Perceived importance of weight loss and exercise among endometrial cancer survivors with overweight or obesity: Implications for lifestyle modification interventions.

Objective: Type 1 endometrial cancer (EC) survivors who are overweight or obese are at increased risk of comorbidities and reduced quality of life. Lifestyle modification interventions (e.g., healthy eating, exercise) may help these women reduce excess weight and improve their quality of life. However, existing interventions have shown limited success. Guided by Self-Determination Theory, the proposed study sought to identify factors associated with perceived importance of weight loss and exercise as well as interest in lifestyle modification interventions (components of extrinsic and intrinsic motivation) among EC survivors with overweight or obesity to inform future intervention development. Methods: One hundred type 1 EC survivors [body mass index (BMI) ≥ 25 kg/m2] completed a cross-sectional survey assessing sociodemographics, medical factors, exercise, risk perceptions and provider communication, quality of life, barriers to dieting and exercise, perceived importance of healthy lifestyles, and desired intervention content. Results: EC survivors who were aware obesity is a risk factor for EC were significantly more likely to perceive weight loss as important and were interested in weight loss programs and receiving information about exercise (ps < 0.05). Additionally, EC survivors who reported their provider discussed the importance of a healthy weight after their diagnosis were significantly more likely to perceive exercise as important and were interested in receiving dieting information. Conclusions: EC survivors expressed interest in lifestyle modification interventions. Increasing awareness about the risk of obesity and provider discussions about healthy weight during routine appointments may motivate EC survivors to engage in lifestyle modification interventions.

Starting the Conversation: randomized pilot trial of an intervention to promote effective clinical communication about sexual health for gynecologic cancer survivors.

PURPOSE: Gynecologic cancer survivors often hesitate to raise sexual health concerns with their clinicians. We pilot tested Starting the Conversation (STC), a theory-guided intervention aimed at facilitating survivors' clinical communication about sexual health. METHODS: Survivors (N = 32) were randomized 2:1 to STC (23-min video and accompanying workbook grounded in social cognitive theory that provides information and skills training for communicating with providers about sexual concerns, and resource guide) or control (resource guide only). Feasibility was assessed through enrollment, retention, and intervention completion rates (benchmarks: 60%, 80%, 70%); acceptability was assessed through post-intervention program evaluations (benchmark: 75%). Preliminary effects were assessed for sexual health communication (self-reported after next clinic encounter), self-efficacy for clinical communication about sexual health (post-intervention and 2-month follow-up), and sexual activity and anxiety/depressive symptoms (2-month follow-up). RESULTS: All feasibility/acceptability benchmarks were surpassed; 76% enrolled, 97% retained, ≥ 95% used intervention materials, and 100% endorsed STC as acceptable. Positive STC effects were seen for increases in self-efficacy (Cohen's d's = 0.45 at post-intervention; 0.55 at follow-up). In STC, 35% and 45% of women raised or asked about sexual health concerns during the post-intervention clinic visit, respectively, versus 0 and 27% in the control arm. Other measures showed little change. CONCLUSIONS: Data support the STC intervention as feasible and acceptable, with promising effects for gynecologic cancer survivors' communication about sexual health concerns. Because sexual health communication is relevant across the treatment trajectory, we included both on-treatment and post-treatment survivors. While this may be a limitation, it could also enhance sample generalizability. A larger trial is needed to determine efficacy. IMPLICATIONS FOR CANCER SURVIVORS: Communication about sexual health is important yet lacking for cancer survivors. Patient-focused interventions may help address concerns and improve survivors' health outcomes.

Financial toxicity in ovarian cancer.

Ovarian cancer is the most costly and deadly of the gynecologic malignancies. Financial toxicity from out-of-pocket costs for direct care and medications as well as indirect costs from lost income is a growing challenge in oncology. The aim of this review is to focus on recent financial toxicity literature in the gynecologic oncology sphere and highlight specific issues and challenges regarding financial toxicity in ovarian cancer. Treatment options for ovarian cancer lead to variable costs for patients, and there are risk factors for high financial toxicity unique to gynecologic oncology patients. Identification and prompt intervention for those most at risk can help alleviate financial distress from ovarian cancer care.

Non-Gestational Ovarian Choriocarcinoma: A Rare Ovarian Cancer Subtype.

