Dilemmas and Strategy When Companion Participation During Appointments Differs from Patient and Companion Expectations.

Cancer patients often attend medical interactions with at least one companion. The degree to which companions participate varies, ranging from passive observer to active advocate. However, the structure of the medical interaction often promotes dyadic rather than triadic communication, creating ambiguity about to the degree to which companions can and should participate. Participants (N = 34, 16 dyads) included gynecologic cancer patients who were undergoing chemotherapy treatment (n = 18) and their companions (n = 16); all participants were separately interviewed. Interviews included discussion of dyadic communication patterns within medical interactions. The normative rhetorical theory (Goldsmith, 2019) was applied as a guiding framework. Patients discussed the dilemma they experience when companions are expected but absent. Patients and companions provided positive reports of companion communication when behavior aligned with expectations. Alternatively, patients and companions experience dilemmas when companions participate more than or differently from how patients and/or companions had expected. Companions provided one strategy for managing the dilemma of how to participate in medical interactions. Implications and limitations are discussed.

The Influence of Perceived Provider Empathic Communication on Disclosure Decision-Making.

Provider empathy is a crucial component in establishing therapeutic provider-patient relationships. The benefits of increased perceptions of empathy can support patient psychological adjustment to their cancer as well as patients' comfort and confidence in disclosing to providers, ultimately promoting patient engagement. Guided by the disclosure decision-making model, this manuscript explores how perceptions of empathy influence patient psychological adjustment and how those variables influence patient disclosure efficacy. The model ultimately predicts patient sharing and withholding of information during the medical interaction. This study tested a mediation model to investigate how current (n = 111) and former (n = 174) breast cancer patients' psychological adjustment mediates the relationship between patient perceptions of oncologist empathic communication and efficacy to disclose health information to their oncologist and their disclosure enactment in sharing and withholding. Overall, former patients compared to current patients had more positive perceptions of their oncologist's empathic communication, had better psychological adjustment, felt more self-efficacy to disclose to their oncologist, and shared more and withheld less information from their oncologist (p < .05 in all cases). Structural equation modeling revealed good fit to the data for both current and former patients such that more perceived empathic communication was associated with more efficacy for disclosure, which was associated with more sharing and less withholding. Additionally, there was an indirect relationship from perceptions of empathic communication to disclosure efficacy through patients' psychological adjustment to the diagnosis. Results reinforce the importance of providers' empathic communication for cancer patients' psychological adjustment because patient sharing and withholding of information remain crucially important to achieving holistic care across the cancer trajectory.

Neoadjuvant Chemotherapy in Ovarian Cancer: Are There Racial Disparities in Use and Survival?

BACKGROUND: We investigated racial and ethnic disparities in treatment sequence [i.e., neoadjuvant chemotherapy (NACT) plus interval debulking surgery (IDS) versus primary debulking surgery (PDS) plus adjuvant chemotherapy] among patients with ovarian cancer and its contribution to disparities in mortality. METHODS: Study included 37,566 women ages ≥18 years, diagnosed with stage III/IV ovarian cancer from the National Cancer Database (2004-2017). Logistic regression was used to compute ORs and 95% confidence intervals (CI) for racial and ethnic disparities in treatment sequence. Cox proportional hazards regression was used to estimate HRs and 95% CI for racial and ethnic disparities in all-cause mortality. RESULTS: Non-Hispanic Black (NHB) and Asian women were more likely to receive NACT plus IDS relative to PDS plus adjuvant chemotherapy than non-Hispanic White (NHW) women (OR: 1.12; 95% CI: 1.02-1.22 and OR: 1.12; 95% CI: 0.99-1.28, respectively). Compared with NHW women, NHB women had increased hazard of all-cause mortality (HR: 1.14; 95% CI: 1.09-1.20), whereas Asian and Hispanic women had a lower hazard of all-cause mortality (HR: 0.81; 95% CI: 0.74-0.88 and HR: 0.83; 95% CI: 0.77-0.88, respectively), which did not change after accounting for treatment sequence. CONCLUSIONS: NHB women were more likely to receive NACT plus IDS and experience a higher all-cause mortality rates than NHW women. IMPACT: Differences in treatment sequence did not explain racial disparities in all-cause mortality. Further evaluation of racial and ethnic differences in treatment and survival in a cohort of patients with detailed treatment information is warranted.

