R. Ruskin

Recommendations for Intrauterine Contraception: A Randomized Trial of the Effects of Patients’ Race/Ethnicity and Socioeconomic Status

OBJECTIVE Recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to health disparities. This study investigated the effect of these factors on recommendations for contraception. STUDY DESIGN One of 18 videos depicting patients of varying sociodemographic characteristics was shown to each of 524 health care providers. Providers indicated whether they would recommend levonorgestrel intrauterine contraception to the patient shown in the video. RESULTS Low socioeconomic status whites were less likely to have intrauterine contraception recommended than high socioeconomic status whites (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.06-0.69); whereas, socioeconomic status had no significant effect among Latinas and blacks. By race/ethnicity, low socioeconomic status Latinas and blacks were more likely to have intrauterine contraception recommended than low socioeconomic status whites (OR, 3.4; and 95% CI, 1.1-10.2 and OR, 3.1; 95% CI, 1.0-9.6, respectively), with no effect of race/ethnicity for high socioeconomic status patients. CONCLUSION Providers may have biases about intrauterine contraception or make assumptions about its use based on patient race/ethnicity and socioeconomic status.

Improvement in symptom burden within one day after palliative care consultation in a cohort of gynecologic oncology inpatients

OBJECTIVE The aim of this study is to evaluate the magnitude and time course of change in symptom burden after palliative care (PC) consultation in a cohort of gynecologic oncology inpatients. METHODS Women with a gynecologic malignancy and PC consultation for symptom management between 3/1/12 and 2/28/13 were identified. Charts were reviewed for demographic and disease characteristics. Symptom scores on a modified Edmonton Symptom Assessment System (ESAS) scale were abstracted for pain, anorexia, fatigue, depression, anxiety, nausea and dyspnea. Prevalence of moderate-to-severe symptom intensity was compared between the day of PC consultation (D1), the day after PC consultation (D2) and the last recorded symptoms before discharge (DLast). RESULTS PC was consulted for symptom management during 129 admissions of 95 unique patients. Median age was 59, 84% were white and 67% had stage III/IV disease, with ovarian the most common site (52%). Symptom prevalence on D1 for at least mild intensity ranged 14% (dyspnea) to 80% (pain) and for at least moderate intensity from 3% (dyspnea) to 50% (pain). Statistically significant decreases in prevalence of moderate to severe symptom intensity between D1 and DLast occurred for pain, anorexia, fatigue and nausea (magnitude 58-66%) and between D1 and D2 for pain, fatigue and nausea (magnitude 50-55%). The majority of the improvement that occurred between D1 and DLast happened by D2. CONCLUSIONS PC consultation is associated with improvement in symptom burden, the majority of which occurs within one day of consultation. PC may be an effective tool for symptom management in patients with moderate to severe symptom intensity even during short hospitalizations and should be considered early in the hospitalization to effect timely symptom relief.

Predictors of high symptom burden in gynecologic oncology outpatients: Who should be referred to outpatient palliative care?

OBJECTIVE To characterize symptom prevalence in gynecologic oncology outpatients and identify predictors of high symptom burden. METHODS We performed a retrospective analysis of a convenience sample of symptom surveys from gynecologic oncology patients at a single cancer center over a 20-month period. The survey was based on the Edmonton Symptom Assessment System (ESAS), and assessed pain, depression, anxiety, fatigue and well-being. Information on demographics, disease, treatment and history of chronic pain, depression or anxiety was abstracted from medical records. Data was analyzed with descriptive and t-test statistics. RESULTS We analyzed 305 surveys from unique patients. Symptom prevalence (severity score>0/10) ranged from 60.1% (pain) to 79.7% (fatigue). Prevalence of moderate to severe symptoms (score≥4/10) ranged from 32% (pain) to 47% (fatigue). There were no differences in symptom burden by site or stage of cancer. Patients with no active disease (38%) were less symptomatic. There was a trend toward higher symptom burden in patients younger than 50years. There was higher symptom burden in patients receiving cancer treatment or with a pre-existing history of pain, anxiety or depression. Patients who expressed an interest in being seen by a symptom management service also had higher symptom burden. CONCLUSIONS Gynecologic oncology outpatients have a high symptom burden regardless of stage and site of cancer. Patients who are young, on treatment or have a history of chronic pain, depression or anxiety have a higher symptom burden. Consideration should be given to targeting these patients for outpatient palliative care services.

