Breast Conservative Surgery for Breast Cancer: Indian Surgeon's Preferences and Factors Influencing Them.

Background: It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient's choice, availability and accessibility of infrastructure, and surgeon's choice. We aimed to elucidate the Indian surgeons' perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS. Methods: We conducted a survey-based cross-sectional study in January-February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS. Results: A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25-44 years age group with the majority (80%) being males. 66.4% of surgeons 'almost always' offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p < 0.01). Surgeons working in hospitals with in-house radiation oncology facilities were 9 times more likely to offer BCS (p < 0.05). Surgeons' years of practice, age, sex and hospital setting did not influence the surgery offered. Conclusion: Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01601-y.

World Gynecologic Oncology Day: the use of Twitter to raise awareness of gynecologic cancers.

BACKGROUND: Social media provides an opportunity for people to connect and form communities. This community architecture can help to disseminate health-related information in the form of an awareness campaign. The European Society of Gynaecological Oncology and the European Network of Gynaecological Cancer Advocacy Groups initiated a global campaign, World Gynecologic Oncology Day, on September 20, 2020. We studied and analyzed the impact and reach of this Twitter campaign. OBJECTIVE: This study aimed to assess the impact and reach of the 2020 World Gynecologic Oncology Day Twitter campaign. STUDY DESIGN: We analyzed gynecologic oncology-specific posts (tweets) between 12 am on September 17, 2020, to 11:59 pm on September 25, 2020 (Coordinated Universal Time), covering the days immediately before and after World Gynecological Oncology Day (September 20, 2020), using Tweepy. The European Network of Gynecological Cancer Advocacy Groups suggested hashtags (#GoForPurple, #WorldGODay, and #GoForCheckup) should be used for this social media campaign. We used these hashtags for our data (tweet) collection. RESULTS: A total of 382 Twitter accounts participated in this campaign and 662 tweets, including retweets, were reported. Of those, 22% of participants were healthcare professionals. A total of 164 unique hashtags were identified, and #WorldGODay was the most frequently used among the Twitter accounts. #VaginalCancer, #CervicalCancer, and #VulvarCancer were used in relation to the campaign. We identified 5 significant communities that contributed to raising awareness. CONCLUSION: Twitter campaigns should be designed around a single, short, easy-to-spell hashtag and coordinated with previously identified influential accounts using timed tweets. #WorldGOday hashtag was relevant, easy to spell, memorable, and the most effective hashtag used in this campaign.

Assessing the Rates and Reasons of Elective Surgical Cancellations on the Day of Surgery: A Multicentre Study from Urban Indian Hospitals.

BACKGROUND: Cancellations of elective surgeries on the day of surgery (DOS) can lead to added financial burden and wastage of resources for healthcare facilities; as well as social and emotional problems to patients. These cancellations act as barriers to delivering efficient surgical services. Optimal utilisation of the available resources is necessary for resource-constrained low-and-middle-income countries (LMIC). This study investigates the rate and causes of cancellations of elective surgeries on the DOS in various surgical departments across ten hospitals in India. METHODS: A research consortium 'IndSurg' led by World Health Organisation Collaboration Centre (WHOCC) for Research in Surgical Care Delivery in LMICs, India conducted this multicentre retrospective cross-sectional study to analyse the cancellations of elective/planned surgical operations on DOS across urban secondary and tertiary level hospitals. We audited surgical records of a pre-decided period of six weeks for cancellations, documented relevant demographic information and reasons for cancellations. RESULTS: We analysed records from the participating hospitals, with an overall cancellation rate of 9.7% (508/5231) on the DOS for elective surgical operations. Of these, 74% were avoidable cancellations. A majority (30%) of these 508 cancellations were attributed to insufficient resources, 28% due to patient's refusal or failure to show-up, and 22% due to change in patient's medical status. CONCLUSION: We saw a preponderance of avoidable reasons for elective surgery cancellations. A multidisciplinary approach with adequate preoperative patient counselling, timely communication between the patients and caregivers, adequate preoperative anaesthetic assessment, and planning by the surgical team may help reduce the cancellation rate.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey.

OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC. METHODS: An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists. RESULTS: The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated. CONCLUSIONS: Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

International Gynaecological Cancer Society (IGCS) 2020 Annual Global Meeting: Twitter activity analysis.

OBJECTIVES: Twitter is the most frequently used social media platform by healthcare practitioners, at medical conferences. This study aimed to analyze Twitter conversations during the virtual International Gynecological Cancer Society 2020 conference to understand the interactions between Twitter users related to the conference. METHODS: Tweets using the hashtag '#IGCS2020' were searched using the Twitter Search Application Programming Interface (API) during the period 10-13 September 2020. NodeXL Pro was used to retrieve data. The Clauset-Newman-Moore cluster algorithm clustered users into different groups or 'clusters' based on how users interacted. RESULTS: There were 2009 registrants for the virtual IGCS 2020 conference. The total number of users within the network was 168, and there were 880 edges connecting users. Five types of edges were identified as follows: 'replies to' (n=18), 'mentions' (n=221), 'mentions in retweets' (n=375), retweets (n=198), and tweets (n=68). The most influential account was that of the IGCS account itself (@IGCSociety). The overall network shape resembled a community where distinct groups formed within the network. Our current analyses demonstrated that less than 10% of the total members interacted on Twitter. CONCLUSION: This study identified the most influential Twitter users within the '#IGCS2020' community. he results also confirmed the community network shape of the #IGCS2020 hashtag and found that the most frequent co-related words were 'ovarian' and 'cancer' (n=39).

