Financial toxicity of withdrawn poly (ADP-ribose) polymerase inhibitor indications for ovarian cancer.

OBJECTIVE: We sought to quantify exposure to and financial impacts of PARPi treatments for eventually withdrawn ovarian cancer indications. METHODS: We identified in Optum's de-identified Clinformatics® Data Mart database 1695 patients with ovarian cancer diagnoses who received olaparib, rucaparib, or niraparib between January 2015 and September 2021. We describe PARPi use and out-of-pocket (OOP), total health care, and PARPi spending among ovarian cancer patients with 3 or more prior lines of therapy (LOT). RESULTS: Of the 1695 patients who received PARPi, 254 were estimated to have been heavily pretreated and exposed to eventually withdrawn indications. Cumulative total medical and pharmacy costs for these patients were $53,392,184; PARPi costs accounted for 34%. Median PARPi cost per patient was $43,347. Cumulative out-of-pockets costs totaled $533,281. CONCLUSIONS: Potential patient harm, including financial toxicity, might have been mitigated through more stringent drug approval requirements.

Financial toxicity: A practical review for gynecologic oncology teams to understand and address patient-level financial burdens.

Financial toxicity describes the adverse impact patients experience from the monetary and time costs of cancer care. The financial burden patients experience comes from substantially increased out-of-pocket spending that often occurs concurrent with reduced income due to sick leave from work. Financial toxicity is common affecting approximately half of patients with a gynecological cancer depending on the validated instrument used for measurement. Financial toxicity is experienced by patients in three domains: economic hardship affecting patients' material conditions (i.e., medical debt), psychological response (i.e., distress), and health-related coping behaviors that patients adopt (i.e., foregoing care due to costs). Higher financial toxicity among cancer patients has been associated with decreased quality of life, impaired adherence to recommended care, and worse overall survival. In this review, we describe the current literature on financial toxicity, including how it can be assessed with validated tools, the downstream impact on patients, risk factors, and employment concerns of survivors. Whenever possible, we highlight data from research featuring patients with gynecologic cancer specifically. We also review studies with interventions aimed to mitigate financial toxicity and offer the reader real world examples of interventions currently being used. Lastly, we provide an overview of health policy developments relevant to financial toxicity and advocate for innovation in the development and implementation of strategies to decrease the financial toxicity patients experience following a diagnosis of gynecologic cancer.

Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer.

PURPOSE: We evaluated financial toxicity (FT) in patients with gynecologic cancer treated with radiation and assessed the impact of the COVID-19 pandemic on patients' financial wellbeing. METHODS: Patients completed a survey 1 month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included the COmprehensive Score for Financial Toxicity (COST) tool, EQ-5D to measure quality of life (QOL) and pandemic-related questions for the second survey period. High FT was COST score ≤ 23. RESULTS: Of 97 respondents (92% response rate), 49% completed the survey pre-pandemic and 51% after; the majority were white (76%) and had uterine cancer (64%). Sixty percent received external beam radiation with or without brachytherapy; 40% had only brachytherapy. High FT was associated with worse QOL (r = -0.37, P < 0.001), younger age and type of insurance (both p ≤ 0.03). Respondents with high FT were 6.0 (95% CI 1.0-35.9) times more likely to delay/avoid medical care, 13.6 (95% CI 2.9-64.3) times more likely to borrow money, and 6.9 (95% CI 1.7-27.2) times as likely to reduce spending on basic goods. The pandemic cohort had a smaller proportion of respondents with high FT than the pre-pandemic cohort (20% vs. 35%, p = 0.10) and a higher median COST score (32 (IQR 25-35) vs. 27 (IQR 19-34), p = 0.07). CONCLUSION: Privately insured, younger respondents who received radiation for gynecologic cancer were at risk for FT. High FT was associated with worse QOL and economic cost-coping strategies. We observed less FT in the pandemic cohort, though not statistically different from the pre-pandemic cohort.

Financial toxicity in pregnancy and postpartum.

