrospective analysis of the medical records of GO patients treated 1/2007-12/2011 and deceased 1/2012-8/2014 evaluated patient demographics, disease characteristics, and utilization of EoL resources. Chi-square, Fishers exact test, Mann Whitney and Kruskal-Wallis tests were used for statistical analysis. RESULTS Of 189 patients analyzed, 113 (60%) were white, 38 (20%) Hispanic, 31 (16%) black, and seven (4%) Asian. Ninety-five (48%) had ovarian cancer, 51 (26%) uterine, 47 (23%) cervical, seven (3%) vulvar/vaginal. In the last 30days of life (DoL), 18 (10%) had multiple hospital admissions, 10 (5%) admitted to the Intensive Care Unit (ICU), 30 (16%) multiple Emergency Room (ER) visits, 45 (24%) received aggressive medical care and eight (4%) received chemotherapy in the final 14 DoL. Furthermore, 54 (29%) had no Supportive Care referral and 29 (15%) no hospice referral. Only 46 (24%) had a Medical Power of Attorney (PoA) or Living Will (LW) on file. Non-white race was associated with increased odds of dying without hospice (OR 3.07; 95%CI [1.27, 2.46], p=0.013). However, non-white patients who enrolled in hospice did so earlier than white patients (42 v. 27days before death, p=0.054). Non-white patients were also significantly less likely to have PoA/LW documentation (24% v. 76%, p=0.009) even if enrolled in hospice (12% v. 31%, p=0.007). CONCLUSIONS Significant racial disparities in hospice enrollment and PoA/LW documentation were seen in GO patients. This warrants further study to identify barriers to use of EoL resources.

What Is the Real Rate of Surgical Site Infection

PURPOSE Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. METHODS We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fishers exact test. RESULTS Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). CONCLUSION There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.

All the darkness we don't see

Trafficking of women and children for sexual exploitation is the fastest growing criminal enterprise in the world. This is a public health crisis; as physicians who have direct contact with victims, we have a unique opportunity to intervene. The authors developed a specialty clinic for survivors of sex trafficking in 2013 at an academic medical center in New York City. Twenty of the 24 women seen in the Survivor Clinic saw a physician while being trafficked. Sex trafficking violates basic human rights, which include the rights to bodily integrity, dignity, health, and freedom from violence and torture. The stories of the patients seen in the Survivor Clinic bear witness to the health consequences of commercial sexual exploitation and reinforce the previous literature on the rates of physical and psychologic harms of trafficking. Health consequences of trafficking include traumatic brain injuries, drug addiction, depression, and neglect of chronic health conditions. All physicians, but gynecologists especially, need more education about the prevalence and dynamics of trafficking and how to assess and intervene on behalf of survivors.

End-of-Life Racial and Ethnic Disparities Among Patients With Ovarian Cancer

Purpose To assess disparities in end-of-life care among patients with ovarian cancer. Patients and Methods Using Texas Cancer Registry-Medicare data, we assessed patients with ovarian cancer deceased in 2000 to 2012 with at least 13 months of continuous Medicare coverage before death. Descriptive statistics and multivariate logistic regressions were conducted to evaluate end-of-life care, including chemotherapy in the final 14 days of life, intensive care unit (ICU) admission in the final 30 days of life, more than one emergency room (ER) or hospital admission in the final 30 days of life, invasive or life-extending procedures in the final 30 days of life, enrollment in hospice, enrollment in hospice during the final 3 days of life, and enrollment in hospice while not hospitalized. Results A total of 3,666 patients were assessed: 2,819 (77%) were white, 553 (15%) Hispanic, 256 (7%) black, and 38 (1%) other. A total of 2,642 (72%) enrolled in hospice before death, but only 2,344 (64%) died while enrolled. The median hospice enrollment duration was 20 days. In the final 30 days of life, 381 (10%) had more than one ER visit, 505 (14%) more than one hospital admission, 593 (16%) ICU admission, 848 (23%) invasive care, and 418 (11%) life-extending care. In the final 14 days of life, 357 (10%) received chemotherapy. Several outcomes differed for minorities compared with white patients. Hispanic and black patients were less likely to enroll and die in hospice (black odds ratio [OR], 0.66; 95% CI, 0.50 to 0.88; P = .004; Hispanic OR, 0.76; 95% CI, 0.61 to 0.94; P = .01). Hispanic patients were more likely to be admitted to an ICU (OR, 1.37; 95% CI, 1.05 to 1.78; P = .02), and black patients were more likely to have more than one ER visit (OR, 2.20; 95% CI, 1.53 to 3.16; P < .001) and receive a life-extending procedure (OR, 2.13; 95% CI, 1.49 to 3.04; P < .001). Conclusion We found being a minority was associated with receiving intensive and invasive end-of-life care among patients with ovarian cancer.

Hormonal based treatment of ovarian anaplastic ependymoma with anastrozole

Objective Ovarian anaplastic ependymoma is a rare gynecologic malignancy that poses diagnostic and treatment challenges. Treatment of sub-optimally debulked disease usually portends poor prognosis. Molecular testing of tumor specimen can identify more specific targets for additional therapy such as estrogen and progesterone receptors (ER/PR). Case A 29-year-old woman presented with incidental finding of large bilateral adnexal masses and elevated CA 125. Biopsy proved anaplastic ovarian ependymoma with high ER/PR expression. She underwent sub-optimal surgical debulking followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin (BEP) which resulted in a partial response. Due to extensive residual disease she has been maintained on anastrozole for over fifteen months without increased tumor burden. Targeted somatic mutation testing was negative for all high risk clinically useful variants. Conclusion Aromatase inhibitors may be considered in patients with extra-axial anaplastic ependymoma and can produce prolonged stable disease.

Disparities in treatment and survival among elderly ovarian cancer patients

OBJECTIVE To determine correlation between race and receipt of optimal treatment for ovarian cancer and the impact of this on overall survival. METHODS Using SEER-linked Medicare database, women 66 and older diagnosed with advanced ovarian cancer between 2002 and 2011 were identified. Patients with unclear histology, diagnosed on autopsy and without Medicare Parts A and B were excluded. We used Chi-square test for categorical variables, F test for continuous variables, and multivariable logistic regression to identify characteristics associated with receipt of surgery and chemotherapy. Kaplan-Meier analysis was used to compare overall survival rates. Cox Proportional Hazards regression was performed to identify factors associated with 5-year survival. RESULTS 9016 ovarian cancer patients were included. 2638 had primary chemotherapy, 4854 had primary surgery, and 1524 had no treatment. 7653 (84.9%) were white, 572 (6.3%) black, 479 (5.3%) Hispanic, and 312 (3.5%) were of other race/ethnicity. More white patients (57.2%) received both chemotherapy and surgery compared to black (39.9%), Hispanic (48.9%), or other (54.2%) (p < .001). Receipt of either only surgery or chemotherapy, or receipt of neither, resulted in higher risk of death when compared to receipt of both. On multivariable analysis, black (OR 0.58 [0.46-0.73]) and Hispanic (0.69 [0.54-0.88]) patients were less likely to receive both chemotherapy and surgery. Being of black race was significantly correlated with worse overall survival [HR 1.13 (1.03-1.23); p = .02]. CONCLUSIONS Non-white women are less likely to receive the standard of care treatment for ovarian cancer and more likely to die from their disease than white women.