Quality corner: Safely using cephalosporins in almost all patients with penicillin allergies: Mini-review and suggested protocol to improve efficacy and surgical outcomes.

Surgical site infections (SSI) are one of the most common gynecologic oncology postoperative complications and they have a significant deleterious impact on the healthcare system and in patients' outcomes. Cefazolin is the recommended antibiotic in women undergoing gynecologic surgical procedures that require that require prophylaxis. However, 10-20% of patients may report a penicillin allergy which can result in administration of a less effective antibiotic. This quality review evaluated the literature around this common perioperative issue and demonstrated that healthcare teams should consider the implementation of a protocol to safely use cefazolin in most patients with a penicillin allergy. Overall, literature shows this is a safe adjustment and would improve antimicrobial stewardship, decrease SSI rates, avoid acute kidney injury, and increase cost savings.

Impact of steroid use and glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy.

Objective: We aimed to assess the impact of preoperative steroid administration and perioperative glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy. Methods: This retrospective cohort study included gynecologic oncology patients with Type I and Type II diabetes (DM) undergoing laparotomy for any gynecologic indication at a single academic center from 10/2017 to 09/2020. The primary outcome was the rate of postoperative complications. Preoperative steroid administration and 24-hour postoperative average serum blood glucose (BG) ≥ 180 mg/dL were the studied exposures. Data was analyzed with SPSS Statistics v.28. Results: 225 patients met inclusion criteria; 47.6 % had postoperative complications. Patient demographics were similar between patients with and without postoperative complications. Patients with complications had higher BMIs (36.8 vs. 34.0; p = 0.03), bowel surgery (33.0 % vs. 17.1 %; p = 0.008), operative time ≥ 240 min (14.2 % vs. 5.1 %; p = 0.02) and average BG ≥ 180 (63.6 % vs. 40.2 %; p < 0.01). On multivariate analysis, bowel surgery (OR 2.4 (1.2-4.8); p = 0.01) and average BG ≥ 180 (OR 2.8 (1.6-4.9); p < 0.01) remained significant predictors of postoperative complications. There were no differences in complication rates (42.3 % vs. 42.6 %; p = 1.0) between patients who received preoperative steroids and those who did not. When stratified by average postoperative BG < 180 mg/dL vs. BG ≥ 180 mg/dL, there was no difference in Clavien-Dindo classification, 30-day readmission rate (28.2 % vs. 22.1 %; p = 0.49) or 30-day mortality rate (2.9 % vs. 0.0 %; p = 0.53). Conclusion: The administration of preoperative steroids did not increase complication rates. Perioperative hyperglycemia was associated with an increased risk of postoperative complications. Optimizing perioperative glycemic control is imperative to decrease postoperative complications.

New Paradigms in the Treatment of Cervical Cancer.

Despite effective screening strategies and the development and implementation of prophylactic high-risk human papillomavirus vaccination, cervical cancer remains a significant public health burden. This burden is most pronounced in under-resourced countries without fully developed screening and vaccination programs, although the disease remains present worldwide, including in industrialized countries. To that end, the World Health Organization (WHO) has an active focus on the elimination of cervical cancer, with objective metrics to be achieved by countries by the year 2030. Although increased vaccination and screening will be needed to approach potential eradication of cervical cancer, as recognized by the WHO initiative, treatment will need to continue to not only be effective in the near term, but to improve outcomes as well. Accordingly, assessments to improve primary treatment options, including surgery for women with early-stage disease, modification of chemoradiation for those with locally advanced cervical cancer, and systemic therapy for those with recurrent or metastatic presentations, are ongoing. Accordingly, we highlight important areas of both recent and ongoing focus as they relate to improving cervical cancer outcomes.

Use of a mobile health patient engagement technology improves perioperative outcomes in gynecologic oncology patients.