INTRODUCTION: The financial burden of pregnancy in the United States can be high and is associated with worse mental health and birth outcomes. Research on the financial burden of health care, such as the development of the COmprehensive Score for Financial Toxicity (COST) tool, has been conducted primarily among patients with cancer. This study aimed to validate the COST tool and use it to measure financial toxicity and its impacts among obstetric patients. METHODS: We used survey and medical record data from obstetric patients at a large medical center in the United States. We validated the COST tool using common factor analysis. We used linear regression to identify risk factors for financial toxicity and to investigate associations between financial toxicity and patient outcomes including satisfaction, access, mental health, and birth outcomes. RESULTS: The COST tool measured two distinct constructs of financial toxicity in this sample: current financial toxicity and concern over future financial toxicity. Racial/ethnic category, insurance, neighborhood deprivation, caregiving, and employment were associated with current financial toxicity (P < 0.05 for all). Only racial/ethnic category and caregiving were associated with concern over future financial toxicity (P < 0.05 for all). Both current and future financial toxicity were associated with worse patient-provider communication, depressive symptoms, and stress (P < 0.05 for all). Financial toxicity was not associated with birth outcomes or keeping obstetric visits. CONCLUSIONS: The COST tool captures two constructs among obstetric patients, current and future financial toxicity, both of which are associated with worse mental health and patient-provider communication.

Crowdsourcing to measure financial toxicity in gynecologic oncology.

OBJECTIVE: To utilize a novel crowdsourcing method to measure financial toxicity and its effects among a national cohort of gynecologic cancer patients. METHODS: Crowdsourcing methods were used to administer an online survey to women in the United States with gynecologic cancers. We used the Comprehensive Score for Financial Toxicity (COST) tool to measure financial toxicity and the EQ-5D-3L to measure quality of life (QOL). Based on prior work, we defined high financial toxicity as a COST score ≤ 23. We assessed correlation of COST scores with QOL. We used log-binomial regression to examine associations between high financial toxicity and cost-coping strategies. RESULTS: Among the final study sample of 334 respondents, 87% were white, median age at diagnosis was 55 (interquartile range 47-63), 52% had stage III or IV disease and 90% had private insurance or Medicare. Median COST score was 24 (interquartile range 15-32) and 49% of respondents reported high financial toxicity. Greater financial toxicity was correlated with worse QOL (p < 0.001). Participants reporting high financial toxicity were more likely to use cost-coping strategies, including spending less on basic goods (RR: 3.3; 95% CI: 2.1-5.1), borrowing money or applying for financial assistance (RR: 4.0; 95% CI: 2.4-6.9), and delaying or avoiding care (RR: 5.6; 95% CI: 2.6-12.1). CONCLUSIONS: Crowdsourcing is an effective tool to measure financial toxicity. Nearly half of respondents reported high financial toxicity, which was significantly associated with worse QOL, utilization of cost-coping strategies and delays or avoidance of care.

Germline mutations of SMARCA4 in small cell carcinoma of the ovary, hypercalcemic type and in SMARCA4-deficient undifferentiated uterine sarcoma: Clinical features of a single family and comparison of large cohorts.

OBJECTIVE: Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) and SMARCA4-deficient undifferentiated uterine sarcoma (SMARCA4-DUS) are rare and aggressive tumors, primarily affecting pre- and perimenopausal women. Inactivating SMARCA4 mutations are thought to be the driving molecular events in the majority of these tumors. Here, we report the clinical course of a family with germline SMARCA4 mutation and compare large cohorts of these rare tumor types. METHODS: We extracted clinico-pathological medical record data for the family with germline SMARCA4 mutation. Clinico-genomic data from SCCOHT and SMARCA4-DUS cohorts were retrospectively extracted from the archives of a large CLIA-certified reference molecular laboratory. RESULTS: We identified a single family with an inherited germline SMARCA4 mutation, in which two different family members developed either SCCOHT or SMARCA4-DUS, both of whom died within one year of diagnosis, despite aggressive surgical, chemotherapy and immunotherapy treatment. Retrospective comparative analysis of large SCCOHT (n = 48) and SMARCA4-DUS (n = 17) cohorts revealed that SCCOHT patients were younger (median age: 28.5 vs. 49.0) and more likely to have germline SMARCA4 alterations (37.5% vs. 11.8%) than SMARCA4-DUS patients. CONCLUSIONS: Growing understanding of the role SMARCA4 plays in the pathogenesis of these rare cancers may inform recommended genetic testing and counseling in families with these tumor types.

Financial toxicity in gynecologic oncology.