Technique for inguino-femoral lymph node dissection in vulvar cancer: an international survey.

BACKGROUND: Vulvar cancer is a rare disease and despite broad adoption of sentinel lymph node mapping to assess groin metastases, inguino-femoral lymph node dissection still plays a role in the management of this disease. Inguino-femoral lymph node dissection is associated with high morbidity, and limited research exists to guide the best surgical approach. OBJECTIVE: To determine international practice patterns in key aspects of the inguino-femoral lymph node dissection technique and provide data to guide future research. METHODS: A survey addressing six key domains of practice patterns in performing inguino-femoral lymph node dissection was distributed internationally to gynecologic oncology surgeons between April and October 2020. The survey was distributed using the British Gynecological Cancer Society, the Society of Gynecologic Oncology, authors' direct links, the UK Audit and Research in Gynecology Oncology group, and Twitter. RESULTS: A total of 259 responses were received from 18 countries. The majority (236/259, 91.1%) of respondents reported performing a modified oblique incision, routinely dissecting the superficial and deep inguino-femoral lymph nodes (137/185, 74.1%) with sparing of the saphenous vein (227/258, 88%). Most respondents did not routinely use compression dressings/underwear (169/252 (67.1%), used prophylactic antibiotics at the time of surgery only (167/257, 65%), and closed the skin with sutures (192 74.4%). Also, a drain is placed at the time of surgery by 243/259 (93.8%) surgeons, with most practitioners (144/243, 59.3%) waiting for drainage to be less than 30-50 mL in 24 hours before removal; most respondents (66.3%) routinely discharge patients with drain(s) in situ. CONCLUSION: Our study showed that most surgeons perform a modified oblique incision, dissect the superficial and deep inguino-femoral lymph nodes, and spare the saphenous vein when performing groin lymphadenectomy. This survey has demonstrated significant variability in inguino-femoral lymph node dissection in cases of vulvar cancer among gynecologic oncology surgeons internationally.

Pharmacological Prophylaxis and Personal Protective Equipment (PPE) Practices in Gynecological Cancer Surgery During COVID-19 Pandemic.

PURPOSE: In the absence of vaccine, proper use of personal protective equipment (PPE) is the most important strategy to protect healthcare workers against COVID-19 infection. The recommendations on pharmacological prophylaxis against COVID-19 infection are controversial. The aim of current study was to assess PPE practices during surgery on COVID-19 negative gynecological cancer patients and use of pharmacologic prophylaxis by clinicians practicing gynecologic oncology. METHODS: We disbursed a survey questionnaire through various social media platforms among clinicians practicing gynecologic oncology. The survey consisted of 37 questions divided into five subgroups evaluating demographic details, use of pharmacological prophylaxis against COVID-19, preoperative COVID-19 screening protocol, details on PPE usage and associated discomfort, if any. RESULTS: Two hundred twenty oncologists from 13 countries responded to the survey. Pharmacological prophylaxis was being used by 85 (38.6%) respondents; most common agent was hydroxychloroquin (HCQ) by 24.5% respondents. Routine preoperative screening for COVID-19 was performed by 214 (97.3%) respondents. Some degree of discomfort during surgery due to PPE use was reported by 170 (77.3%) respondents, which was moderate to severe in 73 (33.2%) respondents. Most common difficulties associated with face mask/shield were problems in communication (69.5%) and breathing (58.1%). Eye protection was associated with poor visibility, fogging and headache. Unusual fatigue attributed to PPE use was experienced by 143(65%) respondents. CONCLUSION: Use of pharmacological prophylaxis against COVID-19 is controversial and the same is reflected in our survey. Most respondents adhered to PPE use despite experiencing some physical discomfort. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40944-021-00500-4.

Impact of COVID-19 Pandemic on Gynecological Oncology Care: Glimpse into Association of Gynecological Oncologists of India (AGOI) Perspective.

PURPOSE: The notorious COVID 19 pandemic has caused rapid and drastic changes in cancer care worldwide in 2020. This online survey aims to assess the extent to which the pandemic has affected cancer care in gynecological oncology amongst members of the Association of Gynecological Oncologists of India (AGOI), a registered professional society founded in 1991. METHODS: We developed and administered a cross-sectional, flash survey to members of AGOI in the first week of April 2020. Data were analyzed using Microsoft Office Excel 2016. Results were expressed as percentages of total responses excluding blank or unattended response. Overall theme-specific responses were described as a spectrum of findings, and related inferences were drawn. RESULTS: Among approached practitioners, 90 responded to the survey, more than 80% were practicing consultants, and more than 50% from academic institutions. The results of the study showed that the ongoing pandemic had severely affected gynecological oncology practice and care amongst all respondents. There were modifications in diagnostic pathways, interventions, and follow-ups across all organ sites. There was a near-unanimous opinion on the use of general safety measures to combat the virus and to use complete PPEs in a high-risk situation. There were mixed responses to alternative educational activities, especially using electronic technology and distant learning methods. There was optimism among respondents with regards to the current situation normalizing in 3-6 months. CONCLUSION: This study documents the pandemic affected scenario of gynecological cancer care and perceptions of Gynecological Oncologists in India. A significant effect on all aspects of cancer care was observed. Technological learning methods, both for patient care and educational activities, were being adopted by many respondents.

