Patient perspective on virtual prechemotherapy visits in gynecologic oncology.

Objective: To assess gynecologic oncology patients' experiences with virtual prechemotherapy evaluation and determine preference for incorporating virtual visits into a chemotherapy schedule. Methods: From June-August 2023, a survey was distributed to patients with gynecologic malignancies who had both an in-person and virtual prechemotherapy visit at a tertiary comprehensive cancer center. Patient satisfaction and preference for incorporating virtual visits was elicited. Patients who preferred ≥ 50 % of prechemotherapy visits to be virtual were classified as "virtual-leaning" and those who preferred < 50 % virtual as "in-person-leaning." Results: Of 110 eligible patients, 93 agreed to participate and 73 completed the survey, yielding an overall 66.4% response rate and 78.5% (73/93) survey completion rate. Overall satisfaction with in-person and virtual visits were rated positively at similar rates (in-person 87.7%, virtual 87.2%). Sixty-four (88.4%) patients preferred some proportion of their visits to be virtual, 5 (7.0%) preferred no virtual care, and 4 (5.0%) had no preference. In a 6-cycle schedule of chemotherapy, the median number of preferred virtual visits was 3 (IQR 1.8-4.2). Forty-six (63.0%) patients were "virtual-leaning" and 23 (32.0%) were "in-person-leaning." When comparing groups, there was no difference in age, race, category of residence, commute, experience with technical difficulty, primary disease site, disease stage, number of prior chemotherapy cycles, or number of prior virtual visits. Conclusions: Most patients are highly satisfied with virtual visits and prefer virtual care to be included when undergoing chemotherapy. A hybrid model should be offered to gynecological cancer patients undergoing chemotherapy, with patient preference dictating the cadence of virtual visits.

Implementation of routine venous thromboembolism prophylaxis during neoadjuvant chemotherapy for patients with ovarian cancer.

OBJECTIVE: To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis. METHODS: This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models. RESULTS: Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07-0.52) and post-implementation period (OR 0.34; 95% CI 0.17-0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07-0.53). CONCLUSION: Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.

Prophylactic Ureteral Stent Placement and Urinary Injury During Hysterectomy for Placenta Accreta Spectrum.

OBJECTIVE: To evaluate the association between prophylactic ureteral stent placement at the time of hysterectomy for placenta accreta spectrum and genitourinary injury. METHODS: We conducted a retrospective cohort study of patients with placenta accreta spectrum who underwent hysterectomy at two referral centers from 2001 to 2021. The exposure was prophylactic ureteral stent placement. The primary outcome, genitourinary injury, was a composite of bladder injury, ureteral injury, or vesicovaginal fistula. Secondary outcomes included components of the primary outcome. We evaluated differences between groups using χ 2 and t test. To evaluate differences in the primary outcome, we reported odds ratios (ORs) and adjusted odds ratios (aORs) using multivariable logistic regression analyses to control for potential confounding variables. We used a Cochran-Armitage χ 2 trend test to evaluate difference in stent use and injury over time. RESULTS: In total, 236 patients were included. Prophylactic ureteral stents were used in 156 surgeries (66%). Overall, genitourinary injury occurred less frequently in the stent group compared with the no stent group (28% vs 51%, OR 0.37, 95% CI 0.21-0.65). This association persisted after controlling for urgency of delivery, three or more prior cesarean deliveries, and whether a gynecologic oncologist was present (aOR 0.27, 95% CI 0.14-0.52). Unintentional bladder injury occurred less frequently in the stent group compared with the no stent group (13% vs 25%, P =.018), as did ureteral injury (2% vs 9%, P =.019). CONCLUSION: Prophylactic ureteral stent placement was associated with a decreased risk of genitourinary injury during hysterectomy for placenta accreta spectrum.

Association between short interpregnancy interval and placenta accreta spectrum.