OBJECTIVE: To evaluate the impact of a mobile health patient engagement technology (PET) on postoperative outcomes in gynecologic oncology patients. METHODS: All gynecologic oncology patients undergoing laparotomy on an enhanced recovery program (ERP) were approached from July 2019 to May 2021 to enroll in a PET, which can be accessed by computer, tablet, or smart phone. This platform provides enhanced pre- and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbidities and were asked to complete daily health checks during the postoperative period. Participants in the PET were compared to patients who opted out as well as to a historical cohort from prior to PET implementation. Patient and procedure-level factors were recorded. The primary outcomes were length of stay (LOS) and 30-day readmission rate. Analysis was performed using SPSS v.26. RESULTS: 682 women met inclusion criteria during the study time; 347 in the PET group and 335 in the control group. Demographic and other factors including race, BMI (kg/m2), Charlson Comorbidity Index (CCI), surgical complexity, and insurance status were not different between the PET and control group; however, patients in the PET cohort were slightly younger (55.0 yo vs. 57.2 yo; p = 0.04). Patients in the PET group had a significantly shorter LOS (2.9 days vs. 3.6 days; p < 0.01) and lower readmission rate (4.3% vs. 8.6%; p < 0.01) when compared with the control group. CONCLUSIONS: Use of a PET in our gynecologic oncology patients decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors other than age. Furthermore, there was a 50% reduction in readmission rates in the PET group. The use of a PET allows for healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care.

An Update on Human Papillomavirus Vaccination in the United States.

Cervical cancer remains a significant disease in the United States. Although the human papillomavirus (HPV) vaccine has been approved for those aged 9-26 years and for some individuals up to age 45 years, there are many circumstances in which health care professionals may not know whether the vaccine should be recommended, such as for patients with previous infection, health care workers, and those older than age 26 years. This article highlights the evidence that the HPV vaccine is a safe and highly effective way to prevent cervical cancer, with the strongest predictor of vaccine uptake being practitioner recommendation.

Increased disparities associated with black women and abnormal cervical cancer screening follow-up.

Background: To determine whether race and ethnicity impacts patient adherence to follow-up for colposcopy after abnormal cervical cancer screening. Methods: This retrospective chart review included women that were randomly selected from patients presenting to our colposcopy clinic from 1/2019 to 12/2019. Inclusion criteria were females age ≥21 years-old and appropriate referral for colposcopy. Patients were grouped into three categories: (1) ADHERENT to follow-up if they came to their first scheduled appointment; (2) DELAYED if they presented more than three months from their original referral (usually missing 1-3 appointments); and (3) NOT ADHERENT if they did not show for their appointment after referral. Analysis was performed using SPSS v.26. Results: 284 women met inclusion criteria for the study. The majority of women were Black (65.2 %) followed by non-Hispanic Whites (20.0 %) and Latinx (14.8 %). Overall, 39.1 % were ADHERENT, 18.6 % were DELAYED, and 42.3 % were NOT ADHERENT. When compared with non-Hispanic White women, there was a significant difference between race/ethnicity and timing of follow-up (p = 0.03). Blacks were more likely to be NOT ADHERENT (45.9 %; p = 0.03), and Latinx and Blacks were the most likely to be DELAYED (35.7 % and 21.1 %; p = 0.03). Private insurance patients were more likely to be ADHERENT for care compared with un-/underinsured patients (78.9 vs 27.8 %, p = 0.0001). Conclusion: There is inadequate follow-up after abnormal cervical cancer screening across all races/ethnicities; however, lack of adherence is higher in Black patients. Moreover, 25% of Hispanic and Black women present in a delayed fashion. Culturally relevant assessments and interventions are needed to understand and address these gaps.

The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes.

OBJECTIVE: The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy. METHODS: This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used. RESULTS: We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5). CONCLUSION: This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

Piloting use of an out-of-pocket cost tracker among gynecologic cancer patients.