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs have been shown to improve clinical outcomes in gynecologic oncology, with the majority of published reports originating from a small number of specialized centers. It is unclear to what degree ERAS is implemented in hospitals globally. This international survey investigated the status of ERAS protocol implementation in open gynecologic oncology surgery to provide a worldwide perspective on peri-operative practice patterns. METHODS: Requests to participate in an online survey of ERAS practices were distributed via social media (WhatsApp, Twitter, and Social Link). The survey was active between January 15 and March 15, 2020. Additionally, four national gynecologic oncology societies agreed to distribute the study among their members. Respondents were requested to answer a 17-item questionnaire about their ERAS practice preferences in the pre-, intra-, and post-operative periods. RESULTS: Data from 454 respondents representing 62 countries were analyzed. Overall, 37% reported that ERAS was implemented at their institution. The regional distribution was: Europe 38%, Americas 33%, Asia 19%, and Africa 10%. ERAS gynecologic oncology guidelines were well adhered to (>80%) in the domains of deep vein thrombosis prophylaxis, early removal of urinary catheter after surgery, and early introduction of ambulation. Areas with poor adherence to the guidelines included the use of bowel preparation, adoption of modern fasting guidelines, carbohydrate loading, use of nasogastric tubes and peritoneal drains, intra-operative temperature monitoring, and early feeding. CONCLUSION: This international survey of ERAS in open gynecologic oncology surgery shows that, while some practices are consistent with guideline recommendations, many practices contradict the established evidence. Efforts are required to decrease the variation in peri-operative care that exists in order to improve clinical outcomes for patients with gynecologic cancer globally.

COVID-19 and gynecological cancer: a review of the published guidelines.

On March 11, 2020 the COVID-19 outbreak was declared a 'pandemic' by the World Health Organization. COVID-19 is associated with higher surgical morbidity and mortality. An array of guidelines on the management of cancer during this pandemic have been published since the first reports of the outbreak. This narrative review brings all the relevant information from the guidelines together into one document, to support patient care. We present a detailed review of published guidelines, statements, comments from peer-reviewed journals, and nationally/internationally recognized professional bodies and societies' web pages (in English or with English translation available) between December 1, 2019 and May 27, 2020. Search terms included combinations of COVID, SARS-COV-2, guideline, gynecology, oncology, gynecological, cancer. Recommendations for surgical and oncological prioritization of gynecological cancers are discussed and summarized. The role of minimally invasive surgery, patient perspectives, medico-legal aspects, and clinical trials during the pandemic are also discussed. The consensus is that elective benign surgery should cease and cancer surgery, chemotherapy, and radiotherapy should continue based on prioritization. Patient and staff face-to-face interactions should be limited, and health resources used efficiently using prioritization strategies. This review and the guidelines on which it is based support the difficult decisions currently facing us in gynecological cancer. It is a balancing act: limited resources and a hostile environment pitted against the time-sensitive nature of cancer treatment. We can only hope to do our best for our patients with the resources available to us.

Can Surgical Apgar Score (SAS) Predict Postoperative Complications in Patients Undergoing Gynecologic Oncological Surgery?

Surgeons constantly try to achieve optimal surgical outcome, number, or extent of postoperative complications being an important part of it. Oncological surgeries are conventionally more challenging and complex compared with most nononcological ones. Gawande et al. devised SAS in 2007 in Boston as a predictor tool for postoperative complications (J Am Coll Surg 204:201-208, 2007). A validation study was done by in another cohort of 100 patients; however, only 70% of them had pathologically confirmed malignancies (Ann Surg 240(2):205-213, 2004). We attempt to assess SAS as a tool to predict postoperative complications in a series of 100 gynecological oncological patients operated at tertiary care center. SAS score of 100 patients with gynecologic malignancies, undergoing surgery at a tertiary care center, was prospectively collected over 4 years. These patients were observed for development of any complications occurring up to 30 days postsurgery. The complication events were graded as per Clavien-Dindo classification (Indian J Gynecol Oncolog 15:49, 2017). The data obtained was statistically analyzed by chi-square test. Thirty complication events were recorded in these 100 patients over a period of 4 years. Majority of complication events were grade IIIa or less (22 out of 30); there was only one death on 8th postoperative day. Fifty percent of patients were with SAS score of 5 or less developed complications compared with just 22.9% in patients with a score of 6 or more. Lower SAS score might be associated with higher postoperative complications in patients undergoing gynecologic oncological surgeries. Thus, patients with lower scores may benefit from a triage to more intensive postoperative care.