OBJECTIVES: Financial toxicity is increasingly recognized as an adverse outcome of cancer treatment. Our objective was to measure financial toxicity among gynecologic oncology patients and its association with demographic and disease-related characteristics; self-reported overall health; and cost-coping strategies. METHODS: Follow-up patients at a gynecologic oncology practice completed a survey including the COmprehensive Score for Financial Toxicity (COST) tool and a self-reported overall health assessment, the EQ-VAS. We abstracted disease and treatment characteristics from medical records. We dichotomized COST scores into low and high financial toxicity and assessed the correlation (r) between COST scores and self-reported health. We calculated risk ratios (RR) and 95% confidence intervals (CI) for the associations of demographic and disease-related characteristics with high financial toxicity, as well as the associations between high financial toxicity and cost-coping strategies. RESULTS: Among 240 respondents, median COST score was 29. Greater financial toxicity was correlated with worse self-reported health (r = 0.47; p < 0.001). In the crude analysis, Black or Hispanic race/ethnicity, government-sponsored health insurance, lower income, unemployment, cervical cancer and treatment with chemotherapy were associated with high financial toxicity. In the multivariable analysis, only government-sponsored health insurance, lower income, and treatment with chemotherapy were significantly associated with high financial toxicity. High financial toxicity was significantly associated with all cost-coping strategies, including delaying or avoiding care (RR: 7.3; 95% CI: 2.8-19.1). CONCLUSIONS: Among highly-insured gynecologic oncology patients, many respondents reported high levels of financial toxicity. High financial toxicity was significantly associated with worse self-reported overall health and cost-coping strategies, including delaying or avoiding care.

Endosalpingiosis: More than just an incidental finding at the time of gynecologic surgery?

OBJECTIVE: To describe the clinical characteristics of patients with endosalpingiosis (ES) and examine its association with endometriosis and gynecologic malignancies. METHODS: We queried the medical record for patients who underwent gynecologic surgery (Gynecologic Surgery Cohort (GSC), n=58,161) from 1998 to 2013 at a single institution for the presence of "endosalpingiosis" (ES). Demographic and clinical characteristics were collected for patients with pathologically confirmed ES (n=838). Within GSC, we compared the frequency of endometriosis and gynecologic malignancies with and without ES. We estimated the expected distribution of ovarian cancer subtypes using cases from the New England Case Control Study (NECC). We used chi-square tests to test for significant differences in frequency distributions and unconditional logistic regression to calculate multivariate odds ratios for the association between ES and ovarian cancer subtypes. RESULTS: We observed concurrent endometriosis (p<0.0001), uterine cancer (p<0.0001), and ovarian cancer (p<0.0001) more frequently in women with ES. Women from the GSC with ES and ovarian cancer were more likely to have serous borderline (OR=10.2, 95% CI=5.1-20.7), clear cell (OR=3.0, 95% CI=1.1-8.0), and invasive mucinous tumors (OR=5.0, 95% CI=1.5-16.6) as compared to ovarian cancer cases from the NECC without ES, after accounting for age, race, menopausal status, parity, tubal ligation, and endometriosis. CONCLUSION: Women with ES are more likely to also be diagnosed with endometriosis, uterine, and ovarian cancers. Further study is needed to understand these associations so we may appropriately counsel patients with ES diagnosed at time of gynecologic surgery.

Solitary Fibrous Tumor of the Uterus Presenting With Lung Metastases: A Case Report.

We describe the case of an 81-yr-old woman who presented with bilateral pulmonary nodules in the setting of a large uterine mass, concerning for a gynecologic malignancy such as leiomyosarcoma. However, fine-needle aspiration of a lung nodule revealed a spindle cell neoplasm consistent with solitary fibrous tumor (SFT), a rare mesenchymal neoplasm characterized by a patternless architecture of spindle cells and branching ectatic vessels. Total abdominal hysterectomy demonstrated a primary SFT of the uterus. Both the lung lesion and uterine mass were positive for STAT6, a sensitive and specific biomarker for SFT. SFT infrequently metastasizes and only rarely occurs in the uterus. These tumors are considered to have uncertain malignant potential, and the diagnosis of "malignant" SFT requires the presence of >4 mitoses per 10 high-power fields. The uterine SFT we report did not meet this criterion for malignancy, emphasizing that this entity can behave aggressively even without increased mitoses or atypical histology. To our knowledge, this is the first reported case of a uterine SFT with metastasis to the lung. We discuss the differential diagnosis for the finding of multiple pulmonary spindle cell lesions in the setting of a uterine mass.

