The impact of primary human papillomavirus screening on negative loop excision histology following biopsy-proven high-grade cervical intra-epithelial lesions: A review from a large tertiary colposcopy unit.

BACKGROUND: The renewed National Cervical Screening Program incorporating primary human papillomavirus (HPV) screening was implemented in Australia in December 2017. In a previous study conducted in the UK, primary HPV screening was found to be associated with a 25% reduction in the incidence of negative histology following loop electrosurgery excision procedure (LEEP). AIM: To examine the change in incidence and associated risk factors for a negative LEEP with introduction of primary HPV screening. MATERIALS AND METHODS: A retrospective review of the records of all patients undergoing a LEEP excision for biopsy-proven high-grade cervical intra-epithelial lesions between 1 January 2014 and 30 June 2019 in a specialised centre. RESULTS: There were 1123 patients who underwent a LEEP included in the analysis. The incidence of a negative LEEP specimen was 7.5% (59/784) and 5.3% (18/339) in the pre- and post-HPV screening cohort. More patients in the post-HPV screening group had low-grade cytology on referral (P < 0.001), smaller cervical lesions on colposcopy (P = 0.012) and longer biopsy to treatment interval (P = 0.020). Primary HPV screening was associated with a significant reduction in the incidence of a negative LEEP specimen in a propensity matched cohort (11.2% to 5.1%, P = 0.006) and a 41% (P = 0.045) decreased relative risk of a negative LEEP on multivariate analysis. CONCLUSIONS: Primary HPV screening results in a lower incidence of negative LEEP histology, despite a longer biopsy to treatment wait time and higher proportion of low-grade cytology at triage.

Assessment of current follow-up for complete molar pregnancies: A single centre review.

BACKGROUND: Current guidelines recommend that resolution of a complete molar pregnancy (CMP) can only be confirmed once a negative ß-human chorionic gonadotropin (ß-hCG) has been maintained for six months following uterine surgical evacuation. However, multiple studies have found that the risk of developing gestational trophoblastic neoplasia (GTN) once a negative ß-hCG had been obtained is negligible, which suggests that a shorter follow-up may be reasonable. AIM: To determine the trend in ß-hCG following diagnosis of a CMP and the incidence of GTN, in a single unit. MATERIALS AND METHODS: All patients presenting to the tertiary hospital, Royal Prince Alfred Hospital Early Pregnancy Assessment Service (RPAH EPAS), with a histopathological diagnosis of a CMP between 2010 and 2017 were included. Data collected included age, parity, ß-hCG at diagnosis, subsequent ß-hCG levels, incidence of GTN and treatment required. RESULTS: Sixty-seven patients were diagnosed with CMP between January 2010 and July 2017 through RPAH EPAS. The mean age of women diagnosed with a CMP was 33 years. None of the 40 patients who spontaneously achieved a negative ß-hCG and completed their six months follow-up had a subsequent rise in ß-hCG. The median number of days from surgical evacuation to normalisation of ß-hCG was 55.5 days. Sixteen out of 67 patients who had a CMP required further management for persistent GTN. None of these patients achieved a negative ß-hCG prior to further management. CONCLUSIONS: Consideration could be made to decreasing the period of ß-hCG monitoring for women who achieve a spontaneous negative ß-hCG following surgical evacuation of a CMP.

Age-related supportive care needs of women with gynaecological cancer: A qualitative exploration.

Women with gynaecological cancer (GC) experience significant morbidity with associated needs for support, not all of which are currently met by the current system. Types and levels of unmet needs vary across age and the care continuum. This study aimed to identify the shared and unique supportive care needs of younger and older GC patients and survivors to inform improved supportive care. Nineteen younger and ten older women, 3 months to 5 years post a GC diagnosis, were purposively recruited during active treatment, and at early and extended survivorship. Audiotaped and transcribed semi-structured interviews were thematically analysed to establish areas of needs. GC patients reported nine shared needs relating to support, isolation, uncertainty, information, asking questions, escape from illness, advocacy, loss and finding meaning. Younger patients reported unique needs related to the impact of treatment-induced menopause. There is a need for a systematic screening process to identify women who require and want additional help, to ensure appropriate and timely assistance or referrals are provided. Identification of needs will allow health professionals to provide relevant and timely information and support services, resulting in improved quality of life for women affected by GC.

Nurse confidence in gynaecological oncology practice and the evaluation of a professional development module.

