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.

Assessment of Cancer Survivorship Training and Knowledge Among Resident Physicians in Obstetrics and Gynecology.

The number of gynecologic cancer survivors in the USA is expected to grow to nearly 2 million by 2029. Gynecologic oncologists alone will not be able to care for all of these women. Thus, preparation of general obstetrician/gynecologists (OBGYNs) to deliver this care is crucial. Our objective was to assess cancer survivorship training (CST) among OB/GYN residents and to evaluate knowledge in basic gynecologic cancer survivorship. OB/GYN residents were recruited nationally to complete a de novo questionnaire, querying demographics, hours of CST received, teaching methods used, and efficacy of those methods. Survivorship knowledge was assessed by ten questions based on the 2017 Society of Gynecologic Oncology recommendations on post-treatment surveillance, which includes topics appropriate for generalists. Analyses were done using t tests and ANOVA, with significance set at p = 0.05. In total, 128 residents responded to the survey. Observation was the most common method of CST (53%), with patient contact reported as the most effective method (42.6%). The mean score of correct responses (MSCRs) among all respondents was 61.5%. MSCR significantly improved with increasing post-graduate year (PGY) (p = 0.003). Survivorship training method was not associated with improved MSCR. Improvements in MSCR were observed with an increasing number of CST hours (p = 0.011). A total of 13.9% of residents reported feeling "very comfortable" with survivorship care, yet 88.5% of respondents indicated they did not want additional CST. More hours of CST are associated with improved resident in knowledge in cancer survivorship care, though deficits still remain. Further investigation into optimizing CST is warranted.

mRNA expression in low grade serous ovarian cancer: Results of a nanoString assay in a diverse population.

OBJECTIVE: Mutations in the MAP kinase pathway (KRAS, NRAS, BRAF) are common in low grade serous ovarian carcinoma (LGSOC). The effect of these and other mutations on RNA transcription in this disease is poorly understood. Our objective was to describe patterns of somatic mutations and gene transcription in a racially diverse population with LGSOC. METHODS: Utilizing an institutional tumor registry, patients with LGSOC were identified and charts were reviewed. RNA was extracted from available tumor tissue. Commercial tumor profiling results were analyzed with PanCancer pathway nanoString mRNA expression data. Along with nanoString n-Solver software, Chi-squared, Fishers Exact, and Cox proportional hazards models were used for statistical analysis, with significance set at p < 0.05. RESULTS: 39 patients were identified-20% Black, 43% Hispanic, and 36% non-Hispanic White. 18 patients had commercial somatic DNA test results, and 23 had available tumor tissue for RNA extraction and nanoString analysis. The most common somatic alterations identified was KRAS (11 patients, 61%), followed by ERCC1 and TUBB3 (9 each, 50%). KRAS mutations were less common in smokers (14.3% vs 90.9%, p = 0.002). RNA expression analysis demonstrated a greater than two-fold decrease in expression of HRAS in tumors from older patients (p = 0.04), and a greater than two-fold decrease in the expression of HRAS in recurrent tumors (p = 0.007). No significant differences were seen in somatic testing results, RNA expression analysis, or progression free survival between different racial and ethnic cohorts. CONCLUSIONS: Somatic deficiencies in ERCC1, TUBB3, and KRAS are common in LGSOC in a population of minority patients. HRAS demonstrates decreased expression in tumors from older patients and recurrent tumors.

Low-grade serous ovarian cancer: State of the science.

In January 2019, a group of basic, translational, and clinical investigators and patient advocates assembled in Miami, Florida, to discuss the current state of the science of low-grade serous carcinoma of the ovary or peritoneum-a rare ovarian cancer subtype that may arise de novo or following a diagnosis of serous borderline tumor. The purpose of the conference was to review current knowledge, discuss ongoing research by established researchers, and frame critical questions or issues for future directions. Following presentations and discussions, the primary objective was to initiate future collaborations, uniform database platforms, laboratory studies, and clinical trials to better understand this disease and to advance clinical care outside the boundaries of single academic institutions. This review summarizes the state of the science in five principal categories: epidemiology and patient outcomes, pathology, translational research, patient care and clinical trials, and patients' perspective.

Rare metastatic patterns after malignant transformation of serous borderline tumor of the ovary.

Serous borderline tumors are rare, benign ovarian neoplasms that may recur and undergo malignant transformation to low-grade serous carcinomas (LGSCs). In this report, a 50-year-old female with a remote history of a serous borderline ovarian tumor experienced a recurrence of LGSC, presenting as a large solitary subcutaneous mass anterior to the sternum after a 33-year disease-free interval. The described case highlights the unpredictable nature of this disease and the importance of implementing lifelong surveillance strategies.

Low grade serous ovarian carcinoma: identifying variations in practice patterns.

OBJECTIVES: Low grade serous ovarian carcinoma is a rare subtype of ovarian cancer with an indolent and chemorefractory course. As such, treatment strategies among practitioners are not uniformly known. The primary objective of this study was to identify differences in practice patterns among physicians who treat low grade serous carcinoma. METHODS MATERIALS: A de novo survey was distributed to members of the Society of Gynecologic Oncology. Questions about demographics, management of primary and recurrent disease, and use of consolidation therapy were included. Statistical analyses were performed using χ2 and Fisher's exact tests. RESULTS: 194 gynecologic oncologists completed the survey. Approximately two-thirds of respondents practiced in a university based setting and treated a high volume of ovarian cancers, including low grade serous carcinoma. 82% recommended somatic testing during treatment and 84% routinely sent patients for genetic counseling. Treatment preferences for primary disease varied by debulking status. 48% of practitioners used hormone antagonism as consolidation after primary treatment. Secondary cytoreduction was preferred for patients with platinum sensitive recurrence and a long disease free interval following primary treatment (P<0.001). Hormone antagonism was the preferred treatment for the first platinum resistant recurrence (54%), while a BRAF inhibitor was the preferred agent in platinum resistant recurrence in the presence of a known BRAF mutation (56%). CONCLUSIONS: There was significant variation in the preferred management of low grade serous carcinoma among practitioners. Further efforts to improve knowledge of this disease, identify optimal treatment modalities, and provide guidelines for management should be encouraged.

Preparation in the business and practice of medicine: perspectives from recent gynecologic oncology graduates and program directors.

BACKGROUND: Preparation in the business of medicine is reported to be poor across a number of specialties. No data exist about such preparation in gynecologic oncology training programs. Our objectives were to evaluate current time dedicated to these initiatives, report recent graduate perceptions about personal preparedness, and assess areas where improvements in training can occur. METHODS: Two separate surveys were created and distributed, one to 183 Society of Gynecologic Oncology candidate members and the other to 48 gynecologic oncology fellowship program directors. Candidate member surveys included questions about perceived preparedness for independent research, teaching, job-hunting, insurance, and billing. Program director surveys assessed current and desired time dedicated to the topics asked concurrently on the candidate survey. Statistical analysis was performed using Chi-squared (or Fisher's exact test if appropriate) and logistic regression. RESULTS: Survey response rates of candidate members and program directors were 28% and 40%, respectively. Candidate members wanted increased training in all measures except retrospective protocol writing. Female candidates wanted more training on writing letters of intent (LOI) (p = 0.01) and billing (p < 0.01). Compared to their current schedules, program directors desired more time to teach how to write an investigator initiated trial (p = 0.01). 94% of program directors reported having career goal discussions with their fellows, while only 72% of candidate members reported that this occurred (p = 0.05). CONCLUSION: Recent graduates want more preparation in the non-clinical aspects of their careers. Reconciling program director and fellow desires and increasing communication between the two may serve to achieve the educational goals of each.