The Role of Endometrial Biopsy in the Preoperative Detection of Uterine Leiomyosarcoma.

STUDY OBJECTIVE: To assess the sensitivity of preoperative endometrial biopsy in detection of uterine leiomyosarcoma (ULMS). STUDY DESIGN: Retrospective analysis of a prospectively collected database (Canadian Task Force III). SETTING: Two academic tertiary referral centers. PATIENTS: All cases of ULMS treated at participating institutions between January 2005 and August 2012 were identified following IRB approval. INTERVENTIONS: Abstracted data included demographics, preoperative evaluation, presenting symptom, surgical management, pathology and clinical outcomes. Chi-square tests were used for statistical analysis. MEASUREMENTS AND MAIN RESULTS: 329 cases were identified, of which 152 cases had complete pathologic data available for review. Sixty-eight (45%) of 152 patients had endometrial sampling prior to surgery. Patients with postmenopausal bleeding were significantly more likely to be biopsied preoperatively (51.6% vs 9.5%, p = <.0001). Of those sampled, 43 (63%) underwent endometrial pipelle biopsies and 25 (37%) had dilation and curettage. Endometrial sampling was significantly more likely to detect a concern for malignancy in patients who presented with postmenopausal bleeding (72.7% vs 32.3%, p = 0.002), however it was less likely to detect malignancy in patients with abnormal premenopausal bleeding (31.8% vs 64.3%, p = .02), compared to other presenting symptoms. Overall, 51.5% of patients with ULMS on final pathology had preoperative endometrial biopsies in which leiomyosarcoma or atypical spindle cell proliferation were diagnosed, whereas 35.5% of the pre-operative biopsies identified ULMS specifically. CONCLUSIONS: The sensitivity of an endometrial biopsy to detect ULMS is low, illustrating the difficulty of diagnosing ULMS preoperatively. As expected, the probability that an endometrial biopsy will detect ULMS or a related worrisome pathological finding is higher for patients with post-menopausal bleeding. Thus, benign endometrial biopsy results, particularly in pre-menopausal patients, should be interpreted with caution if there is suspicion for leiomyosarcoma. However, a positive or suspicious result can play an important role in the subsequent management of patients with ULMS, even if the absolute numbers of affected patients are small.

Genomic aberrations in cervical adenocarcinomas in Hong Kong Chinese women.

Although the rates of cervical squamous cell carcinoma have been declining, the rates of cervical adenocarcinoma are increasing in some countries. Outcomes for advanced cervical adenocarcinoma remain poor. Precision mapping of genetic alterations in cervical adenocarcinoma may enable better selection of therapies and deliver improved outcomes when combined with new sequencing diagnostics. We present whole-exome sequencing results from 15 cervical adenocarcinomas and paired normal samples from Hong Kong Chinese women. These data revealed a heterogeneous mutation spectrum and identified several frequently altered genes including FAT1, ARID1A, ERBB2 and PIK3CA. Exome sequencing identified human papillomavirus (HPV) sequences in 13 tumors in which the HPV genome might have integrated into and hence disrupted the functions of certain exons, raising the possibility that HPV integration can alter pathways other than p53 and pRb. Together, these provisionary data suggest the potential for individualized therapies for cervical adenocarcinoma based on genomic information.

Does plastic surgical consultation improve the outcome of patients undergoing radical vulvectomy for squamous cell carcinoma of the vulva?

OBJECTIVES: To analyze margin status and prognostic factors for complications in patients undergoing vulvectomy for invasive squamous cell cancer (iSCC) with and without plastic-assisted closure. METHODS: Demographic and clinical data were collected on 94 patients with iSCC who underwent vulvectomy between 2004 and 2013. All pathology slides were re-reviewed by two gynecologic pathologists. Data were analyzed using XLSTAT-Pro v2014.2.02. RESULTS: Of 88 eligible patients, 15 (17%) had plastic-assisted vulvar closure and 73 (83%) did not. There were significantly more patients in the plastics group with recurrent disease (53% v 10%) and history radiation therapy prior to surgery (40% versus 5%). Plastic-assisted closure was associated with larger tumors (3.73 cm versus 2.03 cm, p<0.01) and a higher frequency of adequate margins (53% versus 29%, p=0.06). For tumors≥3.0 cm, plastic-assisted closure was significantly associated with adequate margins (44% versus 6%, p=0.03). Prior radiation use was associated with plastic-assisted closure, larger tumors, older age, and recurrent disease. Complications occurred in 36 patients (41%) and significantly more occurred in those with plastic-assisted closure (67% versus 36%, p=0.04). On multivariate analysis including age, tumor size, recurrent disease, plastic-assisted closure, and history of radiation, only history of radiation therapy was a significant predictor of complications (OR=17, 95%CI 2.05-141.35; p=0.01). CONCLUSIONS: Plastic-assisted vulvectomy closure was more often utilized in cases involving past radiation therapy and larger tumors. Plastic-assisted closure significantly increased the frequency of adequate margins in tumors≥3 cm and did not impact complications.

