Incorporation of Palliative Care in Gynecologic Oncology.

PURPOSE OF REVIEW: This review serves to provide clarity on the nature, scope, and benefits of early palliative care integration into the management of patients with gynecologic malignancies. RECENT FINDINGS: There is increased recognition that timely referral to palliative care improves quality of life for patients and their families by providing goal-concordant care that reduces physical and emotional suffering and limits futile and aggressive measures at the end of life. Palliative care services rendered throughout the continuum of illness ultimately increase engagement with hospice services and drive down health expenditures. Despite these myriad benefits, misconceptions remain, and barriers to and disparities in access to these services persist and warrant continued attention. Palliative care should be offered to all patients with advanced gynecologic cancers early in the course of their disease to maximize benefit to patients and their families.

Therapeutic Options for Brain Metastases in Gynecologic Cancers.

OPINION STATEMENT: Brain metastases (BM) are rare in gynecologic cancers. Overall BM confers a poor prognosis but other factors such as number of brain lesions, patient age, the presence of extracranial metastasis, the Karnofsky Performance Status (KPS) score, and the type of primary cancer also impact prognosis. Taking a patient's whole picture into perspective is crucial in deciding the appropriate management strategy. The management of BM requires an interdisciplinary approach that frequently includes oncology, neurosurgery, radiation oncology and palliative care. Treatment includes both direct targeted therapies to the lesion(s) as well as management of the neurologic side effects caused by mass effect. There is limited evidence of when screening for BM in the gynecology oncology patient is warranted but it is recommended that any cancer patient with new focal neurologic deficit or increasing headaches should be evaluated. The primary imaging modality for detection of BM is MRI, but other imaging modalities such as CT and PET scan can be used for certain scenarios. New advances in radiation techniques, improved imaging modalities, and systemic therapies are helping to discover BM earlier and provide treatments with less detrimental side effects.

Employment disruption among women with gynecologic cancers.

BACKGROUND: Adverse employment outcomes pose significant challenges for cancer patients, though data patients with gynecologic cancers are sparse. We evaluated the decrease in employment among patients in the year following the diagnosis of a gynecologic cancer compared with population-based controls. METHODS: Patients aged 18 to 63 years old, who were diagnosed with cervical, ovarian, endometrial, or vulvar cancer between January 2009 and December 2017, were identified in Truven MarketScan, an insurance claims database of commercially insured patients in the USA. Patients working full- or part-time at diagnosis were matched to population-based controls in a 1:4 ratio via propensity score. Multivariable Cox proportional hazards models were used to evaluate the risk of employment disruption in patients versus controls. RESULTS: We identified 7446 women with gynecologic cancers (191 vulvar, 941 cervical, 1839 ovarian, and 4475 endometrial). Although most continued working following diagnosis, 1579 (21.2%) changed from full- or part-time employment to long-term disability, retirement, or work cessation. In an adjusted model, older age, the presence of comorbidities, and treatment with surgery plus adjuvant therapy versus surgery alone were associated with an increased risk of employment disruption (p<0.0003, p=0.01, and p<0.0001, respectively) among patients with gynecologic cancer. In the propensity-matched cohort, patients with gynecologic cancers had over a threefold increased risk of employment disruption relative to controls (HR 3.67, 95% CI 3.44 to 3.95). CONCLUSION: Approximately 21% of patients with gynecologic cancer experienced a decrease in employment in the year after diagnosis. These patients had over a threefold increased risk of employment disruption compared with controls.

Employment disruption following the diagnosis of endometrial cancer.

