Endometrial Cancer Survival in Populations of African Descent.

To examine whether the endometrial cancer (EC) survival disadvantage among Black populations is US-specific, a comparison between African descent populations from different countries with a high development index is warranted. We analyzed 28,213 EC cases from cancer registries in Florida (2005-2018) and Martinique (2005-2018)/Guadeloupe (2008-2018), French Caribbean islands. Kaplan-Meier and all-cause Cox proportional hazards models were used to compare survival. Models were stratified by EC histology type and the main predictor examined was race/ethnicity [non-Hispanic White (NHW) and Black (NHB) women in the US versus Black women residing in the Caribbean]. For endometrioid and non-endometrioid EC, after adjusting for age, histology, stage at diagnosis, receipt of surgery, period of diagnosis, and poverty level, US NHB women and Caribbean Blacks had a higher risk of death relative to US NHWs. There was no difference between US NHBs and Caribbean Blacks (HR 1.07, 95% CI: 0.88-1.30) with endometrioid EC. However, Caribbean Black women with non-endometrioid carcinomas had a 40% (HR 1.40, 95% CI: 1.13-1.74) higher risk of death than US NHBs. The low EC survival among US Black women extends to foreign populations of African descent. For the aggressive non-endometrioid ECs, survival in Caribbean Blacks outside of the US is considerably worse.

The Effect of Disability and Social Determinants of Health on Breast and Cervical Cancer Screenings During the COVID-19 Pandemic.

Introduction: The objective of this study was to examine the effect of disability status and social determinants of health (SDOH) on adherence to breast and cervical cancer screening recommendations during the COVID-19 pandemic. Methods: We conducted a secondary analysis of the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) data sets. We defined adherence to screenings according to the US Preventive Services Task Force guidelines for breast and cervical cancer screening. The analysis included respondents assigned female at birth, aged 50 to 74 years (breast cancer screening) or aged 21 to 65 years (cervical cancer screening). We performed logistic regression to evaluate breast and cervical cancer screening adherence, by disability status and SDOH (health insurance coverage, marital status, and urban residency), independently and simultaneously. Results: Our analysis included 27,526 BRFSS respondents in 2018 and 2020. In 2018, women with disabilities had lower adjusted odds than women without disabilities of being up to date with mammograms (adjusted odds ratio [AOR] = 0.76, 95% CI, 0.63-0.93) and Pap (Papanicolaou) tests (AOR = 0.73; 95% CI, 0.59-0.89). In 2020, among women with disabilities, the adjusted odds of mammogram and Pap test adherence decreased (AOR = 0.69; 95% CI, 0.54-0.89; AOR = 0.59; 95% CI, 0.47-0.75, respectively). In 2018, the adjusted odds of mammogram adherence among rural residents with and without disabilities were 0.83 (95% CI, 0.70-0.98), which decreased to 0.76 (95% CI, 0.62-0.93) in 2020. Conclusion: The findings of this study highlight the effect of disability status and SDOH on breast and cervical cancer screening rates during the COVID-19 pandemic. Public health strategies that acknowledge and address these disparities are crucial in preparing for future public health crises.

Endometrial cancer risk and trends among distinct African descent populations.