BACKGROUND: A tertiary-based education program on gynaecological oncology was attended by 62 registered nurses (RN). AIMS: The program aimed to update nurses' knowledge, improve skills and ability to manage common situations and to assess program efficacy. DESIGN: Evaluation framework with specifically designed pre-post questionnaire about program content and nurse confidence. METHOD: RN interested in gynaecological oncology were invited to attend. Nurses rated their confidence about gynaecological oncology skills one week prior to the program, immediately post-course, 3 months post and 12 months post. Speaker presentations were evaluated immediately post-course. RESULTS: Participants indicated improved confidence immediately after participating in the course (z = -6.515, p < .001); whilst confidence subsequently declined and stabilised up to 12 months post-course, it still remained significantly higher than before the course: 3 months post- (z = -5.284, p < .001) and 12 months post- (z = -4.155, p < .001). CONCLUSIONS: Results support the value of continuing professional education for improving nurse confidence in the gynaecological oncology setting.

Optimising recovery after surgery: Predictors of early discharge and hospital readmission.

BACKGROUND: Fast track surgery (FTS) programs minimise the stress response after surgery and allow for enhanced recovery. AIMS: To document the frequency and incidence of adverse events in patients enrolled on a FTS program and to investigate factors associated with shorter length of stay and readmission to hospital. METHODS: A seven-year updated surgical audit of patients undergoing laparotomy for suspected or confirmed malignancy on a FTS program. RESULTS: Five hundred and fifty patients comprise the study group. Average age and body mass index (BMI) were 55 years and 28, respectively. Mean length of stay (LOS) was 3.4 days with 194 (35%) patients discharged on day 2. Six (1%) patients had confirmed venous thromboembolism (VTE), three of whom were diagnosed on pre-operative imaging. Overall, transfusion rate was 5%. Adverse events in decreasing frequency were hospital readmission (4%) and significant wound infection (3%). All other adverse events were uncommon with rates <0.5%. Factors associated with a discharge on or after day 3 include age, pathology, Eastern Cooperative Oncology Group performance status, incision type, operating time, blood transfusion and cyclo-oxygenase 2 inhibitors. Factors associated with hospital readmission include longer operating time, performance of lymph node sampling/dissection, longer LOS, development of wound infection, febrile morbidity, return to the operating room, unplanned intensive care unit admission and presence of other complications. CONCLUSIONS: Patients managed by a FTS protocol can expect enhanced outcomes when compared to historical controls.

Predictors of early discharge after open gynecological surgery in the setting of an enhanced recovery after surgery protocol.

AIM: Enhanced recovery after surgery (ERAS) protocols have been proven to decrease length of hospital stay without increasing readmission rates or complications. However, patient and operative characteristics that improve the chance of successful early hospital discharge are unknown. The aim of this study was to determine the characteristics of patients undergoing open gynecological surgery in an ERAS protocol who could be discharged home by postoperative day 3. METHODS: A retrospective review was performed on patients undergoing laparotomy by a single surgeon and managed by an ERAS protocol between January 2008 and April 2013. Data collection on patient characteristics, hospitalization and post-discharge details was performed prospectively. Patients successfully discharged home on or by day 3 (early discharge) were compared to patients who had a longer admission (late discharge). RESULTS: During the study period, 454 consecutive patients were identified and included in the study. No patients were excluded. A total of 335 patients (73.8%) were successfully discharged home within 3 days. After adjusting for age and Eastern Cooperative Oncology Group performance score, patients with early discharge were significantly less likely to have a malignancy (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.36-0.97; P = 0.038), intensive care unit admission (OR, 0.59; 95%CI, 0.36-0.97; P = 0.046), vertical midline incision (OR, 0.28; 95%CI, 0.07-0.82), complications (OR, 0.21; 95%CI, 0.09-0.49; P = 0.0003), or FIGO Stage III or IV disease (OR, 0.39; 95%CI, 0.23-0.67; P = 0.001). Prior abdominal surgery, body mass index > 25 and lymph node dissection did not significantly influence length of hospital stay. CONCLUSION: Malignancy, advanced-stage disease, intensive care unit admission, vertical midline incision and perioperative complications are significantly associated with longer hospital stay in patients managed by an ERAS protocol.

Facilitating psychosexual adjustment for women undergoing pelvic radiotherapy: pilot of a novel patient psycho-educational resource.