Stress and burnout among gynecologic oncologists: A Society of Gynecologic Oncology Evidence-based Review and Recommendations

Burnout in physicians is a significant problem in all fields of medicine. A 2008 survey of members of the American College of Surgeons (ACS) and a 2014 survey of members of the Society of Gynecologic Oncology (SGO) reported that physician burnout occurs in 32% to 40% of gynecologic oncologists and surgeons This article describes the risk factors responsible for burnout in gynecologic oncologists and other physicians and the consequences of burnout and explores potential solutions. Data from the oncology, trauma, and surgical literature have shown that physicians treating themost acutely ill patients have 40% or greater prevalence of burnout. At the individual level, burnout is indicative of emotional exhaustion and stress, depersonalization in relationships with coworkers, detachment from patients, a sense of inadequacy or low personal accomplishment, mental illness, substance abuse, and risk of suicide. In the SGO survey, 33% of respondents screened positive for depression, 11% took medication for depression, and 14% experienced panic attacks. The ACS survey corroborated these findings, reporting that 30% of surgeons screened positive for symptoms of depression. Substance abuse was identified in 15% of gynecologic oncologists; there was a positive screen for alcohol abuse and suicidal ideation. The SGO survey reported that only 9% of respondents had sought psychiatric care in the previous 12months, and 45%were reluctant to seek psychiatric care. Suicide is a significant problem among all physicians who experience burnout; suicide rates are higher among female physicians. In both the SGO survey and the ACS survey, 13% to 14% of respondents reported suicidal ideation. At the professional level, physician burnout impacts patient care as shown by suboptimal patient outcomes, increased medical errors, increased liability claims, and inappropriate prescriptions. Because few studies have specifically assessed burnout in gynecologic oncologists, much of what is understood about burnout has been extrapolated from a variety of other physician specialties. Risk factors for burnout: Job stress is one of the most important factors associated with physician burnout. Gynecologic oncologists with a low perception of internal locus of control and increased anxiety with end-of-life care have greater work-related stress. Loss of a sense ofmeaning fromwork has been shown to increase the risk of physician burnout. Changing interests and career drift can develop over time. Gynecologic oncologists who devote most of their time and effort to patient care and surgery may find that they derive more job satisfaction and meaning in research and be unable to do so. The difficulty balancing career with family/personal life is a key factor contributing to burnout. In the AGS survey, worklife balance issues predicted burnout equally in both sexes, but the effect was more pronounced among female physicians. Modern home computer technology has a major affect on work-life balance in that physicians have 24-hour access to patient records, shared communication with colleagues, and on-demand educational resources. Risk factors for burnout in the AGS survey were having younger children between the ages of 5 and 21 years, income based on patient care billing, and working at least 60 hours per week. The SGO survey reported that independent risk factors associated with burnout were low mental quality of life, depression, being stressed and overwhelmed, suicidal ideation, alcohol abuse, and reluctance to seek care. The findings of a large study among US physicians assessing work-home conflict in dual-career relationships reported that female physicians were more likely to report signs or symptoms of burnout than male physicians. Copyright

Predictors of intensive care unit utilization in gynecologic oncology surgery

Objectives: The objectives of the study were to examine factors predicting intensive care unit (ICU) admission after surgery for gynecologic cancer and to determine the impact of ICU admission on survival. Methods: This was a retrospective study of women undergoing laparotomy for staging and debulking of gynecologic cancer at an academic hospital with tertiary ICU facilities from July 2000 through June 2003. Data on clinicopathologic factors, comorbidities, operative outcomes, and survival were obtained from medical records and institutional cancer registry. The &khgr;2 analysis, Kaplan-Meier analysis, and Cox regression methods were used for analyses. Results: Two hundred fifty-five patients met our inclusion criteria, 43 of whom had a postoperative admission to the ICU. Factors predicting ICU admission on univariate analysis included age 60 years or older, hematocrit of 30% or less, albumin of 3.5 g/dL or less, and Charlson Comorbidity Index (CCI) score greater than 8; after multivariate analysis, CCI score of greater than 8 (hazard ratio, 2.5; confidence interval, 1.11-5.69) and albumin of 3.5 or less (hazard ratio, 3.8; confidence interval, 1.66-8.85) were associated with an increased risk of ICU admission. After adjusting for albumin and CCI score, ICU admission did not have a significant effect on survival. Conclusions: The ability to predict ICU admission helps in appropriate counseling of patients and identification of institutional resource utilization.