BACKGROUND: Endometrial cancer (EC) is the fourth most common cancer among Black women in the United States, a population disproportionately affected by aggressive nonendometrioid subtypes (e.g., serous, carcinosarcoma). To examine EC vulnerability among a wider spectrum of African descent populations, a comparison between Black women residing in different countries, rather than in the United States alone, is needed. METHODS: The authors analyzed 34,789 EC cases from Florida (FL) (2005-2018), Martinique (2005-2018), and Guadeloupe (2008-2018) based on cancer registry data. Age-adjusted incidence rates, incidence rate ratios (IRRs), and annual percent changes (APC) in trends were estimated for Black populations residing in the United States (non-Hispanic Blacks [NHB]) and Caribbean. The US non-Hispanic White (NHW) population was used as a reference. RESULTS: Caribbean Black women had the lowest rates for endometrioid and nonendometrioid subtypes. Nonendometrioid types were most common among US (FL) NHBs (9.2 per 100,000), 2.6 times greater than NHWs (IRR, 2.60; 95% confidence interval [CI], 2.44-2.76). For endometrioid EC, rates increased 1.8% (95% CI, 0.1-3.5) yearly from 2005 to 2018 for US (FL) NHBs and 1.2% (95% CI, 0.9-1.6) for US (FL) NHWs whereas no change was observed for Caribbean Blacks. For nonendometroid carcinomas, rates increased 5.6% (95% CI, 4.0-7.2) among US (FL) NHB, 4.4% (95% CI, 0.3-8.6) for Caribbean Black, and 3.9% for US (FL) NHW women (95% CI, 2.4-5.5). CONCLUSIONS: Lower rates of nonendometrioid EC among Caribbean Black women suggest that vulnerability for these aggressive tumor subtypes may not currently be an overarching African ancestry disparity. Most importantly, there is an alarmingly increasing trend in nonendometrioid across all populations studied, which warrants further surveillance and etiological research for this particular subtype. PLAIN LANGUAGE SUMMARY: We analyze population-based incidence rates and trends of endometrial cancer (EC) for African descent populations residing in different countries (i.e., United States, Martinique, Guadeloupe) to examine whether EC vulnerability among Black women is socio-environmental or more ancestry-specific in nature. The increased EC risk was not uniform across all Black women since the Caribbean had the lowest rates (for endometrioid and nonendometrioid histology subtypes). Regardless, from 2005 to 2018, there was an increasing trajectory of nonendometrioid EC for all groups, regardless of race.

Intra-racial disaggregation reveals associations between nativity and overall survival in women with endometrial cancer.

OBJECTIVE: Prior studies have demonstrated survival differences between Black women with endometrial cancer (EC) born in the US and Caribbean. Our objective was to determine if country of birth influences EC overall survival (OS) in disaggregated subpopulations of Black women. METHODS: Using the Florida Cancer Data System, women with EC diagnosed from 1981 to 2017 were identified. Demographic and clinical information were abstracted. Women who self-identified as Black and born in the US (USB), Jamaica (JBB), or Haiti (HBB) were included. Statistical analyses were performed using chi-square, Cox proportional hazards models, and Kaplan-Meier methods with significance set at p < 0.05. RESULTS: 3817 women met the inclusion criteria. Compared to USB, JBB and HBB had more high-grade histologies, more advanced stage disease, had a greater proportion of uninsured or Medicaid insured, and had a higher proportion of women who received chemotherapy (all p < 0.05). In multivariate analyses, age (HR 1.03 [1.02-1.05]), regional stage (HR 1.52 [1.22-1.89]), distant stage (HR 3.73 [2.84-4.89]), lymphovascular space invasion (HR 1.96 [1.61-2.39]), receipt of surgery (HR 0.47 [0.29-0.75]), and receipt of chemotherapy (HR 0.77 [0.62-0.95]) were independently associated with OS. Compared to USB, Haitian nativity was an independent negative predictor of OS when evaluating all histologies together (HR 1.54 [1.18-2.00]) and for endometrioid EC specifically (HR 1.77 [1.10-2.83]). Among women with serous EC, HBB had markedly worse median OS (18.5 months [13.4-46.5]) relative to USB (29.9 months [26.3-35.9]) and JBB (41.0 months, [34.1-82.6], p = 0.013). CONCLUSION: Country of birth is associated with endometrial cancer survival in Black women, with HBB demonstrating worse outcomes.

Disparities in refusal of surgery for gynecologic cancer.

OBJECTIVE: To identify sociodemographic and clinical factors associated with refusal of gynecologic cancer surgery and to estimate its effect on overall survival. METHODS: The National Cancer Database was surveyed for patients with uterine, cervical or ovarian/fallopian tube/primary peritoneal cancer treated between 2004 and 2017. Univariate and multivariate logistic regression were used to assess associations between clinico-demographic variables and refusal of surgery. Overall survival was estimated using the Kaplan-Meier method. Trends in refusal over time were evaluated using joinpoint regression. RESULTS: Of 788,164 women included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. Patients who refused surgery were older at diagnosis (72.4 vs 60.3 years, p < 0.001) and more likely Black (OR 1.77 95% CI 1.62-1.92). Refusal of surgery was associated with uninsured status (OR 2.94 95% CI 2.49-3.46), Medicaid coverage (OR 2.79 95% CI 2.46-3.18), low regional high school graduation (OR 1.18 95% CI 1.05-1.33) and treatment at a community hospital (OR 1.59 95% CI 1.42-1.78). Patients who refused surgery had lower median overall survival (1.0 vs 14.0 years, p < 0.01) and this difference persisted across disease sites. Between 2008 and 2017, there was a significant increase in refusal of surgery annually (annual percent change +1.41%, p < 0.05). CONCLUSIONS: Multiple social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely from vulnerable, underserved populations and have inferior survival, refusal of surgery should be considered a surgical healthcare disparity and tackled as such.