Non-Gestational Ovarian Choriocarcinoma (NGOC) is an extremely rare ovarian tumor, with an incidence of less than 0.6% of malignant ovarian germ cell tumors. Its close pathologic resemblance to Gestational Ovarian Choriocarcinoma (GOC), however, requires special attention as the treatments differ greatly. NGOC typically affects patients in late adolescence or early reproductive years. As a result, NGOCs are often misdiagnosed as ectopic pregnancies due to their common presentation of bleeding, abdominal pain, adnexal mass, and positive serum beta-HCG. On pathologic examination, the tumor is indistinguishable from GOC, and only after review of tissue for paternal genetic components can the diagnosis of NGOC be made. Imaging studies often show highly vascular lesions with further investigation with computer topography (CT) sometimes showing metastatic lesions in the lungs, pelvis, vagina, and liver. These lesions are often hemorrhagic and can lead to catastrophic bleeding. Treatment is vastly different from GOC; NGOC requires treatment with both surgical resection and chemotherapy, with Bleomycin, Etoposide, and Cisplatin (BEP) being the most used regimen. With correct diagnosis and treatment, patients can often receive fertility sparing treatment with long term survival.

Uterine leiomyosarcoma: A review of the literature and update on management options.

Uterine leiomyosarcoma is the most common type of uterine sarcoma. It is an extremely aggressive malignancy associated with a poor overall prognosis. Women affected may vary in age, but are most often diagnosed in their perimenopausal years. Presenting symptoms may be vague and mimic other benign uterine conditions. Preoperative diagnosis of leiomyosarcoma is difficult and often only made at time of surgical resection. These rare mesenchymal tumors are characterized by cytologic atypia, a high mitotic index, and tumor necrosis on histologic inspection. Management of early stage disease entails hysterectomy and complete surgical resection of gross tumor, though routine oophorectomy or lymph node dissection do not appear to confer much clinical benefit. Adjuvant therapy for early stage disease remains controversial as multiple clinical trials have failed to demonstrate benefit on overall survival. Recently, progress has been made in regards to therapy for advanced and recurrent disease. Novel chemotherapeutics, targeted therapies such as olaratumab and pazopanib, and new immunotherapies such as nivolumab and pembrolizumab have demonstrated promise in these previously difficult drug-resistant patients. In this article, we provide a detailed review of uterine leiomyosarcoma including epidemiology, clinical presentation, diagnosis, and pathologic characteristics. We then go on detail management strategies, including options for adjuvant therapy, and highlight new and developing regimens in the field.

Obesity and Endometrial Cancer: A Lack of Knowledge but Opportunity for Intervention.

OBJECTIVE: The causal link between obesity and endometrial cancer is well established; however obese women's knowledge of this relationship is unknown. Our objective was to explore patients' understanding of this relationship and assess the acceptability of a technology-based weight loss intervention. METHODS/MATERIALS: Obese women with Type I endometrial cancer/hyperplasia were surveyed about their assessment of their body mass, knowledge of the relationship of obesity and endometrial cancer, and eating and activity habits. Interest in participation in an intervention also was assessed. RESULTS: Eighty-one women with early stage (71.6% stage I) and grade (41.7% grade 1) disease completed the survey. The median BMI was 35.4 kg/m2 (IQR 32.2-43.5 kg/m2) and the average age was 59.3 (SD 11.1) yr. 76.25% of women were unable to categorize their BMI correctly and 86.9% of those incorrectly underestimated their BMI category. One-third (35.9%) were unaware of any association between obesity and endometrial cancer and 33.3% responded that obesity decreased or did not significantly increase the risk of endometrial cancer. 59% expressed interest in a weight loss intervention. CONCLUSIONS: Endometrial cancer survivors with obesity underestimated their obesity and lacked knowledge regarding the link between obesity and endometrial cancer. However, the majority expressed interest in electronically delivered weight loss interventions.

Two sisters with Mayer-Rokitansky-Küster-Hauser syndrome and serous adenocarcinoma of the ovary.

BACKGROUND: Mayer-Rokitansky-Küster-Hauser syndrome is a rare entity with proposed genetic underpinnings. Ovarian carcinoma has well-described genetic associations and syndromes, although much of the etiology of the disease remains unknown. CASES: Two sisters present in the 1970s with primary amenorrhea, 46, XX karyotypes, and absent uteri consistent with MRKH syndrome. In the 2010s, both sisters again present for care. Case 1 presents one sister with stage IIIC serous ovarian adenocarcinoma and negative BRCA panel. Case No 2 presents the other sister with stage IIIC serous ovarian adenocarcinoma and a negative panel for 32 genetic variants associated with ovarian carcinoma. CONCLUSION: The familial association of two rare diseases and negative genetic workup could point to a new genetic understanding of reproductive structure development and ovarian carcinogenesis.