Contribution of age to clinical trial enrollment and tolerance with ovarian cancer

INTRODUCTION Increasing age has been correlated with shorter survival in ovarian cancer patients, a finding attributed to diminished tolerance of standard therapy. Elderly patients, however, are less likely to enroll on clinical trials; thus, limited data exists to evaluate their response to front line treatment. This study describes how elderly patients on trial fared, with respect to toxicity and response, compared to younger women. METHODS A retrospective cohort study was performed of ovarian cancer patients enrolled in front line chemotherapy trials at our institution between 2000 and 2013. Patients were dichotomized by age: <70 and ≥70years. Clinical, pathologic, and treatment characteristics were recorded and analyzed using SAS version 9.3. RESULTS 336 patients were enrolled. Of these, 79 (23.5%) were ≥70yrs. Demographics were similar between the two groups. Compared to patients <70, those ≥70 completed a comparable number of chemotherapy cycles (p=0.16) and had similar numbers of dose modifications (p=0.40) and delays (p=0.26). Both hematologic and non-hematologic toxicities occurred at similar rates as well. Age≥70 (HR 1.8, 95% CI 1.27-2.54, p=0.0009), stage III/IV (HR 3.44, 95% CI 1.08-10.95, p=0.036), and residual disease (HR 2.63, 95% CI 1.82-3.78, p<0.0001) were independently predictive of shorter overall survival. CONCLUSION Our data continues to support reports of shorter survival for older women with ovarian cancer. With physician bias removed and similar chemotherapy tolerance noted, our study suggests that inherent tumor biology may be a significant contributor. Further research is needed to identify the mechanisms which contribute to the inequality that age imposes on outcomes.

Evaluation of the efficacy and toxicity profile associated with intraperitoneal chemotherapy use in older women

OBJECTIVE Intraperitoneal (IP) chemotherapy (CT) for treatment of epithelial ovarian cancer (EOC) has been shown to provide a substantial OS advantage. This study aims to compare the toxicity and benefits of IP CT in patients ≥70 with those <70. METHODS We performed a single institution retrospective review of patients diagnosed with Stage IIA-IIIC EOC from 2000 to 2013 who received IP CT. Clinicopathologic characteristics were extracted, and survival was calculated. RESULTS 133 patients were included with 100 pts. <70years old and 33 pts. ≥70years old. Clinical trial enrollment was similar despite age. In trial enrolled patients, older patients received statistically fewer cycles of therapy (6.4 vs 5.8, p=0.002) but had similar dose delays (0.9 vs 0.7, p=0.72), and modifications (0.9 vs 0.36, p=0.11). Median PFS (27 vs 31months) and OS (71 and 62months) were not statistically different. Grade 3/4 neutropenia was significantly worse in the older patients (82% vs 100%, p=0.04). Neuropathy grade ≥2 and other non-hematologic toxicities were not different between age groups. CONCLUSIONS Despite completing fewer cycles of IP CT, older EOC patients had comparable survival to younger patients. The population of older patients receiving IP CT in this study were on clinical trial and likely to be heartier than the general older population. IP CT appears well tolerated and effective among select older patients and is likely under-utilized outside of clinical trials.