Palliative Medicine Referral and End-of-Life Interventions Among Racial and Ethnic Minority Patients With Advanced or Recurrent Gynecologic Cancer.

BACKGROUND: Referral to palliative medicine (PM) has been shown to improve quality of life, reduce hospitalizations, and improve survival. Limited data exist about PM utilization among racial minorities with gynecologic malignancies. Our objective was to assess differences in palliative medicine referrals and end of life interventions (within the last 30 days of life) by race and ethnicity in a diverse population of gynecologic oncology patients. METHODS: A retrospective cohort study of patients receiving gynecologic oncologic care at a tertiary referral center between 2017 - 2019 was conducted. Patients had either metastatic disease at the time of diagnosis or recurrence. Demographic and clinical data were abstracted. Exploratory analyses were done using chi-square and rank sum tests. Tests were two-sided with significance set at P < .05. RESULTS: A total of 186 patients were included. Of those, 82 (44.1%) were referred to palliative medicine. Underrepresented minorities accounted for 47.3% of patients. English was identified as the primary language for 69.9% of the patients and Spanish in 24.2%. Over 90% of patients had insurance coverage. Ovarian cancer (37.6%) and uterine cancer (32.8%) were the most common sites of origin. Most patients (75%) had advanced stage at the time of diagnosis. Race and language spoken were not associated with referral to PM. Black patients were more likely to have been prescribed appetite stimulants compared to White patients (41% vs 24%, P = .038). Black patients also had a higher number of emergency department visits compared to White patients during the study timeframe. Chemotherapy in the last 30 days of life was also more likely to be given to Black patients compared to White (P = .019). CONCLUSIONS: Race was associated with variation in interventions and healthcare utilization near end-of-life. Understanding the etiologies of these differences is crucial to inform interventions for care optimization as it relates specifically to the health of minority patients.

Differences in Cervical Cancer Outcomes by Caribbean Nativity in Black and White Women in Florida.

OBJECTIVE: Racial disparities among women with cervical cancer have been reported but are understudied in Caribbean immigrants. The objective of this study is to describe the disparities in clinical presentation and outcomes between Caribbean-born (CB) and US-born (USB) women with cervical cancer by race and nativity. METHODS: An analysis of the Florida Cancer Data Service (FCDS), the statewide cancer registry, was performed to identify women diagnosed with invasive cervical cancer between 1981 and 2016. Women were classified as USB White or Black and CB White or Black. Clinical data were abstracted. Analyses were done using chi square, ANOVA, Kaplan-Meier and Cox proportional hazards models, with significance set at P < .05. RESULTS: 14 932 women were included in the analysis. USB Black women had the lowest mean age at diagnosis, while CB Black women were diagnosed at later stages of disease. USB White women and CB White women had better OS (median OS 70.4 and 71.5 months, respectively) than USB Black and CB Black women (median OS 42.4 and 63.8 months, respectively) (P < .0001). In multivariable analysis, relative to USB Black women, CB Blacks (HR .67, CI .54-.83), and CB White (HR .66, CI .55-.79) had better odds of OS. White race among USB women was not significantly associated with improved survival (P = .087). CONCLUSION: Race alone is not a determinant of cancer mortality in women with cervical cancer. Understanding the impact of nativity on cancer outcomes is crucial to improve health outcomes.

Low Perceived Anal Cancer Risk and Screening Utilization Among High-Risk Transgender Men and Women Living in an HIV / STI Epicenter.

Although risk behaviors could place transgender people at increased risk of anal cancer, few studies have examined anal cancer knowledge and screening use among this population. This study assessed knowledge of anal cancer and associated screening tools, self-perceived risk for anal cancer, and willingness to undergo anal cytology testing among transgender persons in an HIV/sexually transmitted infection (STI)-dense region. Adult transgender persons were recruited locally and surveyed electronically. Descriptive statistics, student's t tests, ANOVA, and Pearson's chi-squared test were performed. Among 79 transgender persons, identified anal cancer risk factors included smoking, STI history, anoreceptive intercourse, and inconsistent condom use. Nearly half (43%) reported little to no knowledge of anal cancer. The vast majority (82%) had little to no perceived risk of developing anal cancer. Twenty-eight percent had heard of anal cytology, and few (17%) had undergone it. Despite susceptibility, transgender persons lack knowledge and have a low perception of personal risk of anal cancer, highlighting the need to increase awareness of anal cancer, risk factors, and screening methods among this population.

