Too Close for Comfort? Attitudes of Gynecologic Oncologists Toward Caring for Dying Patients.

PURPOSE: To assess gynecologic oncologists' attitudes relating to palliative care referrals among advanced cancer patients. METHODS: Gynecologic oncologists were surveyed using validated measures to assess stigmatizing attitudes toward palliative care, anticipated stigma of palliative care, acceptance of palliative care, and willingness to refer to palliative care. Descriptive statistics were calculated. Analysis was performed using linear regression. RESULTS: 1200 physicians received the survey and 108 (9%) completed it. Most were female (69.4%) and white (82.4%). Most practiced in academics (64.8%) in urban environments (71.3%). Respondents did not have anticipated stigma surrounding palliative care referral (mean score 1.89, range 1-7, higher score indicating more stigma), were accepting of palliative care (mean score 1.45, range 1-7, higher score indicating less acceptance), and were willing to refer patients to palliative care (mean score 5.75, range 1-7, higher score indicating more willingness to refer). Linear regression demonstrated females had less anticipated stigma surrounding palliative care (B = -.213, P = .04) and higher acceptance of palliative care (B = -.244, P = .01). Most surveyed derived satisfaction from work with advanced cancer patients (83%). Nineteen percent were depressed by managing advanced cancer patients. One fourth felt emotionally burned out by dealing with too many deaths. CONCLUSIONS: Most gynecologic oncologists did not exhibit stigma surrounding palliative care and derive satisfaction from their work. Some gynecologic oncologists experience depression and burnout related to their profession. This close connection with patients as they transition to the end of life may take a toll on providers.

Isolated subcutaneous recurrence of high-grade neuroendocrine tumor of the cervix.

•This case reports an isolated subcutaneous recurrence of neuroendocrine carcinoma of the cervix.•Multiple recurrences of NECC were treated surgically without additional systemic therapy.•There is a need for further studies to evaluate optimal treatment regimens for NECC.

Venous Thromboembolism Prediction in Postoperative Urogynecology Patients: The Utility of Risk Assessment Tools.

OBJECTIVES: The aim of the study was to evaluate the utility of risk assessment tools (Rogers and Caprini Score models) in predicting venous thromboembolism (VTE) in a urogynecology patient population. METHODS: All surgical patients underwent a procedure in the operating room with 1 of 7 female pelvic medicine and reconstructive surgery.Attendings from January 1 to December 31, 2015, were investigated. Rogers and Caprini Scores were calculated for each patient as well as the occurrence of any VTE in the 30 days after surgery. Patients were then grouped into risk categories based on the American College of Chest Physicians guidelines. RESULTS: A total of 783 patients were identified and included in this study. The average patient age was 58 years (range = 18-89 years). The average operative time was 109 minutes (range = 4-491 minutes). Most patients obtained a Rogers Score of 5 (32%) and a Caprini Score of 4 (34%). Based on Caprini scoring, the American College of Chest Physicians category distribution was as follows: 10% low risk, 61% moderate risk, and 29% high risk. Based on Rogers scoring, this distribution was as follows: 96.8% very low risk, 3.1% low risk, and 0.1% moderate risk. Two VTE events were identified in the cohort. Overall, the incidence of VTE was 0.26%. CONCLUSIONS: The standard VTE risk assessment tools grade urogynecology patients very differently. Although the Caprini Scale seems to appropriately differentiate individual patient VTE risk, the Rogers Scale does not adequately stratify this risk, thus potentially limiting its use within this population.

Features of the cervicovaginal microenvironment drive cancer biomarker signatures in patients across cervical carcinogenesis.

Persistent human papillomavirus (HPV) infection is the vital factor driving cervical carcinogenesis; however, other features of the local cervicovaginal microenvironment (CVM) may play a critical role in development of precancerous cervical dysplasia and progression to invasive cervical carcinoma (ICC). Here we investigated relationships between locally secreted cancer biomarkers and features of the local CVM to better understand the complex interplay between host, virus and vaginal microbiota (VMB). We enrolled women with ICC, high- and low-grade squamous intraepithelial lesions, as well as, HPV-positive and healthy HPV-negative controls. A broad range of cancer biomarkers was present in the local CVM and specifically elevated in ICC patients. The majority of cancer biomarkers were positively correlated to other biomarkers and linked to genital inflammation. Several cancer biomarkers were also negatively correlated to Lactobacillus abundance and positively correlated with abnormal vaginal pH. Finally, a hierarchical clustering analysis of cancer biomarkers and immune mediators revealed three patient clusters, which varied in levels of cancer biomarkers, genital inflammation, vaginal pH and VMB composition. Specific cancer biomarkers discriminated patients with features of the CVM, such as high genital inflammation, elevated vaginal pH and dysbiotic non-Lactobacillus-dominant VMB, that have been associated with HPV persistence, dysplasia and progression to ICC.

Linking cervicovaginal immune signatures, HPV and microbiota composition in cervical carcinogenesis in non-Hispanic and Hispanic women.

While high-risk human papillomavirus (HPV) infection is a well-established risk factor for cervical cancer, there are likely other factors within the local microenvironment that contribute to cervical carcinogenesis. Here we investigated relationships between HPV, vaginal pH, vaginal microbiota (VMB) composition, level of genital immune mediators and severity of cervical neoplasm. We enrolled women with low- and high-grade cervical dysplasia (LGD, HGD), invasive cervical carcinoma (ICC), and healthy controls. HPV16, HPV45, HPV58, and HPV31 were the most prevalent in our cohort with HPV16 and HPV31 genotypes more prevalent in Hispanics. Vaginal pH was associated with ethnicity and severity of cervical neoplasm. Lactobacillus dominance decreased with the severity of cervical neoplasm, which correlated with elevated vaginal pH. Hispanic ethnicity was also associated with decreased Lactobacillus dominance. Furthermore, Sneathia was enriched in all precancerous groups, ICC, abnormal pH and Hispanic origin. Patients with ICC, but not LGD and HGD, exhibited increased genital inflammatory scores and elevated specific immune mediators. Notably, IL-36γ was significantly associated with ICC. Our study revealed local, host immune and microbial signatures associated with cervical carcinogenesis and provides an initial step to understanding the complex interplay between mucosal inflammation, HPV persistence and the VMB.

The vaginal and gastrointestinal microbiomes in gynecologic cancers: a review of applications in etiology, symptoms and treatment.

The human microbiome is the collection of microorganisms in the body that exist in a mutualistic relationship with the host. Recent studies indicate that perturbations in the microbiome may be implicated in a number of diseases, including cancer. More specifically, changes in the gut and vaginal microbiomes may be associated with a variety of gynecologic cancers, including cervical cancer, uterine cancer, and ovarian cancer. Current research and gaps in knowledge regarding the association between the gut and vaginal microbiomes and the development, progression, and treatment of gynecologic cancers are reviewed here. In addition, the potential use of probiotics to manage symptoms of these gynecologic cancers is discussed. A better understanding of how the microbiome composition is altered at these sites and its interaction with the host may aid in prevention, optimization of current therapies, development of new therapeutic agents and/or dosing regimens, and possibly limit the side effects associated with cancer treatment.