PURPOSE: This pilot study aimed to obtain feedback on the feasibility, safety and acceptability of a psychosexual rehabilitation booklet developed for women undergoing pelvic radiation therapy (PRT) and to explore women's sexual, informational and supportive care needs post-PRT rehabilitation. METHODS: Twenty women treated with PRT for gynaecological or anorectal cancer within the last 5 years, who had received vaginal dilators, provided feedback on the format, content and utility of the booklet and discussed their post-treatment information needs, via a semi-structured phone interview. Women completed standardized (HADS, IES-R) and study-specific scales to characterize psychological status of the sample and to assess participants' booklet knowledge and feedback, respectively. RESULTS: The booklet was perceived as very helpful, informative and not distressing, providing additional information to that discussed with clinicians. After reading the booklet, women had good understanding of strategies to reduce the sexual impact of PRT. Many women reported that discussion of sexuality was often avoided during consultations, despite them experiencing distressing sexual experiences and difficulties post-PRT. CONCLUSIONS: This novel resource which addresses an important component of post-pelvic radiation care appears acceptable and highly valued. Findings have highlighted a need for sexual health communication training for clinicians who treat this population so that they can initiate conversations about vaginal health and sexual health in an informed and comfortable manner. The impact of the revised booklet on psychosexual and clinical outcomes is being evaluated in a multicentre RCT.

Patients' perspectives of fast-track surgery and the role of the fast-track clinical nurse consultant in gynecological oncology.

This study examines the role of the fast-track nurse in gynecology from a patient perspective. The fast-track nurse is a specialist nursing role, which coordinates patient care, in addition to providing specialized clinical care. Semistructured interviews were conducted with women who had fast-track surgery for gynecological cancer.

Direct hospital costs of total laparoscopic hysterectomy compared with fast-track open hysterectomy at a tertiary hospital: a retrospective case-controlled study.

AIMS: To assess the direct intraoperative and postoperative costs in women undergoing total laparoscopic hysterectomy and fast-track open hysterectomy. METHODS: A retrospective review of the direct hospital-related costs in a matched cohort of women undergoing total laparoscopic hysterectomy (TLH) and fast-track open hysterectomy (FTOH) at a tertiary hospital. All costs were calculated, including the cost of advanced high-energy laparoscopic devices. The effect of the learning curve on cost in laparoscopic hysterectomy was also assessed, as was the hospital case-weighted cost, which was compared with the actual cost. RESULTS: Fifty women were included in each arm of the study. TLH had a higher intraoperative cost, but a lower postoperative cost than FTOH (AUD$3877 vs AUD$2776 P < 0.001, AUD$3965 vs AUD$6233 P < 0.001). The total cost of TLH was not different from FTOH (AUD$7842 vs AUD$9009 P = 0.068) and after a learning curve; TLH cost less than FTOH (AUD$6797 vs AUD$8647, P < 0.001). The use of high-energy devices did not impact on the cost benefit of TLH, and hospital case-weight-based funding correlated poorly with actual cost. CONCLUSION: Despite the use of fast-track recovery protocols, the cost of TLH is no different to FTOH and after a learning curve is cheaper than open hysterectomy. Judicious use of advanced energy devices does not impact on the cost, and hospital case-weight-based funding model in our hospital is inaccurate when compared to directly calculated hospital costs.

Chore or priority? Barriers and facilitators affecting dilator use after pelvic radiotherapy for gynaecological cancer.

PURPOSE: Pelvic radiotherapy for gynaecological cancer often leads to damage of the vaginal mucosa, resulting in stenosis (obstruction by scar tissue). Stenosis has been associated with sexual dysfunction and can hinder medical examinations to detect recurrence. The use of vaginal dilators is frequently recommended to prevent or minimise stenosis, but women are reluctant to use these devices. The aim of this study was to explore the patient experience of dilator use and identify the barriers and facilitators affecting compliance with clinician recommendations. METHODS: Women were eligible for the study if they had undergone pelvic radiotherapy for gynaecological cancer up to 2 years ago and received a vaginal dilator as part of their post-treatment rehabilitation. Fifteen participants completed a semi-structured interview. RESULTS: Barriers to dilator use included: uncertainty about how/when to use dilators, viewing it as a negative experience, lack of time or forgetting and the need for discretion due to an association with sex aids. Facilitators included: concern about stenosis, belief that dilators work, reminders of stenosis, acceptance of dilator use as part of their normal routine or an extension of medical treatment and focusing on positive aspects. These factors were incorporated into a model of dilator use based on the Health Belief Model. CONCLUSIONS: This is the first qualitative study to specifically investigate the patient experience of dilator use. The barriers and facilitators identified in this study and the proposed theory-based model provide new insights to inform future research and clinical management of dilator use.