Wilms Tumor of the Uterus.

Wilms tumor (WT) is an uncommon malignant neoplasm that occurs predominantly in the kidney of pediatric patients; its extrarenal counterpart is exceedingly rare. We present the case of an adult female diagnosed with uterine WT. Following hysterectomy due to a uterine mass, histopathologic examination demonstrated a triphasic malignancy composed of epithelial, stromal, and blastemal elements. The characteristic morphologic features, which were supported by immunohistochemical analysis, were diagnostic of WT of the uterus. A summary of the main clinicopathologic parameters, along with a review of all previously reported cases, are described.

Cisplatin-induced bradycardia and the importance of the QT interval.

Cisplatin is a very common chemotherapeutic agent used in the treatment of gynecologic malignancies, including cervical, ovarian, and endometrial cancers. Bradycardia is a rare, though potentially severe, side effect of this medication. Here we present the case of a young woman with ovarian cancer who demonstrated significant short-lived cardiotoxicity associated with cisplatin treatment.

Lifestyle modification in cervical cancer survivors: an ongoing need.

OBJECTIVE: With the introduction of multimodality therapy for cervical cancer, many women will be long-term survivors in need of comprehensive surveillance care. Our goals were to evaluate patterns of obesity and smoking in a cohort of cervical cancer survivors and to assess the potential influence of these comorbidities on subsequent follow-up. METHODS: We reviewed the records of patients treated for invasive cervical cancer at our institution from 2000 to 2003 who had no evidence of disease for 3 or more years. Demographic and clinical data were collected, including smoking history and anthropometric measurements. Body mass index (BMI) was categorized according to World Health Organization criteria. Logistic regression and Wilcoxon rank sum analyses were performed. RESULTS: Two hundred ninety-eight women had complete follow-up data at 3 years. The median age at diagnosis was 43.5 years (range, 17.6-87.1 years). At diagnosis, 31.9% had a normal BMI, 28.2% were overweight, and 34.6% were obese compared with 31.7%, 21.1%, and 30.2% at 3 years, respectively. Of the 51 women whose BMI categorization changed, 33 (64.7%) had weight gain, and 18 (35.3%) had weight loss. By paired analyses, increase in BMI was significant over the 3-year interval (P < 0.001). Seventy patients actively smoked at diagnosis. Compared with nonsmokers, current smokers had a greater odds of referral to the pain service (odds ratio [OR], 6.56; confidence interval [CI], 6.26-16.43; P < 0.001), physical therapy (OR, 4.74; CI, 1.29-17.36; P = 0.02), and gastroenterology (OR, 2.25; CI, 1.14-4.24; P = 0.02). CONCLUSIONS: Obesity and smoking are significant comorbidities that may complicate care in cervical cancer survivors. Interventions aimed at modifying these risk factors should be routinely undertaken in this population.

Gynecologic oncology fellowship leadership trends by gender.

Our objective was to examine the educational, research, and leadership trends among gynecologic oncology (GYO) fellowship program directors (PD) and how these vary by gender. PDs were identified using the Society of Gynecologic Oncology Fellowship Directory. Surveys were sent to PDs' emails to obtain information about demographics, education, and research background. Publicly available data and institutional biographies were used to supplement primary survey data for incomplete responses or survey non-responders. Scopus was used to determine the h-index and number of publications and citations for each PD. Parametric data were compared using unpaired two-tailed t-tests. Chi-square and Fisher's exact tests were performed for categorical data. The significance level was p < 0.05. Approximately one-half of PDs were female (50.8%). Female PDs had a younger mean age than male PDs (46.4 years vs 51.9 years, p = 0.0014). The average overall h-index was 22 (SD = 14.5) and the average number of publications was 71.2 (SD = 63.3). The average h-index was higher in male PDs than females (27.8 vs 16.3, p = 0.0012), as were the number of publications (97.3 vs 45.8, p = 0.0008). Differences exist among GYO PDs by gender. While research productivity may be reflective of age, gender-based equity in research time should be further explored.