BACKGROUND: The incidence of placenta accreta spectrum is increasing in parallel with the growing number of cesarean deliveries performed. A shorter interpregnancy interval following cesarean delivery may prevent adequate scar healing, which could impact the risk of placenta accreta spectrum. OBJECTIVE: We aimed to investigate the association between short interpregnancy intervals and placenta accreta spectrum. STUDY DESIGN: We conducted a retrospective cohort study of patients at risk for placenta accreta spectrum at a tertiary academic center between 2002 and 2020. Our cohort was defined as pregnant individuals at risk for placenta accreta spectrum meeting the following criteria: placenta previa with previous cesarean delivery and/or uterine surgery, anterior low-lying placenta with previous cesarean delivery and/or uterine surgery, ≥3 previous cesarean deliveries, or any previous cesarean delivery with sonographic findings suspicious for placenta accreta spectrum. The primary outcome was surgically or histopathologically confirmed placenta accreta spectrum. Short interpregnancy interval was defined as <18 completed months from previous delivery and last menstrual period of the index pregnancy. Univariable analyses were performed with chi-square and Student's t-test, as appropriate, and Kruskal-Wallis for nonparametric variables. The unadjusted and adjusted odds ratios were calculated using multivariate logistic regression models. Covariates were selected if P<.2 in univariable analyses or defined a priori as clinically meaningful. The final models were derived using reverse stepwise selection of variables. We used Stata Statistical Software, version 15 (StataCorp, College Station, TX) to perform descriptive statistics. RESULTS: Of 262 patients at risk of placenta accreta spectrum with complete records, 112 (42.7%) had placenta accreta spectrum. Pregnant individuals with short interpregnancy intervals of <18 months were no more likely than those with optimal interpregnancy intervals to have previa (58% [46/80] vs 46% [84/182]; P=.09) or placenta accreta spectrum (49% [39/80] vs 40% [73/182]; P=.19). Short interpregnancy interval of <18 months was not associated with placenta accreta spectrum (unadjusted odds ratio, 1.06; 95% confidence interval, 0.62-1.80). This association did not change when adjusting for previa and number of previous cesarean deliveries (adjusted odds ratio, 1.04; 95% confidence interval, 0.51-2.15). In a secondary analysis, an interpregnancy interval of <12 months was also not associated with placenta accreta spectrum (unadjusted odds ratio, 0.79; 95% confidence interval, 0.04-1.56; adjusted odds ratio, 0.52; 95% confidence interval, 0.21-1.27). CONCLUSION: In patients at risk for placenta accreta spectrum, short interpregnancy intervals of <18 months or <12 months were not associated with placenta accreta spectrum, even when controlling for number of previous cesarean deliveries and previa. Short interpregnancy interval is not likely to be an important modifiable independent risk factor for placenta accreta spectrum.

Determination of test performance of two contemporary screening tests for Lynch syndrome in endometrial cancer: A clinical trial.

BACKGROUND/PURPOSE: Published data on the performance of the immunohistochemistry (IHC) test for mismatch repair (MMR) protein expression to detect Lynch syndrome (LS) index cases suggests it is highly variable; its performance in our system was unknown. Moreover, a brief family history questionnaire (bFHQ) developed by Eiriksson and colleagues in Canada demonstrated 100% sensitivity for LS case identification thus was of interest to us, but its performance outside of its original setting was unknown. Determination of the performance of these tests requires complete LS case identification in the testing population. METHODS: Two hundred women were recruited during routine care for endometrial cancer (EC) to administer the bFHQ and perform genetic testing for the LS genes. Independently, the IHC test was performed to screen for presumptive LS cases. We determined the sensitivity, specificity, and positive and negative predictive values of the bFHQ and IHC test as well as simulating outcomes of the complete protocols. RESULTS: Genetic testing all participants identified 8 cases of LS out of 200 (4% prevalence), the bFHQ identified 5 of 8 of these cases (62.5%, CI: 31.5%-87.6%), and the IHC test identified 6 or 7 of 8 cases (mean of 75% or 87.5%) depending on interpretation of test results. The specificities of the bFHQ and IHC test were 56.8% (CI: 49.8%-63.7%) and 79.8% (CI: 73.6%-85.1%), respectively. CONCLUSIONS: This study is the first, to our knowledge, to test the effectiveness of the bFHQ in an EC population since its original reporting; our results are consistent with many reports of the challenges of collecting family health history. The performance of the IHC test as a screen falls within ranges reported in the literature but do not provide the confidence to drive a decision for or against continued use of this test as a LS screen.