Community-based outpatient cancer rehabilitation services for women with gynecologic cancer: acceptability and impact on patient-reported outcomes.

OBJECTIVE: Women with gynecologic cancers often experience functional impairments impacting quality of life. Physical and occupational therapy (PT/OT) treat functional impairment; however, the acceptability and impact of these services for women with gynecologic cancer are unknown. METHODS: We reviewed rehabilitation charts of women with gynecologic cancer who received PT/OT (i.e., patients) in 2019 and completed patient-reported outcome measures (PROMs) selected by their therapist at intake (pre) and discharge (post). We calculated descriptive statistics for patient, rehabilitation, and acceptability (0-10) data. For PROM data, we used paired samples t-tests to evaluate pre-post change, and then calculated effect size (Hedge's g) and the proportion who achieved a minimal detectable change (MDC). RESULTS: PT/OT patients (N = 84) were 64.63 ± 11.04 years old with predominant diagnoses of ovarian (41.7%) or endometrial (32.1%) cancer. They attended a median of 13 sessions (IQR = 8.0-19.0). Sessions were predominantly PT (86%) vs. OT (14%). Median acceptability was 10 (IQR = 9.8-10.0). Pre-post improvement was observed for each of the 17 PROMs used by therapists. Significant improvement (p < .05) was observed for four PROMs: the Patient-Specific Functional Scale (M∆ = 2.93 ± 2.31, g = 1.47, 71% achieved MDC), the Lower Extremity Functional Scale (M∆ = 12.88 ± 12.31, g = 0.61, 60% achieved MDC), the Lymphedema Life Impact Scale (M∆ = 20.50 ± 20.61, g = 1.18, 58% achieved MDC), and the Modified Fatigue Impact Scale (M∆ = 6.55 ± 9.69, g = 0.33, 7% achieved MDC). CONCLUSION: PT/OT was acceptable and improved patient-reported outcomes for women with gynecologic cancers. Future research is needed to establish gynecologic-specific guidelines for referral and PT/OT practice.

Aligned and Divergent Perceptions of Support Persons' Role in Triadic Gynecologic Cancer Communication.

Health care providers routinely advise cancer patients to involve support persons in oncology care to fulfill critical support roles. This qualitative descriptive study explored alignment of triadic perceptions of support person involvement in oncology treatment visits and cancer-related care from the perspectives of patients with gynecologic cancer (n = 18), regular visit-attending support people (n = 16), and health care providers (n = 10), including oncologists, nurses, and medical assistants. Semi-structured interviews (N = 44) captured perceptions of facilitation and interference of support persons' roles within and outside appointments with oncology providers. Thematic analyses revealed alignment and divergence regarding support persons' instrumental, informational, and emotional support behaviors. Perspectives aligned regarding what support functions companions provide. However, patients and support persons emphasized the significance of instrumental followed by informational and emotional support, whereas oncology providers highlighted informational, followed by emotional and instrumental support. Discussion provides insight into each role's perspective in the triad.

"We Cannot Have any Negativity": A secondary analysis of expectancies for the experience of emotion among women with gynecologic cancer.

This study aimed to elucidate whether gynecologic cancer patients and their support persons have certain expectancies for emotion and whether these expectancies, if they exist, affect cancer-related communication. Semi-structured interviews (N = 34) were conducted separately with 18 patients and one of their support persons (n = 16). Thematic analysis revealed a subset of patients and support persons expected patients to not have any negative emotions, which patients also reported they perceived from support persons, and that these expectancies could affect cancer-related communication. These results have implications and can facilitate appropriate recommendations for how cancer patients and support persons co-manage patients' emotions.

Phase II study of atezolizumab in combination with bevacizumab in patients with advanced cervical cancer.