BACKGROUND: Oncologic treatment has been associated with unemployment. As endometrial cancer is highly curable, it is important to assess whether patients experience employment disruption after treatment. We evaluated the frequency of employment change following endometrial cancer diagnosis and assessed factors associated with it. METHODS: A cohort of patients 18-63 years-old who were diagnosed with endometrial cancer (January 2009-December 2017) were identified in the Truven MarketScan database, an insurance claims database of commercially insured patients in the United States. All patients who were working full- or part-time at diagnosis were included and all employment changes during the year following diagnosis were identified. Clinical information, including use of chemotherapy and radiation, were identified using Common Procedural Terminology codes, and International Statistical Classification of Diseases codes. Cox proportional hazards models incorporating measured covariates were used to evaluate the impact of treatment and demographic variables on change in employment status. RESULTS: A total of 4381 women diagnosed with endometrial cancer who held a full-time or part-time job 12 months prior to diagnosis were identified. Median age at diagnosis was 55 and a minority of patients received adjuvant therapy; 7.9% received chemotherapy, 4.9% received external-beam radiation therapy, and 4.1% received chemoradiation. While most women continued to work following diagnosis, 21.7% (950) experienced a change in employment status. The majority (97.7%) of patients had a full-time job prior to diagnosis. In a multivariable analysis controlling for age, region of residence, comorbidities, insurance plan type and presence of adverse events, chemoradiation recipients were 34% more likely to experience an employment change (HR 1.34, 95% CI 1.01-1.78), compared to those who only underwent surgery. CONCLUSION: Approximately 22% of women with employer-subsidized health insurance experienced a change in employment status following the diagnosis of endometrial cancer, an often-curable disease. Chemoradiation was an independent predictor of change in employment.

Managing opioid use in the acute surgical setting: A society of gynecologic oncology clinical practice statement.

Gynecologic oncologists have the unique opportunity of caring for patients in a broad range of surgical and medical settings. With increasing awareness of the opioid epidemic and the various factors that contribute to chronic opioid use, gynecologic oncologists must also better understand how to best address acute postoperative pain without unknowingly placing patients at risk for opioid misuse. This article examines the use of opioids in the acute surgical setting and provides clinical guidelines and various strategies to reduce opioid misuse.

Validation of the surprise question in gynecologic oncology: A one-question screen to promote palliative care integration and advance care planning.

OBJECTIVE: The "surprise question" ("Would you be surprised if this patient died in the next year?") has been shown to be predictive of 12-month mortality in multiple populations, but has not been studied in gynecologic oncology (GO) patients. We sought to evaluate the prognostic performance of the surprise question in GO patients among physician and non-physician providers. METHODS: GO providers at two tertiary care centers were asked the surprise question about a cohort of their patients undergoing chemotherapy or radiation. Demographic and clinical information was chart abstracted. Mortality data were collected at one year; relative risk of death at one year based on response to the surprise question was then calculated. RESULTS: 32 providers (12 MDs, 7 APPs, 13 RNs) provided 942 surprise question assessments for 358 patients. Fifty-seven % had ovarian cancer and 54% had recurrent disease. Eighty-three (24%) patients died within a year. Patients whose physician answered "No" to the surprise question had a 43% one-year mortality (compared to 10% for "Yes"). Overall RR of 12-month mortality for "No" was 3.76 (95% CI 2.75-5.48); this association remained significant in all provider types. Among statistically significant predictors of 12-month mortality (including recurrent disease and >2 prior lines of chemotherapy), the surprise question had the highest RR. CONCLUSIONS: The surprise question is a simple, one question tool that effectively identifies GO patients increased risk of 12-month mortality. The surprise question could be used to identify patients for early referral to palliative care and initiation advance care planning.

Gynecologic oncology providers endorse practice-changing impact of communication skills training.

OBJECTIVE: Effective communication improves patient outcomes and is crucial to good patient care. Communication skills training (CST) has been shown to improve communication skills in non-gynecologic oncology specialties. We sought to develop and test CST for gynecologic oncology (GO) providers. METHODS: We developed and conducted a two-day CST workshop with an interprofessional group of 20 GO providers over two years. Participants were surveyed pre-workshop, immediately post-workshop and one month post-workshop regarding self-assessed preparedness to handle challenging communication tasks, workshop evaluation and impact on practice. McNemar's tests were used for pre-post comparisons. RESULTS: Of 12 challenging communication tasks assessed, all participants reported improvement in at least one, with a median of 10. The proportion of participants feeling more than "somewhat prepared" improved significantly for all communication tasks assessed (p < 0.05); improvement was sustained one month later. One month post-workshop, 86% reported thinking about what they had been taught at least weekly and 93% reported encountering situations where they used their CST skills at least weekly. Rates of reported practice-changing impact were >75% for each communication skill. All participants rated the CST educational quality very good or excellent and strongly agreed it should be required of all GO clinicians. CONCLUSIONS: Participants felt the workshop provided high-quality, practice-changing education. As a result of the workshop, participants reported statistically significant, sustained improvement in preparedness to handle challenging communication tasks. CST for GO providers is feasible, with high rates of perceived effectiveness and impact on clinical practice. CST workshops should be integrated into GO training.