Survival for endometrial cancer as a second primary malignancy.

BACKGROUND: Endometrial cancer (EC) often occurs subsequently to a primary cancer arising from a different site. However, little is known regarding the survival experience of EC as a second primary (ECSP) malignancy, specifically in relation to the original primary site and prior treatment. METHODS: Using Florida's cancer registry, all EC cases (first, second, or higher-order) diagnosed from 2005-2016 were analyzed. Kaplan-Meier methods and Cox Regression were used in a cause-specific survival analysis. RESULTS: A total of 2879 clinically independent ECSPs and 42,714 first primary ECs were analyzed. The most common first primary sites for ECSPs were breast cancer (BC) (n = 1422) and colorectal cancer (CRC) (n = 359). Five-year cause-specific survival was 84.0% (95% CI: 83.6-84.3) for first primary ECs and 81.8% (95% CI: 80.0-83.4) for ECSPs. After adjusting for age, race/ethnicity, histology, and stage at diagnosis, ECSPs had a lower risk of EC mortality than first primary ECs (hazard ratios [HR] 0.88, 95% CI: 0.79-0.97). ECSPs with a first primary CRC had a higher risk of EC-specific death (HR 1.47, 95% CI: 1.04-2.06) compared to ECSPs that followed BC in multivariable analysis. Finally, women who had chemotherapy for ECSP and preceding BC did not have a higher risk of death (HR 0.80, 95% CI: 0.49-1.31) compared to those who only received chemotherapy for first primary EC. CONCLUSIONS: ECSPs present a complex clinical profile. ECSP survival is superior to that of first primary EC. However, ECSPs following CRC may constitute a population of interest for their worse prognosis. Chemotherapy for a previous BC does not seem to impact the effectiveness of chemotherapy for ECs.

Rationale for combination of paclitaxel and CDK4/6 inhibitor in ovarian cancer therapy - non-mitotic mechanisms of paclitaxel.

Taxanes and CDK4/6 inhibitors (CDK4/6i) are two families of successful anti-mitotic drugs used in the treatment of solid tumors. Paclitaxel, representing taxane compounds, has been used either alone or in combination with other agents (commonly carboplatin/cisplatin) in the treatment of many solid tumors including ovarian, breast, lung, prostate cancers, and Kaposi's sarcoma. Paclitaxel has been routinely prescribed in cancer treatment since the 1990s, and its prominent role is unlikely to be replaced in the foreseeable future. Paclitaxel and other taxanes work by binding to and stabilizing microtubules, causing mitotic arrest, aberrant mitosis, and cell death. CDK4/6i (palbociclib, ribociclib, abemaciclib) are relatively new cell cycle inhibitors that have been found to be effective in breast cancer treatment, and are currently being developed in other solid tumors. CDK4/6i blocks cell cycle progression at the G1 phase, resulting in cell death by mechanisms not yet fully elucidated. At first glance, paclitaxel and CDK4/6i are unlikely synergistic agents as both are cell cycle inhibitors that work at different phases of the cell cycle, and few clinical trials have yet considered adding CDK4/6i to existing paclitaxel chemotherapy. However, recent findings suggest the importance of a non-mitotic mechanism of paclitaxel in cancer cell death and pre-clinical data support rationale for a strategic paclitaxel and CDK4/6i combination. In mouse tumor model studies, drug sequencing resulted in differential efficacy, indicating complex biological interactions of the two drugs. This article reviews the rationales of combining paclitaxel with CDK4/6i as a potential therapeutic option in recurrent ovarian cancer.

Implementation and Feasibility of an Electronic Health Record-Integrated Patient-Reported Outcomes Symptom and Needs Monitoring Pilot in Ambulatory Oncology.