BACKGROUND: There are limited treatment options for patients with metastatic or recurrent cervical cancer. Platinum-based chemotherapy plus the anti-vascular endothelial growth factor antibody bevacizumab remains the mainstay of advanced treatment. Pembrolizumab is Food and Drug Agency approved for programmed death ligand 1 (PD-L1) positive cervical cancer with a modest response rate. This is the first study to report the efficacy and safety of the PD-L1 antibody atezolizumab in combination with bevacizumab in advanced cervical cancer. METHODS: We report the results from a phase II, open-label, multicenter study (NCT02921269). Patients with advanced cervical cancer were treated with bevacizumab 15 mg/kg intravenous every 3 weeks and atezolizumab 1200 mg intravenous every 3 weeks. The primary objective was to measure the objective response rate (ORR). Secondary endpoints included disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and safety. RESULTS: In the total evaluable population (n=10), zero patients achieved an objective response as assessed by Response Evaluation Criteria In Solid Tumors (RECIST) V.1.1, resulting in a confirmed ORR of 0%. Of note, there were two patients who achieved an unconfirmed PR. The DCR by RECIST V.1.1 was 60% (0% complete response, 0% partial response, 60% stable disease). Median PFS was 2.9 months (95% CI, 1.8 to 6) and median OS was 8.9 months (95% CI, 3.4 to 21.9). Safety results were generally consistent with the known safety profile of both drugs, notably with two high-grade neurologic events. CONCLUSIONS: The combination of bevacizumab and atezolizumab did not meet the predefined efficacy endpoint, as addition of bevacizumab to PD-L1 blockade did not appear to enhance the ORR in cervical cancer.

Gynecologic cancer screening in the transgender male population and its current challenges.

As the transgender community gains visibility and recognition, healthcare disparities have become more apparent. Reports estimate that 1-1.5 million people belong to this community in the United States. Despite efforts to become more inclusive, access to healthcare is challenging in a system built on a binary model that exacerbates gender dysphoria and on healthcare insurance schemes that do not cover gender affirmation therapy. Another large challenge is the paucity of scientific and medical knowledge when it comes to caring for the transgender community. More research to build knowledge is necessary to provide evidence-based quality care. In an attempt to bring guidance for gynecologic and breast cancer screening for the transgender male population, we conducted a review of the literature published in PubMed. Here, we present a review of the challenges, as well as guidelines for breast, uterus, and cervix screening for the transgender male population.

Morbidity and Mortality Risk Assessment in Gynecologic Oncology Surgery Using the American College of Surgeons National Surgical Quality Improvement Program Database.

INTRODUCTION: Gynecologic oncology patients represent a distinct patient population with a variety of surgical risks. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database provides an opportunity to analyze large cohorts of patients over extended periods with high accuracy. Our goal was to develop a postoperative risk assessment calculator capable of providing a standardized, objective means of preoperatively identifying high-risk patients in the gynecologic oncology population. METHODS: We queried the ACS NSQIP database for gynecologic oncology patients from 2005 to 2013. Multivariate logistic regression was performed to generate predictive models specific for 30-day postoperative mortality and major morbidity. RESULTS: There were 12,831 patients with a primary gynecologic malignancy identified: 7847 uterine, 3366 adnexal, 1051 cervical, and 567 perineum cancers. In this cohort, 125 (0.97%) patients died, and 784 (6.11%) major morbidity events were recorded within 30 days of their surgery. For 30-day mortality, the mean calculated predictive probability was 0.128 (SD, 0.219) compared with 0.009 (SD, 0.027) in patients alive 30 days postoperatively (P < 0.0001). The mean predictive probability of major morbidity was 0.097 (SD, 0.095) compared with 0.059 (SD, 0.043) in patients who did not experience major morbidity 30 days postoperatively (P < 0.0001). CONCLUSIONS: Using NSQIP data, these predictive models will help to determine patients at risk for 30-day mortality and major morbidity. Further clinical validation of these models is required.

Practice Patterns, Attitudes, and Barriers to Palliative Care Consultation by Gynecologic Oncologists.

PURPOSE: We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists. METHODS: Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions. RESULTS: Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary team's responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care. CONCLUSION: The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a significant barrier to palliative care consult.

Port Site Metastases: A Survey of the Society of Gynecologic Oncology and Commentary on the Clinical Workup and Management of Port Site Metastases.