The role of transversus abdominis plane blocks in women undergoing total laparoscopic hysterectomy: a retrospective review.

INTRODUCTION: The transversus abdominis plane (TAP) local anaesthetic block is beneficial in patients undergoing open pelvic surgery; however, there are no data on its use in women undergoing laparoscopic gynaecologic surgery. METHODS: Successive women undergoing TLH were included in this review. All women had local anaesthetic infiltration at the site of port placement and, in addition, received multimodal post-operative analgesia. RESULTS: Sixty-one successive cases were included in the study: 20 had a TAP block and 41 were managed without any blocks. The groups were comparable with respect to age, body mass index, Eastern Co-operative Group performance status, type of operation, cancer status, surgical and anaesthetic time. Women with a TAP block had a significantly shorter length of stay (1.45 vs 2.20 days, P=0.014), lower total peri-operative and post-operative opioid use (12 vs 19 mg in morphine equivalents, P=0.014; 11 vs 21 mg, P=0.05) when compared with those without a TAP block. Multivariate analysis identified patient age and a TAP block with a shorter length of stay (P<0.001 and P=0.015, respectively). Total opioid use was only significantly correlated with a TAP block (P=0.005). There were no complications related to a TAP block. CONCLUSION: A TAP block in women undergoing TLH results in significantly shorter length of stay and lower opioid use. The retrospective nature of this trial and the absence of data on pain scores and nausea and vomiting are best addressed by a large prospective study.

Perioperative outcomes after total laparoscopic hysterectomy compared with fast-track open hysterectomy - a retrospective case-control study.

AIMS: To examine perioperative outcomes after total laparoscopic hysterectomy compared with fast-track open hysterectomy using a retrospective case-control study. METHODS: Consecutive cases of total laparoscopic hysterectomy (TLH) carried out by a single surgeon were matched with cases of fast-track open hysterectomy (FTOH) carried out by a second surgeon. Women were matched for age, body mass index, European Cooperative Oncology Group performance status, benign or malignant disease and extent of surgery. RESULTS: Fifty women were included in each group; women undergoing TLH had a shorter hospital inpatient length of stay (LOS) (1.82 vs 2.62 days, P = 0.02), but longer total theatre time (TT) and surgical time (ST) (226 vs 182 min, P = 0.05; 172 vs 137 min, P = 0.04). LOS, TT and OT were shorter in the second 25 women undergoing TLH than the first 25 cases (1.8 days vs 2.6 days (P = 0.02); 137 min vs 173 min (P = 0.04); 200 min vs 226 min (P = 0.05). A comparison of the second 25 women undergoing TLH with the matched cohort undergoing FTOH revealed a shorter LOS, but no difference in TT or ST (1.8 days vs 3.4 days (P < 0.001); 175 min vs 200 min (P = 0.33); 137 min vs 144 min (P = 0.48)). There were no readmissions in the TLH group and two in the FTOH group, one for a wound infection and another for a small bowel obstruction. CONCLUSION: A TLH results in significantly shorter inpatient stay than FTOH and after an initial learning curve does not result in prolonged theatre or surgical times.

"The booklet helped me not to panic": a pilot of a decision aid for asymptomatic women with ovarian cancer and with rising CA-125 levels.

INTRODUCTION: After first-line treatment, cancer antigen 125 (CA-125) levels can rise many months before there are other signs of recurrent ovarian cancer, leading to a difficult choice about when to initiate second-line treatment. To assist with shared decision making, a decision aid (DA) booklet that compared the options of "wait and see," chemotherapy, and tamoxifen was developed and piloted. METHODS: Twenty patients attending clinics at 2 cancer centers agreed to read the DA booklet, complete a set of standardized and purpose-designed measures, and provide feedback on the DA booklet via a semistructured telephone interview. Participants were either currently making the decision about treatment (n = 14) or had progressed and were now receiving treatment of recurrent cancer (n = 6). RESULTS: Most patients found information in the DA easy to understand (79%) and presented in a balanced way (90%), and almost all (95%) would recommend the booklet to others facing a similar decision. Women showed a good understanding of information contained in the booklet, with a mean of 88% answering each of the knowledge questions correctly. Compared with other ovarian cancer studies, decisional conflict scores were lower, whereas anxiety scores were high but similar to 1 comparable study. Suggestions for improvement related to information about recurrent ovarian cancer and the decision making worksheets. CONCLUSIONS: The DA seems an acceptable and useful decision making resource in this setting. Strategies for reducing anxiety levels linked to booklet administration are outlined. The DA has been revised to reflect pilot findings and changes in clinical evidence, and the effectiveness of the DA in reducing decisional conflict and regret is being evaluated in a randomized controlled trial.