Evolving trends in the management of high-intermediate risk endometrial cancer in the United States.

OBJECTIVE: Gynecologic oncology group protocol 249 (GOG 249) is the contemporary US study that aimed to define the standard of care adjuvant therapy for patients with high-intermediate risk (HIR) endometrial cancer; patients were randomized to pelvic radiation therapy (RT) or vaginal brachytherapy (VBT) with chemotherapy (VBT-C). The preliminary results of GOG 249 were recently presented, yet the management of patients represented in this trial remains controversial. We set out to review US patterns of care for patients meeting eligibility criteria for GOG 249. METHODS: The National Cancer Database (NCDB) was used to identify patients meeting GOG 249 eligibility criteria between 2010 and 2015. The Man-Kendall trend test was used to assess for significant trends over time. RESULTS: We identified 23,015 patients that met study inclusion criteria. Between 2010 and 2015, there was a decline in the use of pelvic RT from 9.8% to 7.5%, although not meeting statistical significance (p = 0.136), and an increase in the use of VBT-C from 4.6% to 7.7% (p = 0.017). Most patients did not receive treatment per either arm of GOG 249, with observation being the most common approach throughout this era, although the percentage of patients observed decreased from 58.1% to 45.8% between 2010 and 2015 (p = 0.003). Further, 21.5% of patients received VBT alone in 2010, increasing to 30.3% by 2015 (p = 0.003). CONCLUSIONS: National practice trends in HIR endometrial cancer reveal that a large number of patients are observed in lieu of receiving adjuvant therapy. Further, the utilization of pelvic RT has declined below utilization of VBT-C, despite a lack of data supporting either improved disease outcomes or toxicity with this experimental regimen on GOG 249.

Molecular markers in recurrent stage I, grade 1 endometrioid endometrial cancers.

OBJECTIVES: Stage I, grade 1 endometrial cancers have low recurrence rates and often do not receive adjuvant therapy. We compared recurrent cases to matched non-recurrent controls to evaluate for molecular markers associated with higher risk of recurrence. METHODS: A case-control study including all cases of recurrent stage I, grade 1 endometrioid endometrial cancer at one institution in a ten-year period. Cases were matched to controls by age, BMI, weight and stage. Molecular testing and immunohistochemistry were performed on archival tumor specimens: microsatellite instability (MSI-H), mismatch repair status, POLE mutational status, and next-generation sequencing. RESULTS: 15 stage I, grade 1 endometrial cancer cases with recurrent disease and available tumor specimens were identified. CTNNB1 and MSI-H were present at significantly higher rates in cases than controls (CTNNB1 60% vs. 28%, OR 3.9, 95%CI 1.1-14.7, p = 0.04 and MSI-H 53% vs. 21%, OR 4.4, 95%CI 1.1-17.0, p = 0.03). POLE mutations were found in 0% of cases vs. 7% of controls (p = 0.54). Among specimens demonstrating microsatellite stability (MSS), 100% of cases vs. 26% of controls had CTNNB1 mutations (p < 0.001). CTNNB1 wild type tumors were MSI-H in 100% of cases vs. 19% of controls (p < 0.001). CONCLUSIONS: Compared to controls, CTNNB1 mutation is present at significantly higher rates in recurrent stage I, grade 1 endometrial cancers and is found most commonly in MSS tumors. MSI-H is also present at significantly higher rates in recurrent cases. These markers may be useful for prognostic risk stratification and adjuvant therapy decision-making in this otherwise low-risk population.