Endosalpingiosis as it relates to tubal, ovarian and serous neoplastic tissues: an immunohistochemical study of tubal and Müllerian antigens.

OBJECTIVE: The origins and clinical significance of endosalpingiosis (ES), ectopic tubal epithelium, are not well understood. These investigations aim to characterize ES as it relates to normal fallopian tube, ovarian surface and serous neoplasms. METHODS: A retrospective review of pathology reports from all prophylactic gynecologic surgeries from 2000 to 2010 was performed to assess the frequency of ES. Twenty-one archival specimens of ES, 6 normal fallopian tubes, 9 normal ovaries, 21 serous neoplasms and a commercially available ovarian tissue microarray were subjected to immunohistochemistry (IHC) with 11 tubal and Müllerian antigens. IHC staining was evaluated with a quantitative scoring system and scores were analyzed using MINITAB statistical software. RESULTS: ES was noted in 3.5% of pathologic specimens from 464 prophylactic surgeries. The majority of antigens showed no significant differences (p > 0.05) in median IHC scores between ES and normal fallopian tube epithelium (nFTE), while they were significantly different (p < 0.05) from the ovarian surface epithelium (OSE). Median IHC scores were unchanged in ES tissues regardless of the location of ES or the presence of a concurrent serous neoplasm. Three antigens emerged as contemporary tubal and ES biomarkers: phospho-Smad2, BCL2 and FOXJ1. All 3 biomarkers were expressed in ES, nFTE and serous neoplasms, but not in OSE or other tumor types. CONCLUSION: This study provides immunophenotypic evidence that ES is more similar to the nFTE than OSE. Further, ES biomarker expression closely resembles serous neoplasms strengthening the growing body of evidence that all Müllerian serous carcinomas arise from tubal-like epithelium.

What is the optimal treatment for obese patients with advanced ovarian carcinoma?

OBJECTIVE: The purpose of this study was to compare primary debulking surgery (PDS) vs neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among obese patients. STUDY DESIGN: Medical records of patients with a body mass index (BMI) of ≥30 kg/m(2) with ovarian/fallopian tube/primary peritoneal carcinoma between January 2005 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures, and postoperative and oncologic outcomes were compared. RESULTS: Of 117 patients, 95 women (81.2%) underwent PDS, and 22 women (18.8%) underwent NACT-IDS. Patients who underwent NACT-IDS were more likely to have stage IV disease (63.6% vs 26.3%; P = .001) and a low surgical complexity score (n = 14; 63.6%). There were no other differences between groups with respect to preoperative characteristics or postoperative morbidity. Compared with the NACT-IDS group, the PDS group had an improved progression-free survival (PFS; 15 vs 11 months; P = .006) and overall survival (OS; 53 vs 32 months; P = .036). Seventy-eight patients (66.7%) had a BMI of 30-34.9 kg/m(2). Within this subset of obese patients, the PDS group had an improved PFS (15 vs 10 months; P = .011) and OS (58 vs 32 months; P = .033), compared with the NACT-IDS group. Among patients with a BMI of ≥35 kg/m(2), there was no difference in PFS (14 vs 12 months; P = .316) or OS (38 vs 32 months; P = .640) when the PDS and NACT-IDS groups were compared. CONCLUSION: Patients with a BMI of 30-34.9 kg/m(2) who undergo PDS have improved oncologic outcomes, compared with those women who undergo NACT-IDS. Patients with a BMI of ≥35 kg/m(2) who undergo PDS have similar oncologic outcomes to those who undergo NACT-IDS. Complication rates were similar at all BMIs, regardless of treatment approach.