STUDY OBJECTIVE: Laparoscopic port site metastases (PSMs) have an incidence of .5% to 2%. The management of an isolated PSM (iPSM), without evidence of recurrence elsewhere, remains unclear. The aim of this study was to elucidate practices regarding iPSMs. DESIGN: A 23-item survey was created using commercially available survey software. Over the course of January 2016 the survey was e-mailed to the members of the Society of Gynecologic Oncology with 2 follow-up reminder e-mails. (Canadian Task Force classification III.) SETTING: Online survey. MEASUREMENTS AND MAIN RESULTS: Of the 709 surveys sent, 132 were returned. Providers practicing for <5 years saw fewer PSMs and those who performed more minimally invasive surgeries (MISs) saw more PSMs. Comparing providers who have or have not seen PSMs, no differences in pneumoinsufflation pressure, the mode of delivery of the specimen, the use of local anesthesia at port site incisions, or the method of deflation were seen. If an iPSM was suspected, most providers indicated they would obtain imaging (computed tomography, 51%, or positron emission tomography/computed tomography, 43%) followed by an interventional radiology-guided biopsy (29%) or resection of the mass. Tendency for treatment is to surgically resect the lesion followed by adjuvant therapy. CONCLUSION: After controlling for time in practice, we did not find a strong risk factor for iPSMs other than performing >75% of oncologic surgeries by MIS. Most respondents performed imaging when suspecting iPSMs and use systemic adjuvant therapy after confirming iPSMs.

Distinct molecular landscapes between endometrioid and nonendometrioid uterine carcinomas.

Endometrial carcinoma (EC) is traditionally characterized as endometrioid and nonendometrioid based on histopathologic phenotypes. Molecular-based classifications have been proposed, but are not widely implemented. Herein we examine molecular profiles between EC histologic subtypes. 3133 ECs were submitted between March 2011 and July 2014: 1634 Type I and 1226 Type II. In situ hybridization and immunohistochemistry were used to assess copy number and protein expression of selected genes. Sequenced variants in 47 genes were analyzed using the Illumina TruSeq Amplicon Cancer Panel. Type II EC included 628 cases of uterine serous cancer (USC), 136 cases of clear cell (CC), 361 cases of carcinosarcoma (CS), 38 cases of mucinous, and 36 cases of squamous cell. PI3K/Akt/mTOR pathway was most frequently dysregulated within Type I and mucinous histologies, least altered in CS and squamous. PD-L1 expression was highest in mucinous, absent in squamous. ER/PR expression was common in Type II, most frequent in USC, mucinous, and squamous. Receptor tyrosine kinase was frequently dysregulated in Type II disease: HER2 amplification highest in USC and CC, EGFR mutations exclusively seen in mucinous EC, KRAS mutations common in mucinous, squamous, and Type I, and c-MET overexpression high in CC and mucinous. BRCA1 and BRCA2 were most frequently mutated in CS. Grade 3 EC shares features of G1 tumor and Type II disease, most notably resembling CS. Endometrial carcinomas are a molecularly heterogeneous group of tumors. A histology-based molecular map can identify rational targets to optimize treatment and guide future clinical trials.

Feasibility and Learning Curve of Robotic Laparoendoscopic Single-Site Surgery in Gynecology.

Single-site laparoscopy has proven to be a desirable option for patients undergoing gynecologic surgery, with some studies indicating improved cosmesis and less perioperative pain compared with standard approaches. This study describes the safety and feasibility of a novel robotic laparoendoscopic single-site surgery (R-LESS) platform as it is incorporated into a surgeon's practice with extensive multiport robotic surgical experience but limited LESS experience. We reviewed 83 women undergoing R-LESS by a single surgeon from September 2013 through August 2015. Operative times (total operative time, console time, docking time) were collected prospectively for the first 53 cases, and total operative time was collected retrospectively for the next 30 cases. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, conversion to laparotomy, procedure type, uterine weight, length of hospital stay, and complications, were retrospectively collected from medical charts. Eighty-two of 83 surgeries were completed successfully with a single incision. One surgery was converted to multiport robotics for para-aortic lymph node dissection. Twelve surgeries were performed for cancer (ovary 1, uterus 8, and cervix 3). Eight patients underwent pelvic lymph node biopsy. The median total operative time for hysterectomies was 128 minutes (range, 60-275). After the first 13 hysterectomies the total operative time and the console time decreased significantly from 165.3 to 131.1 minutes (p = .032) and from 84.9 to 57.1 minutes (p = .028), respectively. Mean docking time halved from 7.8 minutes to 3.4 minutes comparing the first 10 cases to the last 10 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. The mean uterine weight was 164 g (range, 30-460). Complications included 2 umbilical hernias (2.4%) and 1 conversion to multiport. In conclusion, R-LESS is a feasible and safe surgical platform for gynecologic procedures. A small number of cases are needed to significantly improve operative times when it is introduced on a surgeon's practice with limited experience in LESS but familiar with robotic surgery. Further study is needed to investigate the cost, benefits, and long-term outcomes of R-LESS.