PURPOSE: Describe the feasibility and implementation of an electronic health record (EHR)-integrated symptom and needs screening and referral system in a diverse racial/ethnic patient population in ambulatory oncology. METHODS: Data were collected from an ambulatory oncology clinic at the University of Miami Health System from October 2019 to January 2021. Guided by a Patient Advisory Board and the Exploration, Preparation, Implementation, and Sustainment model, My Wellness Check was developed to assess physical and psychologic symptoms and needs of ambulatory oncology patients before appointments to triage them to supportive services when elevated symptoms (eg, depression), barriers to care (eg, transportation and childcare), and nutritional needs were identified. Patients were assigned assessments at each appointment no more than once in a 30-day period starting at the second visit. Assessments were available in English and Spanish to serve the needs of the predominantly Spanish-speaking Hispanic/Latino population. RESULTS: From 1,232 assigned assessments, more than half (n = 739 assessments; 60.0%) were initiated by 506 unique patients. A total of 65.4% of English and 49.9% of Spanish assessments were initiated. Among all initiated assessments, the majority (85.1%) were completed at home via the patient portal. The most common endorsed items were nutritional needs (32.9%), followed by emotional symptoms (ie, depression and anxiety; 27.8%), practical needs (eg, financial concerns; 21.7%), and physical symptoms (17.6%). Across the physical symptom, social work, and nutrition-related alerts, 77.1%, 99.7%, and 78.8%, were addressed, respectively, by the corresponding oncology health professional, social work team member, or nutritionist. CONCLUSION: The results demonstrate encouraging feasibility and initial acceptability of implementing an EHR-integrated symptom and needs screening and referral system among diverse oncology patients. To our knowledge, this is the first EHR-integrated symptom and needs screening system implemented in routine oncology care for Spanish-speaking Hispanics/Latinos.

The vaginal microbiome is associated with endometrial cancer grade and histology.

The human microbiome has been strongly correlated with disease pathology and outcomes, yet remains relatively underexplored in patients with malignant endometrial disease. In this study, vaginal microbiome samples were prospectively collected at the time of hysterectomy from 61 racially and ethnically diverse patients from three disease conditions: 1) benign gynecologic disease (controls, n=11), 2) low-grade endometrial carcinoma (n=30), and 3) high-grade endometrial carcinoma (n=20). Extracted DNA underwent shotgun metagenomics sequencing, and microbial α and ß diversities were calculated. Hierarchical clustering was used to describe community state types (CST), which were then compared by microbial diversity and grade. Differential abundance was calculated, and machine learning utilized to assess the predictive value of bacterial abundance to distinguish grade and histology. Both α- and ß-diversity were associated with patient tumor grade. Four vaginal CST were identified that associated with grade of disease. Different histologies also demonstrated variation in CST within tumor grades. Using supervised clustering algorithms, critical microbiome markers at the species level were used to build models that predicted benign vs carcinoma, high-grade carcinoma versus benign, and high-grade versus low-grade carcinoma with high accuracy. These results confirm that the vaginal microbiome segregates not just benign disease from endometrial cancer, but is predictive of histology and grade. Further characterization of these findings in large, prospective studies is needed to elucidate their potential clinical applications.

Clinicodemographic factors influencing outcomes in patients with low-grade serous ovarian carcinoma.

BACKGROUND: Low-grade serous carcinoma (LGSC) of the ovary is a rare tumor that is distinct from its high-grade counterpart. The objective of this study was to determine whether patient demographic factors and clinical treatment histories affected survival in a population of women with LGSC. METHODS: A review of patients who had pathologically confirmed LGSC of the ovary diagnosed between 1977 and 2009 was performed. Abstracted data included medical and social histories, anthropometric measurements, and details about diagnosis, treatment, and follow-up. Statistical analyses included Fisher exact tests, Cox proportional hazards models, and the Kaplan-Meier method. RESULTS: The study sample included 194 patients who had a median follow-up of 60.9 months (range, 1-383 months). In multivariate analyses, smoking had a negative association with both overall survival (OS) (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.03-2.92; P = .04) and progression-free survival (PFS) (HR, 1.72; 95% CI, 1.00-2.96; P = .05). The median OS was shorter in current smokers than in former/never smokers (48.0 months vs 79.9 months; P = .002). PFS also was predicted by year of diagnosis >1994 (HR, 1.74; P = .01). Although the difference was not statistically significant, hormone consolidation appeared to be associated with better OS (HR, 0.15; P = .06) and better PFS (HR, 0.44; P = .07). A smaller proportion of the patients who received hormone consolidation experienced disease recurrence compared with the patients who did not receive hormone consolidation (66.7% vs 87.6%; P = .07). CONCLUSIONS: Smoking was associated negatively with survival outcomes in women with LGSC of the ovary, whereas consolidation treatment with hormone antagonists demonstrated a protective associative trend with survival. Both lifestyle modification and innovative treatment plans should be considered in this group of patients.

Molecular clustering based on ERα and EIG121 predicts survival in high-grade serous carcinoma of the ovary/peritoneum.