Opportunities and Challenges: Human Papillomavirus and Cancer.

Mucosal exposure to human papillomavirus (HPV) can lead to anogenital and head and neck (H&N) cancer. Vaccination at a young age can be almost 100% effective in preventing HPV infection with the viral subtypes in both men and women, at least for disease in the anogenital tract. Therapeutic strategies targeting HPV in cervical dysplasia and cancer are showing promise as well in regressing dysplasia and controlling disease. That HPV-positive H&N cancer is a different disease from HPV-negative disease, with different molecular and clinical features and prognosis, is becoming better appreciated. At this time, however, the NCCN Guidelines for H&N Cancers do not distinguish between the types. This is expected to change.

The use of novel technology-based weight loss interventions for obese women with endometrial hyperplasia and cancer.

OBJECTIVE: Obesity significantly increases the risk of the development of both endometrial hyperplasia and cancer. Our objective was to assess the feasibility of two technology-based weight loss interventions in this patient population. METHODS: Women with obesity (BMI≥30kg/m(2)) and endometrial hyperplasia or Type I endometrial cancer were randomized 1:1 to a technology-based 6month lifestyle intervention via either telemedicine or text messaging. The telemedicine arm received weekly phone calls, with weights tracked online using Withings© Wi-Fi scales. The text arm received 3-5 personalized messages daily via Text4Diet™. Participants maintained a 1200-1800calorie/day diet, self-monitored food intake and received exercise goals. Biomarkers (IGFBP-1, adiponectin, VEGF, IL1-beta, IL2, IL6, and IL7) were assessed pre- and post-treatment. RESULTS: Twenty women were randomized (Telemedicine: n=10, Text4Diet: n=10), and 90% lost weight. Many were early stage (70%) and grade (43.8%) disease with a median age of 60.5years. We observed a statistically greater weight loss in the Telemedicine arm [median loss: 9.7kg (range: 1.6-22.9kg)] versus 3.9kg (range: 0.3-11.4kg) in the Text4Diet arm (p=0.0231). Similarly, percent weight loss was greater in the Telemedicine (7.6%) as compared to the Text4Diet arm (4.1%, p=0.014). Mean serum levels of IL-2 were significantly (27.15pg/mL vs. 5.18pg/mL, p=0.0495) lower at intervention end as compared to baseline. CONCLUSIONS: A technology-based weight loss intervention is feasible in women with Type I endometrial cancer/hyperplasia. Both interventions produced weight loss, although more person-to-person contact produced more significant outcomes. Reductions in expression of IL-2 were related to weight loss.

Effectiveness and safety of expanded perioperative thromboprophylaxis in complex gynecologic surgery.

OBJECTIVE: To determine the effectiveness and safety of an expanded perioperative venous thromboembolism (VTE) prophylaxis strategy in women undergoing complex gynecologic surgery. METHODS: We performed a cohort study of 527 patients undergoing major surgery at a single institution over a thirty-month interval during which the gynecologic oncology service implemented an expanded approach to VTE prophylaxis. We compared rates of VTE pre- and post-intervention as well as bleeding and infectious complications. RESULTS: Prior to the intervention, there were 23 VTE events in 345 patients (rate of 6.67%): 8 deep vein thromboses (DVTs) and 15 pulmonary emboli (PEs). Post-intervention, there were 5 VTE events in 182 patients (2.7%): 3 DVTs and 2 PEs (RR=0.4, p=0.056). Time-to-event analysis showed a significantly higher incidence of VTE events in the pre-intervention time frame compared to the post-intervention period (p=0.049). There were no significant differences in bleeding or infection complications between groups. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis protocol was safe, feasible and resulted in a clinically significant reduction in symptomatic VTE. Preoperative single-dose unfractionated heparin for all patients, combined with two weeks of thromboprophylaxis in gynecologic cancer patients, may decrease VTE events without increasing bleeding or infection.

Physical activity, daily walking, and lower limb lymphedema associate with physical function among uterine cancer survivors.