Objective: Our objective was to evaluate uptake and satisfaction with an out-of-pocket (OOP) cost tracker as a means for cancer patients to manage their personalized costs of care and to identify characteristics associated with usage. Methods: Within a longitudinal survey evaluating financial toxicity among gynecologic cancer patients on active systemic therapy over a 6-month period, we provided paper worksheets for participants to voluntarily track expenses. We assessed usage and satisfaction at 3 and 6 months using frequency and percentage. We used Fisher's exact test and Wilcoxon rank sum analysis to evaluate patient characteristics based upon usage. Participants were encouraged to submit their completed cost tracker worksheets. Results: Fifty-three of 121 (44%) participants reported ever using the OOP cost tracker. Most users reported it was easy to use (97%, 100%) and helpful (86%, 72%); however, fewer users rated it as useful for budgeting (42%, 26%) at 3 and 6 months, respectively. More patients who knew their insurance premium were users compared to non-users (74.4% vs. 54.4%, p = 0.04). Among thirteen users who submitted their completed cost tracker worksheets, non-medical costs (i.e., transportation) had the highest monthly out of pocket costs (mean $213, range $0-587). User feedback included suggestions to enhance the cost tracker with educational tutorials or a reminder system. Conclusions: Future studies should explore if cost tracker uptake and satisfaction are enhanced with the addition of reminders and whether usage decreases financial toxicity or increases patient self-efficacy in managing the costs of cancer care.

Barriers and facilitators affecting presentation in women with early versus advanced stage cervical cancer.

Background: This study was performed to evaluate the barriers and facilitators associated with patient presentation for early stage (ES) versus advanced stage (AS) cervical cancer (CC). Methods: A mixed-method approach was used to collect quantitative (i.e., demographics and medical/screening histories) and qualitative data (individual interviews assessing patients' perceptions regarding their general health, HPV and CC screening, and barriers and facilitators to CC care). Two separate investigators coded the interviews for major themes that occurred with an agreement that 50% or more of the themes would be included. Results: Twenty-five women agreed to participate in the study with 80% completing the interview. Patients with ES disease were classified as Stage IA1-Stage IB3; patients with Stage IIA-IVB disease were classified with AS disease. Frequent barriers in the ES group were lack of knowledge, competing priorities, feeling healthy, lack of time or health insurance, and being embarrassed/uncomfortable. Frequent barriers in the AS group were lack of knowledge, competing priorities, avoidance/procrastination, fear of the healthcare system or finding something wrong, and lack of perceived risk to CC. Facilitators for ES included understanding the importance of the Pap test, having an abnormal Pap test, and knowing someone with CC. Having abnormal symptoms was the only facilitator for AS patients. Conclusions: Structural and intrapersonal barriers to CC care persist but differ between ES and AS patients. Multi-level interventions are needed to address the wide array of issues that women highlighted in this study including potential innovative methods to increase access to care and engagement with the healthcare system.

Misoprostol and estradiol to enhance visualization of the transformation zone during cervical cancer screening: An integrative review.

The purpose of this integrative literature review was to appraise studies conducted worldwide using misoprostol and estradiol in converting Type 3 transformation zone (TZ) of the cervix into Types 1 or 2 and to assess which regimen could be more feasible in low-and-middle-income countries (LMICs). We reviewed the English language literature for peer-reviewed studies that evaluated strategies to convert Type 3 TZs to Types 1 or 2 for cervical cancer screening. Web of Science and PubMed searches were performed up to July 2020. Search terms included: "cervical colposcopy," "inadequate colposcopy", "cervical cancer screening", "transformation zone," "estrogen", "estradiol", and "misoprostol." Inclusion criteria were articles published in the English language, original research, and peer reviewed articles. A total of 127 articles were abstracted, 24 articles were reviewed, and 9 articles met all inclusion criteria. We found that intravaginal misoprostol, intravaginal estradiol, and oral estradiol can successfully convert Type 3 TZ to Types 1 or 2. A single dose of vaginal misoprostol had a similar maximum response rate (20-80%) to a multi-dose regimen over several days or weeks of both intravaginal estradiol (64-83%) and oral estradiol (50-70%). Misoprostol administration was associated with more side effects such as abdominal cramping and vaginal bleeding compared to estradiol, although these were generally mild. In conclusion, Oral estradiol, intravaginal estradiol, and intravaginal misoprostol can be used to convert Type 3 TZ to Types 1 or 2. Intravaginal misoprostol is well tolerated and more feasible in LMICs due to availability and shorter treatment schedule compared to oral or intravaginal estradiol.

Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery.

OBJECTIVE: To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery. METHODS: This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26. RESULTS: Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again. CONCLUSION: Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education.