Assessment of estrogen receptor (ER) expression by immunohistochemistry has yielded inconsistent results as a prognostic indicator in ovarian carcinoma. In breast and endometrial carcinomas, panels of estrogen-induced genes have shown improved prognostic capability over the use of ER immunohistochemistry alone. For both breast and endometrial cancers, overexpression of estrogen-induced genes is associated with better prognosis. We hypothesized that analysis of a panel of estrogen-induced genes can predict the outcome in ovarian carcinoma and potentially differentiate between tumors of varying hormonal responsiveness. From a cohort of 219 women undergoing ovarian cancer surgery from 2004 to 2007, 83 patients were selected for inclusion. All patients had advanced stage ovarian/primary peritoneal high-grade serous carcinoma and underwent primary surgical debulking, followed by adjuvant treatment with platinum and taxane agents. The expression of ERα and six genes known to be induced by estrogen in the female reproductive tract (namely EIG121, sFRP1, sFRP4, RALDH2, PR, and IGF-1) was measured using quantitative RT-PCR. Unsupervised cluster analyses were used to categorize patients as high or low gene expressors. Gene expression results were then compared with those for ER immunohistochemistry. Clusters were compared using χ(2) analyses, and Cox proportional hazards models were used to evaluate survival outcomes. The median follow-up time was 38.7 months (range: 1-68). A cluster defined by EIG121 and ERα segregated tumors into distinct groups of high and low gene expressors. Shorter overall survival (OS) was associated with high gene expression (HR 2.84 (1.11-7.30), P=0.03), even after adjustment for other covariates. No difference in ER immunohistochemistry expression was noted between gene clusters. In contrast to other hormonally driven cancers, high expression of ERα and the estrogen-induced gene EIG121 predicts shorter OS in patients with high-grade serous ovarian carcinoma. Such a biomarker panel may potentially be used to guide management with estrogen antagonists in this patient population.

Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy.

OBJECTIVE: Vaginal cuff separation is a rare but serious complication following hysterectomy. The goal of our study was to determine the rate of vaginal cuff separation and associated risk factors in patients undergoing laparoscopic or robotic hysterectomy. METHODS: We retrospectively identified patients who underwent a minimally invasive simple or radical hysterectomy at one institution between January 2000 and 2009. Fisher's exact test, Wilcoxon rank sum test and multiple logistic regression were used to determine associations between variables and increased risk of separation. RESULTS: A total of 417 patients underwent laparoscopic (n=285) or robotic (n=132) hysterectomy during the study period. Three hundred and sixty-two underwent simple hysterectomy (249 laparoscopic, 113 robotic) and 57 underwent radical hysterectomy (36 laparoscopic, 19 robotic). Seven (1.7%) patients developed a cuff complication and all had a diagnosis of malignancy. Three (1.1%) patients in the laparoscopy group suffered a vaginal cuff evisceration (n=2) or separation (n=1). Four patients in the robotic group (3.0%) had a vaginal evisceration (n=1) or separation (n=3). There was no difference based on surgical approach (p=0.22). Vaginal cuff complications were 9.46-fold higher among patients who had a radical hysterectomy (p<0.01). Median time to presentation of vaginal cuff complication was 128 days (range, 58-175) in the laparoscopy group and 37 days (range, 32-44) in the robotic group. CONCLUSIONS: The overall risk of vaginal cuff complication was 1.7%. There appears to be no difference in cuff complication rates based on surgical approach. Radical hysterectomy, however, was associated with a 9-fold increase in vaginal cuff complications.

Ethics consultation on a gynecologic oncology service: an opportunity for physician education.

The purpose of this study is to understand the features of gynecologic oncology patients who receive ethics consults in order to identify areas for physician education and improve patient care. A review of ethics consults for gynecologic oncology patients from 1993 to 2008 was performed. Information on all gynecologic oncology patients treated during the study interval was also collected to define a base population for comparison. Forty-one consults were performed. Compared to the base population, a greater proportion of consult patients had pregnancy-related malignancies (7.9% vs. 0.8%, p < 0.0001) and were African American (33.3% vs. 10.9%, p < 0.0001). The most common clinical case types involved identifying levels of appropriate treatment. Support of the health care team and complex family dynamics were key underlying issues. Ethics consultation provides a substantial resource in identifying relevant issues experienced by gynecologic oncology patients upon which physician educational initiatives may be based.