Financial Toxicity in Relation to Childbirth.

OBJECTIVE: To measure change in financial toxicity from pregnancy to the postpartum period and to identify factors associated with this change. DESIGN: Repeated cross-sectional survey. SETTING: Obstetric clinics at an academic medical center in Massachusetts between May 2020 and May 2022. PARTICIPANTS: Obstetric patients who were 18 years of age or older (N = 242). METHODS: Respondents completed surveys that included the Comprehensive Score for Financial Toxicity tool during pregnancy and in the postpartum period. We collected additional medical record data, including gestational age, birth weight, and cesarean birth. We used paired t tests to assess changes in financial toxicity before and after childbirth and one-way analysis of variance to compare average change in financial toxicity by demographic and medical variables. RESULTS: The mean current financial toxicity score was significantly lower after childbirth (M = 19.0, SD = 4.6) than during pregnancy (M = 21.8, SD = 5.4), t(241) = 13.31, p < .001. Concern for future financial toxicity was not significantly different after childbirth (M = 8.5, SD = 2.9) compared to during pregnancy (M = 8.2, SD = 3.0), t(241) = -1.80, p = .07. Individual-level sociodemographic variables (e.g., racial/ethnic category, insurance, employment) and medical factors (e.g., cesarean birth, preterm birth) were not associated with change in financial toxicity. CONCLUSION: Among respondents, financial toxicity worsened after childbirth, and patients are at risk regardless of their individual socioeconomic and medical conditions.

Regulatory histories of recently withdrawn ovarian cancer treatment indications of 3 PARP inhibitors in the US and Europe: lessons for the accelerated approval pathway.

Background: Withdrawals of drug indications may reveal potential inadequacies in the regulatory approval processes of new drugs. Understanding potential weaknesses of the regulatory approval process is paramount given the increasing use of expedited pathways. In this paper, we focus on three poly-ADP-ribose polymerase inhibitors (olaparib, rucaparib and niraparib) for the treatment of women with heavily pretreated, recurrent ovarian cancer, which were eventually withdrawn. Methods: We use a comparative case study approach to evaluate the regulatory histories of these drug indications in the US and Europe. Results: Two drug indications benefited from the FDA's accelerated approval pathway, which explicitly lowers the bar for evidence of efficacy at the time of approval. Following accelerated approval, manufacturers are mandated to conduct post-marketing studies to confirm clinical benefit. The FDA granted accelerated approval to olaparib and rucaparib based on data on surrogate endpoints and converted the approval to regular approval after the submission of additional data on surrogate endpoints from one of two required confirmatory trials, that is, without data on clinical benefit. Niraparib directly received regular approval based only on data on a surrogate endpoint. By contrast, the EMA granted conditional marketing authorisation to rucaparib and was quicker to restrict usage than the FDA. Conclusion: The regulatory histories of these drug indications highlight the need to reform the accelerated approval pathway by ensuring that post-marketing requirements are followed, and that regular approval is only based on evidence of clinical benefit.

Patterns of recurrence in patients treated with bevacizumab in the primary treatment of advanced epithelial ovarian cancer.

OBJECTIVE: The purpose of this study was to compare the distribution of the first site of recurrence in patients with epithelial ovarian cancer (EOC) who received first-line treatment with bevacizumab compared with patients who did not receive bevacizumab. METHODS: From the Cancer Registry database at our institutions, we identified a group of patients with recurrent EOC who underwent treatment from January 1, 2005, to December 31, 2010. Each patient record was evaluated to classify the site of first recurrence. Correlation between categorical variables was assessed with χ² test. RESULTS: Two hundred ninety-two patients with advanced EOC (stage III or IV) who originally responded to chemotherapy and had a recurrence were identified. Of these, 37 (12.5%) had received postoperative chemotherapy bevacizumab, and 255 (87.5%) did not. Compared with those not treated with bevacizumab, there was a lower incidence of liver recurrence (0% vs 9%; P = 0.05) and a higher rate of lung and/or pleural recurrence (22% vs 5%; P = 0.001) and recurrence at distant sites (22% vs 9%; P = 0.03) in patients who received bevacizumab. There was no difference in the incidence of ascites at the time of recurrence between these groups. CONCLUSIONS: Patients who received bevacizumab as part of primary treatment for EOC had a higher rate of lung and/or pleural recurrence and a lower rate of liver recurrence. There was no difference in the rate of ascites at the time of recurrence.