Pathology findings among women with alterations in uterine bleeding patterns in cameroon.

PURPOSE: Endometrial cancer is on the rise in high-income countries but it has not been adequately studied in low-and-middle income countries especially in sub-Saharan Africa (SSA), likely due to scarce pathology facilities. The purpose of this study was to characterize and quantify the prevalence of endometrial hyperplasia or cancer in a cohort of women with abnormal uterine bleeding (AUB) who underwent endometrial biopsy in Cameroon. METHODS: We designed a cross-sectional study using medical records to characterize women who underwent endometrial biopsy in the Cameroon Baptist Convention Health Services (CBCHS) from 2008 to 2019. Pathologic diagnoses were classified as either endometrial hyperplasia, endometrial cancer, or no endometrial hyperplasia/cancer. We reported the overall prevalence of endometrial hyperplasia or cancer. Bivariate analyses compared patient characteristics between women with endometrial cancer, endometrial hyperplasia, and neither. RESULTS: The average age was 46.2 years and women had an average of 5.1 parity. We found that, 61 [(36.7% of 166 women; 95% CI (27.6-47.0%)] had endometrial hyperplasia or cancer. There were no cases of hyperplasia with atypia and 13 women had endometrial cancer. The remainder were comprised of benign or infectious pathologic findings. In bivariate analysis, mean ages were statistically different among the three groups (hyperplasia, cancer, and no hyperplasia/cancer), p < 0.001, and women with cancer had the highest age. Parity was statistically significantly different among the three groups (p = 0.002) and women with endometrial cancer had higher parity. CONCLUSION: We found that just over 1 in 3 women with AUB who underwent endometrial biopsy at a health system in SSA were found to have pathologic findings of endometrial hyperplasia or cancer, with no cases of hyperplasia with atypia. Women with endometrial cancer had higher mean age and parity.

Measuring Financial Distress and Quality of Life Over Time in Patients With Gynecologic Cancer-Making the Case to Screen Early in the Treatment Course.

PURPOSE: Our objective was to measure the trajectory of financial distress and to determine its relationship with quality of life (QOL) among patients with cancer. MATERIALS AND METHODS: We conducted a longitudinal survey of patients with gynecologic cancer starting a new line of systemic therapy at baseline, 3 months, and 6 months. Financial distress was measured using a Comprehensive Score for Financial Toxicity (COST) < 26, and QOL was measured using Functional Assessment of Cancer Therapy-General (FACT-G) with lower scores indicating worse responses. One-way repeated analysis of variances, generalized estimating equation models, and correlation coefficients were used to evaluate financial distress and QOL over time. RESULTS: There were 90 of 121 (74%) baseline participants with a 6-month follow-up. The average age was 60 years, 29% were African-American, 57% had an annual income < $40,000 in US dollars, and 6% were uninsured. At baseline, 54% of patients screened positive for financial distress, which was unchanged at 3 months (50%, P = .27) but decreased at 6 months (46%, P = .04) compared with baseline. There was no change in average COST (23.6, 25.1, 25.6; P = .33) or FACT-G (70.8, 71.0, 72.8; P = .68) over time. Less financial distress was moderately correlated with better QOL (r = 0.63, 0.61, 0.60) at each time point. The presence of financial distress was associated with a 16-point decrease in FACT-G QOL score over time. CONCLUSION: Upfront screening with COST identified 90% of patients who experienced financial distress, and COST did not change significantly over time. More severe financial distress was moderately correlated with worse QOL, and its presence was associated with a clinically meaningful 16-point decrease in QOL.

Standing on the shoulders of giants: Mentorship advice from leaders in the field.

This commentary is presenting opinions and advice on mentorship in the field of gynecologic oncology. Eleven academic gynecologic oncologists from across the country were interviewed and their thoughts about mentorship were recorded with recurring themes and ideas described in this commentary. Trust, respect, and mutual agreement on expectations were all described as vital to a functioning mentor/mentee relationship. Mentorship is critical for fellows and junior faculty to expand and uphold the standards of the field.

Implementation and evaluation of a novel subspecialty society fellows robotic surgical course: the SGO minimally invasive academy surgical curriculum.

