Kellie E. Schneider

The utilization of palliative care in gynecologic oncology patients near the end of life

BACKGROUND Palliative and supportive care services provide excellent care to patients near the end of life. It is estimated that enrollment in such services can reduce end-of-life costs; however, there is limited data available regarding the impact of palliative services in end-of-life care in gynecologic oncology patients. We examined the use of palliative services in gynecologic oncology patients during the last six months of life. METHODS After IRB approval, a retrospective chart review of patients with a diagnosis of a gynecologic malignancy who died between June 2007 and June 2010 was performed. Abstracted data included demographics, admission and procedural history, use of anti-cancer therapy, and palliative care utilization during the last six months of life. RESULTS 268 patients were identified. Most patients were white (76.9%) and had ovarian cancer (56.7%). During the last six months of life, 155 (57.8%) patients underwent anti-cancer therapy with chemotherapy, 19 (7.1%) patients were treated with radiation therapy, and 17 patients (6.3%) underwent treatment with both. 218 patients (81.3%) had at least one admission during this time (range 0-14). The most common reason for admission was gastrointestinal complaints (37.1%), followed by admissions for procedures (18.3%). The median time between the last admission and death was 32 days. 157 patients (58.6%) underwent at least one procedure during the last six months of life (range 0-11). The most common procedure performed was paracentesis (22.6%). 198 (73.9%) patients died at home or in a palliative care unit. 189 (70.5%) patients were referred to hospice or palliative care. 3.2% underwent a procedure or treatment with chemotherapy or radiation after hospice enrollment. The median time between hospice enrollment and death was 22 days. 55% of patients were enrolled in hospice less than 30 days before death. Of the 79 patients not referred to hospice, only 16.5% had documentation of refusing hospice services. CONCLUSIONS During the last six months of life, the majority of gynecologic oncology patients receive anticancer therapy and many have repeated hospital admissions. While the majority of patients are referred for palliative care, it appears that most patients spend less than 30 days on hospice. Earlier referral could decrease the number of hospital admissions and procedures while providing invaluable support during this end of life transition.

Assessment of risk factors for 30-day hospital readmission after surgical cytoreduction in epithelial ovarian carcinoma.

Objective: To evaluate factors that place epithelial ovarian cancer (EOC) patients at increased risk for hospital readmission. Methods: A retrospective review of patients diagnosed with EOC undergoing surgical cytoreduction at the University of Alabama at Birmingham from 2001 to 2008 was performed. Patients who required readmission were identified. Demographic data, comorbidities, surgical data including bowel resections, and hospital length of stay were evaluated. Results: A total of 207 patients were identified. The mean age at diagnosis was 64 years (range, 32-89 years), 58% had optimal debulking (n = 120), and the mean number of comorbidities was 1.3 (range, 0-6). Readmission within 30 days of discharge occurred in 33 (16%) of 207 patients. The readmission group had a statistically higher number of comorbidities (1.75 vs 1.01, P = 0.025). The most common reasons for readmission were small bowel obstruction/ileus, wound complications, and thromboembolic events. Conclusions: The most common reason for readmission after cytoreductive surgery for EOC is small bowel obstruction/ileus. Studies assessing postoperative disease management programs including nursing telephone follow-up, administration of outpatient intravenous fluids, and continuation of antithrombotic agents may offer opportunities to reduce readmissions.

Double prophylaxis for deep venous thrombosis in patients with gynecologic oncology who are undergoing laparotomy: does preoperative anticoagulation matter?

Objective: Double prophylaxis for deep venous thrombosis (DVT) with thromboprophylaxis plus sequential compression devices (SCDs) is recommended for high-risk surgical patients with gynecologic oncology. Despite the use of preoperative thromboprophylaxis in clinical trials, the schedule of perioperative low molecular-weight heparin varies widely. We sought to determine the effectiveness and adverse effects of a preoperative dose of anticoagulation in patients with gynecologic oncology. Methods: A multi-institutional chart review from January 2006 to July 2008 was performed. Patients with gynecologic oncology who received double prophylaxis for laparotomy were eligible. The patients were grouped according to whether they received preoperative anticoagulation (YES PREOP vs NO PREOP). All patients received postoperative low molecular-weight heparin for thromboprophylaxis and SCDs until discharge. Demographic, surgicopathologic, and complication data were collected. Results: A total of 239 patients were identified: YES PREOP (n = 101) and NO PREOP (n = 138). Groups were similar with respect to demographics, diagnosis, and length of hospital stay. There were 2 DVTs in the YES PREOP group compared with 11 in the NO PREOP group (P = 0.04; relative risk, 0.77). There were also fewer DVT-attributable deaths in the YES PREOP group (0 vs 2; P < 0.001). Postoperative hematocrit (30.2% vs 31.4%; P = 0.42) and number of transfusions (26 vs 14; P = 0.31) were similar. Conclusion: The use of preoperative anticoagulation seems to significantly decrease the risk of DVT in this patient population, and complication rates are not increased. Patients receiving double prophylaxis should receive a preoperative dose of anticoagulation for maximum benefit.