How do palliative care needs vary across the disease trajectory in patients with gynecologic cancer

106 Background: The WHOs integrated model emphasizes that palliative care (PC) should be provided concurrently with curative and life-prolonging care, with disease-directed treatments decreasing and PC increasing over time. This study aimed to understand how accurately this theoretical model matches the PC needs of gynecologic cancer (GC) patients. METHODS GC patients at a comprehensive cancer center completed a symptom and needs assessment questionnaire as part of routine care. Needs were divided into physical, emotional, social, practical, and informational domains. Patients reporting at least one symptom score ≥ 4/10 made the physical need domain positive. For the remainder of the categories, patients endorsing at least one need in a given domain made that domain positive. Time points in the illness trajectory were categorized as diagnosis, primary treatment, remission, and progression/recurrence. Univariate analyses were utilized to assess differences in needs at various time points. RESULTS Questionnaires from 1348 patient visits over 3 months were included. Patients had ovarian (39%), uterine (36%), cervical (16%), and vulvar (5%) cancer. Visits occurred around the time of diagnosis (6%), during primary therapy (28%), during remission (42%), and during disease progression or recurrence (23%). Physical needs were most common at diagnosis and during progression/recurrence (p < 0.01). Emotional needs (p < 0.01), social needs (p < 0.01), and informational needs (p < 0.01) all varied throughout the course of disease and were highest at diagnosis. At each time point, at least 65% of patients had one or more PC needs. Having needs in multiple domains ( ≥ 3) was associated with time point, with patients around the time of diagnosis having the highest rate of need in multiple domains (p < 0.01). CONCLUSIONS GC patients have a broad range of PC needs across the trajectory of their illness. The WHO schema fails to capture the full scope of these needs and under-appreciates their prevalence earlier in the course of the disease. These results underscore the importance of training gynecologic oncologists in primary PC as well as increasing referrals to specialist PC providers.

A Non-invasive Liquid Biopsy Screening of Urine-Derived Exosomes for miRNAs as Biomarkers in Endometrial Cancer Patients

Exosomes have great potential to serve as a source of diagnostic and prognostic biomarkers for endometrial cancer (EC). Urine-derived exosomes from patients with EC and patients with symptoms of EC, but without established EC, were used to evaluate a unique miRNA expression profile. Of the 84 miRNA studied, 57 were amplified in qPCR, suggesting the differential packaging of miRNA in exosomes. Further, hsa-miR-200c-3p was identified to be enriched the most. Various bioinformatics and in silico tools were used to evaluate the biological significance of hsa-miR-200c-3p in EC. We conclude that differential miRNA in exosomes can be utilized for discovery of biomarker signatures and EC diagnosis; hsa-miR-200c-3p is one such candidate. Urine-derived exosomes pave the way for the development of non-invasive biomarkers.

Predictors of referral to outpatient specialty palliative care (SPC) in gynecologic cancer (GC) patients.

159 Background: Prior studies in GC patients have described predictors of inpatient palliative care (PC) consultation, but predictors of outpatient SPC consultation have not been elucidated. We sought to identify factors predictive of referral and associated care outcomes. METHODS We performed a cross-sectional study of GC patients seen in the gynecologic oncology clinic at a comprehensive cancer center over a three month period. As a part of routine care, patients completed a symptom questionnaire. Patients previously seen at the outpatient PC clinic were compared to those who had not with respect to demographics, disease characteristics, symptom scores, and provider factors using univariate statistics. A multivariate model was created to identify independent predictors of referral. RESULTS 913 patients completed the symptom survey. 76 patients (8%) had been seen in the outpatient PC clinic. Disease factors associated with referral included site (p < 0.01), stage (p < 0.01), evidence of disease (p < 0.01), active treatment (p < 0.01), and time point in the disease trajectory (p < 0.01). Women with moderate to severe pain (p < 0.01), sadness (p = 0.03), distress (p < 0.01), fatigue (p < 0.01), neuropathy (p = 0.03), and sexual dysfunction (p < 0.01) were more likely to have seen PC. Marital status, number of symptoms, and patient provider were also predictive of referral (all p < 0.01). In a multivariate model, site, stage, number of symptoms, moderate to severe sexual dysfunction, and provider were independently associated with referral. Compared to women who had not been referred, patients seen in the PC clinic were more likely to have a health care proxy documented in the electronic medical record (p < 0.01). Among patients with related symptoms, patients referred to PC more often had an opioid prescribed for pain (p < 0.01) and medications prescribed for depression (p < 0.01), anxiety (p = 0.04), insomnia (p < 0.01), and fatigue (p < 0.01). CONCLUSIONS Women with depression, anxiety, insomnia, and fatigue were more likely to receive pharmacologic treatment for these symptoms from a SPC provider. Future research should identify referral triggers for those patients most likely to benefit from outpatient SPC consultation.