Fast track surgery: a clinical audit.

BACKGROUND: Fast track surgery is a concept that utilises a variety of techniques to reduce the surgical stress response, allowing a shortened length of stay, improved outcomes and decreased time to full recovery. AIMS: To evaluate a peri-operative Fast Track Surgical Protocol (FTSP) in patients referred for abdominal surgery. METHODS: All patients undergoing a laparotomy over a 12-month period were entered prospectively on a clinical database. Data were retrospectively analysed. RESULTS: Over the study period, 72 patients underwent a laparotomy. Average patient age was 54 years and average weight and BMI were 67.2 kg and 26 respectively. Sixty three (88%) patients had a vertical midline incision (VMI). There were no intraoperative blood transfusions. The median length of stay (LOS) was 3.0 days. Thirty eight patients (53%) were discharged on or before post op day 3, seven (10%) of whom were discharged on postoperative day 2. On stepwise regression analysis, the following were found to be independently associated with reduced LOS: able to tolerate early enteral nutrition, good performance status, use of COX inhibitor and transverse incision. In comparison with colleagues at the SGOG not undertaking FTS for their patients, the authors' LOS was lower and the RANZCOG modified Quality Indicators (QI's) did not demonstrate excess morbidity. CONCLUSIONS: Patients undergoing fast track surgery can be discharged from hospital with a reduced LOS, without an increased readmission rate and with comparative outcomes to non-fast tracked patients.

A prospective study assessing patient satisfaction at a large tertiary gynecologic oncology/dysplasia unit.

BACKGROUND: Patient satisfaction is an important quality assurance measure in the delivery of health care. We conducted a prospective study to assess patient satisfaction at a large tertiary oncology/dysplasia unit. AIMS: To assess current patient satisfaction at a large tertiary oncology/dysplasia unit and identify potential areas for improvement. METHODS: This was a prospective study of patients attending a tertiary oncology/dysplasia unit. Patients were invited to participate and, if they agreed, were given a validated questionnaire to complete at the end of their consultation. Descriptive statistics were then used to analyze the data and identify potential areas of improvement. RESULTS: One hundred eighty-seven patients were recruited, and 96% of patients were satisfied with the overall level of care received. Significant positive features of the service included helpfulness of the staff, cleanliness of the facility, and measures implemented to respect patient privacy. Lack of patient parking, waiting times in the clinic, difficulties in contacting the service, and locating the building were identified as areas for improvement. CONCLUSION: Patients attending our facility were largely satisfied with the overall level of care received. Nonclinical factors including parking, waiting times, and access to the service were identified as areas for improvement.

Patient satisfaction with inpatient care provided by the Sydney Gynecological Oncology Group.

PURPOSE: Patient satisfaction with the provision of hospital oncology services can have a significant impact on their overall treatment experience. AIMS: To assess patient satisfaction with the inpatient hospital services in the gynecological oncology setting using the IN-PATSAT32 questionnaire developed by the European Organization for Research and Treatment of Cancer (EORTC). METHODS: A modified version of the IN-PATSAT32 questionnaire with additional 16 items was administered to 52 adult surgical inpatients admitted with the Sydney Gynecological Oncology Group. All participants were provided with an information leaflet regarding the survey and written consent obtained. RESULTS: A high response rate (100%) from patients with varied social, ethnic, and educational backgrounds confirmed the acceptability of the survey. Standard of medical care provided, frequency of doctors' visits, exchange of information with doctors, friendliness of the staff, and state of the room ranked highly (>95%) on the patient satisfaction scales. Problems were identified with ease of access to and within the hospital, quality of food, and exchange of information with other hospital staff. CONCLUSIONS: Overall the satisfaction with inpatient care was rated very highly in most areas. Deficiencies in certain elements of provision of medical care to the patients were identified and steps have been taken to improve upon these shortcomings.