Outcomes of patients with gynecologic malignancies undergoing video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion

OBJECTIVES We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion. METHODS After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes. RESULTS Forty-two patients with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. Twenty-nine patients (69%) had ovarian cancer. Fifty-seven percent had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. Eight patients (19%) underwent perioperative VATS to improve pulmonary status. Seven patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1-53). Sixty-two percent had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300-4500), and the majority (88%) of patients had a talc pleurodesis performed. Seven patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS. One patient was readmitted with hospital-acquired pneumonia and died during readmission. Median time to death after VATS was 104 days (range 4-1062). Patients who underwent a perioperative VATS had the longest survival (845 days). CONCLUSION Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.

Referral patterns and incidence of cervical intraepithelial neoplasia in adolescent and pregnant patients: The impact of the 2006 guidelines

Objective. The 2006 American Society for Colposcopy and Cervical Pathology consensus guidelines for management of abnormal cervical cytologic diagnosis made significant changes to referral recommendations for adolescent and pregnant populations. In this study, we sought to review the impact of these new guidelines on referral patterns, along with the incidence of cervical intraepithelial neoplasia 2/3 and cervical cancer in these 2 populations. Materials and Methods. After obtaining institutional review board approval, a retrospective chart review of 12,333 patients referred to a single colposcopy clinic between January 2004 and November 2009 was performed. This colposcopy clinic serves as a statewide referral center. All adolescent patients (<21 y) and pregnant patients were included for analysis. Patients were analyzed in 2 groups with respect to implementation of the 2006 guidelines. Statistical analysis was performed using &khgr;2 and Student t test. Results. Between 2004 and 2007, before implementation of the 2006 guidelines, 9,346 patients were referred to the colposcopy clinic. Overall, 1,398 adolescents and 958 pregnant patients were identified and included in the analysis. The mean age was 23.0 years (range = 10-60 y). Of the 1,398 adolescent patients, atypical squamous cells of undetermined significance (ASCUS) Pap smears accounted for 406 referrals (29.0%). Of the 958 pregnant patients, ASCUS cytologic diagnosis accounted for 284 referrals (29.6%). One case of squamous cell carcinoma (SCC) was identified in the pregnant population (0.1%), and no cases of SCC were diagnosed in the adolescent population. After implementation of the 2006 guidelines, between 2008 and 2009, a total of 2,987 patients were referred, including 113 adolescent patients and 168 pregnant patients. Mean age was 25.5 (range = 16-54 y), which was not significantly different from 2004 to 2007, p = .79. Atypical squamous cells of undetermined significance accounted for 6 referrals (5.3%) in the adolescent population and 15 referrals (8.9%) in the pregnant population. The decrease in the proportion of ASCUS cytologic diagnosis referrals in these populations was statistically significant at p < .001. No adolescent or pregnant patients were diagnosed with SCC during their colposcopic evaluation. Conclusions. The 2006 American Society for Colposcopy and Cervical Pathology consensus guidelines decreased the number of ASCUS cytologic diagnosis referrals to colposcopy in the adolescent and pregnant populations. The overall number of patients with SCC in these populations is quite small, therefore practitioners can be reassured that the new screening guidelines are unlikely to miss this diagnosis. These guidelines provide an efficient, evidence-based approach to the cytologic evaluation of these special populations.

Perioperative morbidity and mortality in octogenarians with ovarian cancer.

Background The decision to choose surgical cytoreduction in patients with newly diagnosed ovarian cancer may be influenced by their age. We compared perioperative morbidity and mortality of octogenarians compared with younger patients undergoing surgical cytoreduction. Methods A retrospective chart review identified patients who underwent primary surgical cytoreduction for ovarian cancer between January 2005 and December 2009. Patients were divided into 2 cohorts: younger than 80 years and 80 years or older (octogenarian). Patient demographics, surgical procedures, 30-day readmission, length of stay, 30-day mortality rates, and chemotherapy administration were examined. Student t test and &khgr;2 test were used to evaluate statistical significance. Results Three hundred eighty-four patients who underwent surgical cytoreduction for ovarian cancer were identified. Three hundred fifty-two patients (91.7%) were younger than 80 years, whereas 32 patients (8.3%) were 80 years or older. Two hundred thirty-six women (67.0%) in the younger cohort had optimal cytoreduction (<1 cm) compared with 17 women (53.1%) in the older cohort (P = 0.12). Thirty-day readmission rates and postoperative complications were similar. More patients in the older cohort required preoperative admission for medical clearance (P < 0.01). Mean length of stay was significantly longer in the older cohort (10.0 vs 7.5; P = 0.02). The number of patients who received adjuvant chemotherapy was significantly lower in the older cohort (71.9% vs 93.8%; P < 0.01). The 30-day mortality rate was significantly higher in the older cohort (18.8% vs 4.0%; P < 0.01). Conclusions Although octogenarians with ovarian cancer have similar surgical complication rates as their younger counterparts, they require more medical clearance and have a longer hospital stay. Older patients are less likely to undergo chemotherapy and have a higher 30-day mortality rate than are younger patients.