Cost-effectiveness of cervical cancer prevention.

Cost-effectiveness analyses are an important tool for the evaluation and modification of many health care services. Given the variety of screening tests and treatments available for cervical cancer screening and prevention, the costs associated with these options and with their alternatives, and the differences in resources and settings in which these tests are applied worldwide, cost-effectiveness analyses evaluation can be very useful to help determine best practices.

Patterns of recurrence in advanced epithelial ovarian, fallopian tube and peritoneal cancers treated with intraperitoneal chemotherapy.

OBJECTIVES: To examine the distribution and outcomes of recurrent disease in patients with ovarian, fallopian tube and peritoneal cancers after optimal cytoreduction and adjuvant intraperitoneal (IP) chemotherapy. METHODS: All patients diagnosed with ovarian, fallopian tube, or peritoneal cancer between 2004 and 2009 who underwent optimal cytoreductive surgery and received adjuvant intravenous (IV) and IP chemotherapy with paclitaxel and a platinum-based agent were eligible. Age, performance status, tumor origin, stage, and grade were recorded. First recurrences were identified using CA125 values, radiographic studies, operative notes, and pathology reports. Sites of recurrence were classified as intraperitoneal (IP), extraperitoneal (EP) or distant. Kaplan-Meier estimates and Cox multivariate regression models were used to assess the associations between recurrent disease distribution and progression-free survival (PFS) and overall survival (OS). RESULTS: One hundred forty-three patients met the criteria for inclusion. The majority were Stage III (86%) and serous histology (77%). Eighty-four (58.7%) received IV/IP paclitaxel/cisplatin per GOG-172 and 59 (41.3%) received IV/IP paclitaxel/carboplatin. Seventy-two percent completed 6 cycles. Ninety (62.9%) patients manifested a recurrence. One-hundred twelve sites of recurrence were identified with 70 (62.5%) IP and 42 (37.5%) EP and distant sites. Nineteen (21%) recurred in more than one site, i.e. both IP and EP locations. Site of recurrence did not impact OS, however, patients who recurred in multiples sites had significantly worse OS (p<0.001). CONCLUSION: Approximately 40% of patients treated with IP chemotherapy have a first recurrence outside the peritoneal cavity. Though site of recurrence did not affect OS those with multi-focal recurrence demonstrate worse survival.

Labile Heme and Heme Oxygenase-1 Maintain Tumor-Permissive Niche for Endometriosis-Associated Ovarian Cancer.

Endometriosis, a painful gynecological condition accompanied by inflammation in women of reproductive age, is associated with an increased risk of ovarian cancer. We evaluated the role of peritoneal heme accumulated during menstrual cycling, as well as peritoneal and lesional macrophage phenotype, in promoting an oncogenic microenvironment. We quantified the heme-degrading enzyme, heme oxygenase-1 (HO-1, encoded by Hmox1) in normal peritoneum, endometriotic lesions and endometriosis-associated ovarian cancer (EAOC) of clear cell type (OCCC). HO-1 was expressed primarily in macrophages and increased in endometrioma and OCCC tissues relative to endometriosis and controls. Further, we compared cytokine expression profiles in peritoneal macrophages (PM) and peripheral blood mononuclear cells (PBMC) in women with endometriosis versus controls as a measure of a tumor-promoting environment in the peritoneum. We found elevated levels of HO-1 along with IL-10 and the pro-inflammatory cytokines (IL-1ß, IL-16, IFNγ) in PM but not in PBMC from endometriosis patients. Using LysM-Cre:Hmox1flfl conditional knockout mice, we show that a deficiency of HO-1 in macrophages led to the suppression of growth of ID8 ovarian tumors implanted into the peritoneum. The restriction of ID8 ovarian tumor growth was associated with an increased number of Mac3+ macrophage and B cells in LysM-Cre:Hmox1flfl mice compared to controls. Functional experiments in ovarian cancer cell lines show that HO-1 is induced by heme. Low levels of exogenous heme promoted ovarian cancer colony growth in soft agar. Higher doses of heme led to slower cancer cell colony growth in soft agar and the induction of HO-1. These data suggest that perturbation of heme metabolism within the endometriotic niche and in cancer cells themselves may be an important factor that influences tumor initiation and growth.