Evidence for integration of palliative care into surgical oncology practice and education.

High-quality data support multiple clinical benefits of integrating palliative care into routine oncology care. Though these data come largely from the medical oncology literature, data from surgical oncology populations support similar associations between palliative care integration and improved clinical outcomes, all without compromise in survival. This paper will review data supporting palliative care integration into oncology care, with a focus on surgical populations and recommendations for incorporating palliative care into surgical oncology.

Persistent opioid use after radiation therapy in opioid-naive cervical cancer survivors.

OBJECTIVES: Opioids are first-line therapy for cancer-related pain, but their use should be minimized in disease-free survivors. We sought to describe rates and identify predictors of persistent opioid use among previously opioid-naive cervical cancer survivors treated with radiation. METHODS: Opioid-naive cervical cancer patients treated primarily with radiation and chemosensitization at a single institution, between January 2011 and December 2015, were identified. Charts were reviewed for demographics, disease, and treatment characteristics, and opioid prescriptions. Primary outcome was persistent opioid use, defined as continued opioid prescription use, 6 months after radiation; patients recurring within 6 months were excluded. Groups were compared using χ2 or Fisher's exact test. Multivariable logistic regression identified predictors of persistent opioid use. RESULTS: A total of 96 patients were included, with a median age of 49 years (range 27-84). Most patients (59%) at diagnosis had International Federation of Gynecology and Obstetrics (FIGO) stage I or II cervical cancer. The most common histology was squamous cell carcinoma (72%) and most (94.7%) patients received radiation with chemosensitization. Rates of persistent opioid use at 3 and 6 months after treatment were 29% and 25%, respectively. Persistent users were more likely to be <40 years old, have disease outside the pelvis at diagnosis, and have had a history of substance abuse, depression or anxiety (p<0.05). In multivariable analysis, a history of substance abuse (adjusted OR 6.21, 95% CI 1.08 to 35.67) and depression or anxiety (aOR 6.28, 95% CI 1.70 to 23.30) were independently associated with persistent opioid use. CONCLUSION: Our study showed that 25% of patients with cervical cancer were still using opioids 6 months after radiation. History of substance abuse and depression or anxiety, all known risk factors for opioid misuse, were associated with persistent use. The goal in the disease-free survivor population should be opioid independence.

Pre-operative opioid use in gynecologic oncology: a common comorbidity relevant to the peri-operative period.

OBJECTIVES: Pre-operative opioid use is common and should be considered a comorbidity among surgical candidates. Our objective was to describe the rate of pre-operative opioid use and patterns of post-operative outpatient opioid prescribing in a cohort of gynecologic oncology patients. METHODS: A retrospective cohort study was conducted with 448 gynecologic oncology surgical patients undergoing surgery for a suspected or known cancer diagnosis from January 2016 to December 2016. Pre-operative opioid users (n=97) were identified. Patient and surgical characteristics were abstracted, as was post-operative opioid prescription (type of opioid, oral morphine equivalents amount) and length of stay. For pre-operative opioid users, the type of opioid prescribed post-operatively was compared with the type of pre-operative opioid. Pre-operative opioid users were compared with non-users, stratified by surgery type. Descriptive statistics were analyzed using χ2 statistic, and medians were compared using a Mann-Whitney U statistic. RESULTS: Pre-operative opioid prescriptions were noted in 21% of patients, and 24% of these had two or more opioid prescriptions before surgery. The majority of pre-operative opioid users (51%) were maintained on the same agent post-operatively at the time of discharge, but 36% were switched to a different opioid and 7% were prescribed an additional opioid. Overall and in laparotomies, pre-operative opioid users received higher volume post-operative prescriptions than non-users. There was no difference in post-operative prescription volume for minimally invasive surgeries or in length of stay between pre-operative users and non-users. CONCLUSIONS: Pre-operative opioid use is common in gynecologic oncology patients and should be considered during pre-operative planning. Pre-operative opioid use was associated with a higher volume and wider range of post-operative prescription. Over 40% of opioid users were discharged with either an additional opioid or a new opioid, highlighting a potential missed opportunity to optimize opioid safety. Further research is needed to characterize the relationship between pre-operative opioid use and peri-operative outcomes and to develop strategies to manage pain effectively in this population without compromising opioid safety.

