Risk-reducing salpingo-oophorectomy among diverse patients with BRCA mutations at an urban public hospital: a mixed methods study.

OBJECTIVES: To assess the association of socioeconomic demographics with recommendation for and uptake of risk-reducing bilateral salpingo-oophorectomy (rrBSO) in patients with BRCA1 and BRCA2 (BRCA1/2) mutations. DESIGN: Retrospective cohort, semistructured qualitative interviews. SETTING AND PARTICIPANTS: BRCA1/2 mutation carriers at an urban, public hospital with a racially and socioeconomically diverse population. INTERVENTION: None. PRIMARY AND SECONDARY OUTCOMES: The primary outcomes were rate of rrBSO recommendation and completion. Secondary outcomes were sociodemographic variables associated with rrBSO completion. RESULTS: The cohort included 167 patients with BRCA1/2 mutations of whom 39% identified as black (n=65), 35% white (n=59) and 19% Hispanic (n=32). Over 95% (n=159) received the recommendation for age-appropriate rrBSO, and 52% (n=87) underwent rrBSO. Women who completed rrBSO were older in univariable analysis (p=0.05), but not in multivariable analysis. Completion of rrBSO was associated with residence in zip codes with lower unemployment and documented recommendation for rrBSO (p<0.05). All subjects who still received care in the health system (n=79) were invited to complete interviews regarding rrBSO decision-making, but only four completed surveys for a response rate of 5.1%. Themes that emerged included menopause, emotional impact and familial support. CONCLUSIONS: In this understudied population, genetic counselling and surrogates of financial health were associated with rrBSO uptake, highlighting genetics referrals and addressing social determinants of health as opportunities to improve cancer prevention and reduce health inequities. Our study demonstrates a need for more culturally centred recruiting methods for qualitative research in marginalised communities to ensure adequate representation in the literature regarding rrBSO.

Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status.

Importance: Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer. Objective: To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status. Design, Setting, and Participants: This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023. Exposures: Health inusurance status (private or Medicare insurance vs Medicaid or uninsured). Main Outcomes and Measures: The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status. Results: A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women. Conclusions and Relevance: This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

HE4 and CA125 serum biomarker monitoring in women with epithelial ovarian cancer.

BACKGROUND: CA125 is the gold standard serum biomarker for monitoring patients with epithelial ovarian cancer (EOC). Human epididymal protein 4 (HE4) is a novel serum biomarker for EOC patients. OBJECTIVE: The objective of this trial was to examine the utility of measuring serum HE4 levels for monitoring EOC patients and to compare HE4 performance parameters to serum CA125. METHODS: A retrospective trial using residual longitudinal serum samples drawn during treatment and monitoring from EOC patients. Serum CA125 and HE4 levels were analyzed at each time point, and a velocity of change was calculated and correlated with clinical status. The null hypothesis was that HE4 is inferior to CA125, and this was tested using concordance and two-sided Fisher's exact testing. McNemar's test was used to assess the overall agreement of the two assays with the clinical status. RESULTS: A total of 129 patients with 272 separate clinical periods and 1739 events (serum samples) were evaluated. Using a 25% change in serum biomarker levels to indicate change in disease status, the accuracy and NPV determined for HE4 versus CA125 were 81.8% versus 82.6% (p = 0.846) and 87.4% versus 89.7% (p = 0.082), respectively. Concordance comparison of HE4 accuracy / CA125 accuracy was 0.990, indicating HE4 was not inferior to CA125 (McNemar's test p-value = 0.522). Performing a velocity of change analysis, the accuracy and NPV determined for HE4 versus CA125 were 78.3% versus 78.6% (p = 0.995) and 74.9% versus 76.3% (p = 0.815), respectively. Concordance comparison of HE4 velocity accuracy / CA125 velocity accuracy was 0.996, again indicating HE4 was not inferior to CA125 (McNemar's test p-value = 0.884). The combination of HE4 and CA125 velocity changes showed a similar accuracy of 81.3% (p = 0.797 compared to HE4 and CA125 alone) and NPV of 81.1% (p≥0.172 compared to HE4 and CA125 alone), and an increased sensitivity of 70.5% (p≤0.070 compared to HE4 and CA125 alone). CONCLUSION: HE4 is equivalent to CA125 for monitoring of EOC patients. The combination of CA125 and HE4 velocities is superior to either marker alone.

Leadership aspirations among residents in obstetrics and gynecology in the United States: a cross-sectional analysis.