OBJECTIVE: To evaluate the utility of a society-based robotic surgery training program for fellows in gynecologic oncology. METHODS: All participants underwent a 2-day robotic surgery training course between 2015-2017. The course included interactive didactic sessions with video, dry labs, and robotic cadaver labs. The labs encompassed a wide range of subject matter including troubleshooting, instrument variation, radical hysterectomies, and lymph node dissections. Participants completed a pre- and post-course survey using a 5-point Likert scale ranging from "not confident" to "extremely confident" on various measures. Statistical analysis was performed using SPSS Statistics v. 24. RESULTS: The response rate was high with 86% of the 70 participants completing the survey. Sixteen (26.7%) of these individuals were attending physicians and 44 (73.3%) were fellows. In general, there was a significant increase in confidence in more complex procedures and concepts such as radical hysterectomy (p=0.01), lymph node dissection (p=0.01), troubleshooting (p=0.001), and managing complications (p=0.004). Faculty comfort and practice patterns were cited as the primary reason (58.9%) for limitations during robotic procedures followed secondarily by surgical resources (34.0%). CONCLUSION: In both gynecologic oncology fellows and attendings, this educational theory-based curriculum significantly improved confidence in the majority of procedures and concepts taught, emphasizing the value of hands-on skill labs.

An enhanced recovery protocol decreases complication rates in high-risk gynecologic oncology patients undergoing non-emergent laparotomy.

OBJECTIVE: Enhanced recovery protocols are now established as the standard of care leading to improved perioperative outcomes and associated cost-benefits. The objective of this study was to evaluate the impact of an enhanced recovery program on complication rates in high-risk gynecologic oncology patients undergoing surgery. METHODS: This retrospective cohort study included gynecologic oncology patients with pathology-proven malignancy undergoing non-emergent laparotomy from October 2016 to December 2018 managed on an enhanced recovery protocol, and a control group from October 2015 through September 2016 prior to enhanced recovery protocol implementation. The primary outcome was complication rates in a high-risk population pre- and post-enhanced recovery protocol. High-risk patients were defined as those with obesity (body mass index >30 kg/m2) and/or age ≥65 years. Analysis was performed using Statistical Package for Social Sciences (SPSS) v.24. RESULTS: A total of 363 patients met the inclusion criteria: 104 in the control group and 259 in the enhanced recovery protocol group. Patient demographics, including age, body mass index, diagnosis, and performance status, were similar. Overall complication rates were less in the enhanced recovery protocol group (29% vs 53.8%; p<0.0001). The enhanced recovery protocol group had a shorter length-of-stay compared with control (3.3 vs 4.2 days; p<0.0001). The 30-day readmission rates were similar between the groups (9.6% vs 13.5%; p=0.19). In the enhanced recovery protocol group compared with control, complication rates were less in obese patients (29.4% vs 57.8%; p<0.0001), morbidly obese patients (20.9% vs 76.2%; p<0.0001), and age ≥65 (36.1% vs 57.1%; p<0.0001). The most common complications in the enhanced recovery protocol group were ileus (9.7%), pulmonary complications (2.7%), and blood transfusions (10.8%). CONCLUSIONS: Implementation of an enhanced recovery protocol decreases complication rates and length-of-stay in morbidly obese and geriatric patients with gynecologic malignancy without an increase in readmission rates.

Beyond words: Parental perceptions on human papilloma virus vaccination recommendations and its impact on uptake.