Opioid use in gynecologic oncology in the age of the opioid epidemic: Part I - Effective opioid use across clinical settings, a society of gynecologic oncology evidence-based review.

As the only oncologists that provide both medical and surgical oncologic care, gynecologic oncologists encounter an exceptionally broad range of indications for prescribing opioids, from management of acute post-operative pain to chronic cancer-related pain to end-of-life care. If we are to balance opioid efficacy, safety and accessibility for our patients, we must be intimately familiar with appropriate clinical use of opioids in a range of settings, and engage in the national conversation around opioid misuse and how associated regulations and legislation may impact us and our patients. This article examines the appropriate use of opioids across the range of clinical settings encountered in gynecologic oncology.

Opioid use in gynecologic oncology in the age of the opioid epidemic: Part II - Balancing safety & accessibility.

As the only oncologists that provide both medical and surgical care, gynecologic oncologists encounter an exceptionally broad range of indications for prescribing opioids in clinical situations ranging from management of acute post-operative pain to chronic cancer-related pain to end-of-life care. While opioids are essential to the practice of gynecologic oncology, they can also have significant side effects and can be misused. Due to the explosive growth of opioid prescriptions and opioid-related overdoses and deaths during the first decade of the 21st century, there has been a recent concerted public health effort to prevent and treat opioid misuse through both legislation and education [1]. The first article in this two part series focused on appropriate use of opioids across clinical settings. This article addresses both the clinical and regulatory aspects of balancing opioid safety and accessibility for patients with gynecologic cancer.

Prospective screening with the validated Opioid Risk Tool demonstrates gynecologic oncology patients are at low risk for opioid misuse.

OBJECTIVE: To characterize risk for opioid misuse among gynecologic oncology patients. METHODS: The Opioid Risk Tool (ORT), a validated screen for opioid misuse risk, was administered to a convenience sample of patients with gynecologic cancer receiving opioid prescriptions in gynecologic oncology or palliative care clinics from January 2012-June 2016. Demographic and clinical information was abstracted on chart review. The primary outcome was ORT risk level (low vs. moderate or high). Chi-square tests were performed for categorical variables. RESULTS: A total of 118 women were screened. Most women were Caucasian (79%) with a median age of 57years. Ovarian cancer patients comprised 46% of the cohort with fewer endometrial (25%), cervical (23%), vulvar (4%), and vaginal (2%) cancer patients. The median ORT score was 1.0 (range, 0-10) out of a possible 26. Overall, 87% of patients were categorized as low-risk for opioid misuse, 7% as moderate-risk, and 6% as high-risk. Patients who were at moderate or high-risk of opioid misuse were significantly younger (47 vs. 58years, p=0.02), more likely to have cervical cancer (p=0.02), be smokers (p=0.01) and be uninsured or on Medicare (p=0.03). CONCLUSIONS: Most gynecologic oncology patients in our cohort were low-risk for opioid misuse (87%). Cervical cancer patients were more likely to be moderate to high-risk for misuse. Future screening efforts for opioid misuse may have the highest utility in this subset of patients.

Gynecologic Oncologist Views Influencing Referral to Outpatient Specialty Palliative Care.