BACKGROUND: Most residents and faculty in obstetrics and gynecology (Ob/Gyn) are women. However, only a third of Ob/Gyn academic leadership positions are held by women in the United States. METHODS: This is an IRB-approved cross-sectional study of leadership aspirations among Ob/Gyn residents in the U.S. as related to gender and mentorship using an electronic survey distributed nationwide in 2017. The primary outcome was resident interest in academic leadership. Mediator variables included demographics and training environment characteristics. Descriptive statistics and comparative analyses were performed using SPSS. RESULTS: We received 202 completed surveys, for a representative cross-section of 4% of all Ob/Gyn residents in the U.S. The majority (86%) of respondents were women (n = 174), reflecting the same gender distribution of all Ob/Gyn residents in training. Sixty-seven percent of all respondents reported an interest in pursuing academic leadership (n = 133). Women reported leadership aspirations less often than men (64% vs 86%, p < 0.05) and reported lower mean Likert scores (3.73 vs 4.14, p < 0.05) regarding interest in leadership. A marginal difference between mean Likert scores was observed between women and men when controlled for other demographics (coefficient - 0.344, SE 0.186; p = 0.066). No difference in leadership aspirations was noted between women and men when controlled for mentorship, presence of female program director, and presence of three or more female leaders in a program. CONCLUSIONS: Gender disparity in goal-setting toward leadership is identified as early as residency training in Ob/Gyn. This imbalance in leadership aspirations can be addressed with targeted mentorship.

Palliative Total Pelvic Exenteration for Gynecologic Cancers: A Cross-sectional Study of Society of Gynecologic Oncology Members.

OBJECTIVE: The aim of this study was to evaluate contemporary practices and opinions among gynecologic oncologists regarding the use of total pelvic exenteration (TPE) for palliative intent. METHODS: This cross-sectional study of the membership of the Society of Gynecologic Oncology utilized an electronic survey to assess the opinions and practice patterns of gynecologic oncologists regarding TPEs. The primary outcome was willingness to consider a TPE for palliative intent, and demographic and practice characteristics were collected for correlation. Qualitative data were also collected. Descriptive statistics are presented, and χ tests, Fisher exact tests, and logistic regression analyses were used. RESULTS: We included 315 surveys for analysis, for a completed response rate of 23.5%. Approximately half (52.4%, n = 165) of respondents indicated willingness to consider palliative TPE. When controlled for all variables, gynecologic oncologists who were more than 10 years out of fellowship were less likely to perform a palliative exenteration (odds ratio, 0.55; 95% confidence interval, 0.30-0.98), whereas those who reported experience with minimally invasive exenteration were more likely to offer it for palliation (odds ratio, 2.20; 95% confidence interval, 1.07-4.73). Fifty-three respondents (16.8%) provided qualitative data. The themes that emerged as considerations for TPE as palliation were (1) symptoms and quality of life, (2) surgical and perioperative morbidity, (3) anticipated overall survival, (4) counseling and informed consent, (5) functional status and comorbidities, (6) likelihood of residual disease, and (7) alternative procedures available for palliation. CONCLUSION: Half of gynecologic oncologists seem to be willing to offer a palliative TPE, although more-experienced gynecologic oncologists are more likely to reserve the procedure for curative intent.

Randomised controlled trial comparing hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors: a pilot study.

OBJECTIVES: To compare the efficacy of hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors, and to evaluate the feasibility of conducting a clinical trial comparing a drug with a complementary or alternative method (CAM). DESIGN: Prospective randomised trial. SETTING: Breast health centre of a tertiary care centre. PARTICIPANTS: 15 women with a personal history of breast cancer or an increased risk of breast cancer who reported at least one daily hot flash. INTERVENTIONS: Gabapentin 900 mg daily in three divided doses (control) compared with standardised hypnotherapy. Participation lasted 8 weeks. OUTCOME MEASURES: The primary endpoints were the number of daily hot flashes and hot flash severity score (HFSS). The secondary endpoint was the Hot Flash Related Daily Interference Scale (HFRDIS). RESULTS: 27 women were randomised and 15 (56%) were considered evaluable for the primary endpoint (n=8 gabapentin, n=7 hypnotherapy). The median number of daily hot flashes at enrolment was 4.5 in the gabapentin arm and 5 in the hypnotherapy arm. HFSS scores were 7.5 in the gabapentin arm and 10 in the hypnotherapy arm. After 8 weeks, the median number of daily hot flashes was reduced by 33.3% in the gabapentin arm and by 80% in the hypnotherapy arm. The median HFSS was reduced by 33.3% in the gabapentin arm and by 85% in the hypnotherapy arm. HFRDIS scores improved by 51.6% in the gabapentin group and by 55.2% in the hypnotherapy group. There were no statistically significant differences between groups. CONCLUSIONS: Hypnotherapy and gabapentin demonstrate efficacy in improving hot flashes. A definitive trial evaluating traditional interventions against CAM methods is feasible, but not without challenges. Further studies aimed at defining evidence-based recommendations for CAM are necessary. TRIAL REGISTRATION: clinicaltrials.gov (NCT00711529).