The goal was to evaluate how provider recommendations regarding Human Papillomavirus (HPV) vaccination impact uptake in a rural setting. The study used a cross-sectional, population-based design with cluster sampling to survey parents/guardians of children ages 9 to 18 in 2019 in Alabama. In addition to demographics/knowledge questions, participants were asked about type of healthcare provider recommendation and impressions they had from this interaction. The primary outcome variable was the result of the healthcare provider recommendation with options including: child got vaccinated day of recommendation, HPV vaccination was scheduled, or HPV vaccination was not scheduled. Bivariate analysis and multinomial logistic regression were performed. Of the 358 respondents, approximately 40% indicated receiving a recommendation from a provider to vaccinate their child. Age of the parent, race/ethnicity, educational attainment, and health insurance coverage were similar across groups. Female parents were more likely to report receiving HPV vaccination recommendation than males (44.1% vs. 23.3%; p = 0.009). The type of provider recommendation was not significantly associated with HPV vaccination uptake. The impression from the recommendation of HPV vaccination being "important" was significantly associated with the child being vaccinated that day (OR = 7.31, 95% CI = 2.20-24.3) as well as scheduling HPV vaccination (OR = 3.17, 95% CI 1.01-9.92). Parents who got the impression that "there was no hurry" were less likely to vaccinate their child that day (OR = 0.23, 95% CI = 0.09-0.59). Provider recommedation is well-established as a significant predictor of HPV vaccination, these findings indicate that how the recommendation is perceived may play a more important role in HPV vaccination uptake.

Decreasing opioid use in postoperative gynecologic oncology patients through a restrictive opioid prescribing algorithm.

OBJECTIVE: The objective of this study was to evaluate the impact of a post-surgical restrictive opioid prescribing algorithm (ROPA) in gynecologic oncology patients. METHODS: This cohort study included gynecologic oncology patients undergoing any surgical procedure from 08/2018-7/2019 after implementation of a ROPA. Patients were compared to historical controls managed without a ROPA from 10/2016-9/2017. Patients were educated preoperatively about pain management goals, the ROPA, and opioid disposal. A 4-tiered system was developed to standardize prescriptions at discharge based on surgical complexity and inpatient opioid requirements. Patients were surveyed at their postoperative visit to assess home opioid use and satisfaction. Statistical analysis was performed using SPSS Statistics v.24. RESULTS: 2549 patients met inclusion criteria; 1321 in the historical control group and 1228 in the ROPA group. Demographics, including age, BMI, and performance status were similar. Compared with the control group, the average number of opioid pills prescribed was significantly lower in the ROPA group (30.5 vs 11.3; p < 0.001) along with the morphine milligram equivalents (MME) (152.5 MME vs. 83.3 MME; p < 0.001). The percentage of patients requiring opioid refill within 30 days was similar (13.0% vs. 12.6%; p = 0.71). 95.7% of patients surveyed were satisfied with their pain regimen. The total number of pills prescribed annually decreased from 34,130 in the control group to 13,888 in the ROPA group. CONCLUSIONS: A restrictive prescribing practice allows for a significantly lower number of opioids to be prescribed to postoperative patients while maintaining patient satisfaction. There was no increase in opioid refill requests using a ROPA in patients undergoing surgery.

Extensive financial hardship among gynecologic cancer patients starting a new line of therapy.

OBJECTIVE: Our objective was to evaluate the three domains of financial hardship (psychological response, material conditions, and coping behaviors) among gynecologic cancer patients receiving treatment. METHODS: We conducted a single-institution survey of gynecologic cancer patients starting a new line of therapy for primary or recurrent disease. Psychological response was measured using Comprehensive Score for Financial Toxicity, with score < 26 indicating financial distress. We measured material conditions by patient-reported changes in employment or spending and coping behaviors by patient-reported medication non-adherence. We performed descriptive statistics, bivariate analysis, and multivariate logistic regression. RESULTS: Among 121 participants, the mean age was 59 years, 28% were African-American, 50% reported income < $40,000, 74% had private insurance, 20% had only public insurance, and 7% were uninsured. Sixty-five (54%) participants screened positive for financial distress. Age < 65 years (aOR 2.61, 95% CI 1.04-6.52) and income < $40,000 (aOR 3.41, 95% CI 1.28-9.09) were associated with increased odds of screening positive for financial distress. Participants with financial distress were significantly more likely to report material hardship, including losing wages (46% vs. 18%, p < 0.01), not paying bills on time (40% vs. 7%, p < 0.01), and borrowing money (39% vs. 4%, p < 0.01). Financial distress was not associated with coping behaviors, such as not taking (6% vs. 2%, p = 0.37) or refilling medications (5% vs. 2%, p = 0.62). CONCLUSIONS: Financial distress affects over half of gynecologic cancer patients starting a new line of treatment and is associated with material hardship. Younger age and lower income can be used to identify patients at increased risk.