OBJECTIVE: Early specialty palliative care is underused for patients with advanced gynecologic malignancies. We sought to understand how gynecologic oncologists' views influence outpatient specialty palliative care referral to help inform strategies for improvement. METHODS/MATERIALS: We conducted a qualitative interview study at 6 National Cancer Institute-designated cancer centers with well-established outpatient palliative care services. Between September 2015 and March 2016, 34 gynecologic oncologists participated in semistructured telephone interviews focused on attitudes, experiences, and preferences related to outpatient specialty palliative care. A multidisciplinary team analyzed transcripts using constant comparative methods to inductively develop a coding framework. Through an iterative, analytic process, codes were classified, grouped, and refined into themes. RESULTS: Mean (SD) participant age was 47 (10) years. Mean (SD) interview length was 25 (7) minutes. Three main themes emerged regarding how gynecologic oncologists view outpatient specialty palliative care: (1) long-term relationships with patients is a unique and defining aspect of gynecologic oncology that influences referral, (2) gynecologic oncologists value palliative care clinicians' communication skills and third-party perspective to increase prognostic awareness and help negotiate differences between patient preferences and physician recommendation, and (3) gynecologic oncologists prefer specialty palliative care services embedded within gynecologic oncology clinics. CONCLUSIONS: Gynecologic oncologists value longitudinal relationships with patients and use specialty palliative care to negotiate conflict surrounding prognostic awareness or the treatment plan. Embedding specialty palliative care within gynecologic oncology clinics may promote communication between clinicians and facilitate gynecologic oncologist involvement throughout the illness course.

Symptom management in women with recurrent ovarian cancer: Do patients and clinicians agree on what symptoms are most important?

OBJECTIVE: We sought to compare symptoms identified as a priority by patients with recurrent ovarian cancer to symptoms most frequently documented by their clinicians, and examine the association between clinician documentation of symptoms and subsequent clinical intervention. METHODS: Single-institution, retrospective chart review of patients enrolled in WRITE Symptoms Study (GOG 259), a randomized controlled trial of internet-based recurrent ovarian cancer symptom management. As part of the trial, women completed the Symptom Representation Questionnaire for 28 symptoms and selected 3 priority symptoms (PS). We compared patient-reported PS to clinician documentation of symptoms and interventions over the time period corresponding to study enrollment. RESULTS: At least one PS was documented in 92% of patients. Of 150 PS reported by patients, 53% were never documented by clinicians; these symptoms tended to be less directly related to disease or treatment status. Symptoms not identified by patients as PS were frequently documented by clinicians; these symptoms tended to relate to physiologic effects of disease and treatment toxicity. 58% of patients had at least one PS intervention. PS intervened for were documented at 2.58 visits vs 0.50 visits for PS not receiving intervention (p≤0.0001). CONCLUSIONS: Discordance was identified between symptoms reported by patients as important and symptoms documented by clinicians. Symptoms more frequently documented were also more frequently intervened for. Our study illustrates the need to improve identification of symptoms important to patients, and suggests that improving communication between patients and clinicians could increase intervention rates to enhance quality of life in women with recurrent ovarian cancer.

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.

Needs assessment of palliative care education in gynecologic oncology fellowship: we're not teaching what we think is most important.

OBJECTIVES: We sought to characterize gynecologic oncology fellowship directors' perspectives on (1) inclusion of palliative care (PC) topics in current fellowship curricula, (2) relative importance of PC topics and (3) interest in new PC curricular materials. METHODS: An electronic survey was distributed to fellowship directors, assessing current teaching of 16 PC topics meeting ABOG/ASCO objectives, relative importance of PC topics and interest in new PC curricular materials. Descriptive and correlative statistics were used. RESULTS: Response rate was 63% (29/46). 100% of programs had coverage of some PC topic in didactics in the past year and 48% (14/29) have either a required or elective PC rotation. Only 14% (4/29) have a written PC curriculum. Rates of explicit teaching of PC topics ranged from 36% (fatigue) to 93% (nausea). Four of the top five most important PC topics for fellowship education were communication topics. There was no correlation between topics most frequently taught and those considered most important (rs=0.11, p=0.69). All fellowship directors would consider using new PC curricular materials. Educational modalities of greatest interest include example teaching cases and PowerPoint slides. CONCLUSIONS: Gynecologic oncology fellowship directors prioritize communication topics as the most important PC topics for fellows to learn. There is no correlation between which PC topics are currently being taught and which are considered most important. Interest in new PC curricular materials is high, representing an opportunity for curricular development and dissemination. Future efforts should address identification of optimal methods for teaching communication to gynecologic oncology fellows.