PURPOSE: We sought to quantify the proportion of uterine cancer survivors who self-report poor physical function. We then sought to quantify the association of poor physical function with physical activity (PA), walking, and lower limb lymphedema (LLL), among women with a history of uterine cancer. METHODS: Physical function was quantified using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) questionnaire. PA, walking, and LLL were measured using self-report questionnaire. PA was calculated using metabolic equivalent hours per week (MET-h week(-1)), and walking was calculated using blocks per day (blocks day(-1)). Logistic regression estimated odds ratios (OR) and 95 % confidence intervals (95 % CI). RESULTS: Among the 213 uterine cancer survivors in our survey (43 % response rate), 35 % self-reported poor physical function. Compared to participants who reported <3.0 MET-h week(-1) of PA, participants who reported ≥18.0 MET-h week(-1) of PA were less likely to have poor physical function (OR 0.03, 95 % CI 0.01-0.10; P trend < 0.0001). Compared to participants who reported <4.0 blocks day(-1) of walking, participants who reported ≥12.0 blocks day(-1) of walking were less likely to have poor physical function (OR 0.07, 95 % CI 0.03-0.19; P trend < 0.0001). Compared to participants who did not have LLL, participants with LLL were more likely to have poor physical function (OR 5.25, 95 % CI 2.41-11.41; P < 0.0001). CONCLUSION: Higher levels of PA and walking associate with a lower likelihood of reporting poor physical function. The presence of LLL associates with a higher likelihood of reporting poor physical function. These findings are hypothesis-generating and should be evaluated in future prospective studies.

Cancer-related impairments influence physical activity in uterine cancer survivors.

INTRODUCTION: The extent to which physical activity (PA) participation among uterine cancer survivors may be limited by physical and functional impairments (PFI) related to cancer treatment is unknown. We sought to describe PA participation, characterize the prevalence of PFI, and examine the association between PFI status and PA participation within this population. METHODS: We conducted a study using a mailed survey among uterine cancer survivors who received treatment at a university hospital. We asked about PA and PFI using validated self-report questionnaires. PA was calculated using MET-hours per week (MET·h·wk). PFI was defined as having one or more of the following symptoms: lower limb lymphedema, general pain, fatigue, or severe bladder, bowel, or pelvic issues. Ordinal logistic regression was used to quantify the odds ratio (OR) between PA and PFI. RESULTS: The response rate to our survey was 43%. Among the 213 study participants, 40%, 13%, 13%, 12%, and 23% reported participating in <3.0, 3.0-8.9, 9.0-17.9, 18.0-26.9, and ≥27.0 MET·h·wk of PA, respectively. Walking is the preferred mode of exercise for physically active uterine cancer survivors. Of the survivors, 53% experience at least one PFI. The most common PFI is lower limb lymphedema (36.2%), followed by general pain (22.5%). The OR of PFI decreased as MET-hours per week of PA increased (OR, 0.51; 95% confidence interval, 0.31-0.84; P = 0.009). CONCLUSIONS: The majority of uterine cancer survivors experience PFI that significantly reduce the likelihood of PA participation. PA recommendations for uterine cancer survivors should take into account treatment-related impairments that can affect PA participation.

Vertebral artery dissection and cerebral infarction in a patient with recurrent ovarian cancer receiving bevacizumab.

•Ovarian cancer patients receiving bevacizumab treatment can experience significant adverse events.•We report a case of vertebral artery dissection associated with bevacizumab treatment.

Immunologic consequences of chemotherapy for ovarian cancer: impaired responses to the influenza vaccine.

OBJECTIVES: To examine the effect of chemotherapy for ovarian cancer on immunologic function and to define the effect on the serologic response to the influenza vaccine. METHODS: Under IRB approved protocols, patients with ovarian cancer were administered seasonal trivalent killed influenza vaccines. Peripheral blood was collected for immunologic assessments. Serum was analyzed for hemagglutination inhibition (HAI) antibody titers. Peripheral blood mononuclear cells were isolated to characterize T and B cell populations and function. RESULTS: Thirty-one patients were recruited: 13 in remission receiving a dendritic cell vaccine with or without a single dose of low-dose cyclophosphamide, 3 in remission not receiving treatment, and 15 undergoing standard therapy. Significant effects on T cell and B cell subset distributions were seen. Functional effects were also seen. Few patients were able to mount a 4-fold HAI antibody response. A 4-fold response was observed for H1N1 in 20%, for H3N2 in 26%, and for influenza B in 6%. Pre-existing exposure to influenza was predictive of responders. CONCLUSIONS: Despite CDC recommendations that patients undergoing chemotherapy receive influenza vaccine, there is little evidence to support its serologic effectiveness in this population. Patients with ovarian cancer are almost uniformly unable to mount a meaningful antibody response. These findings have serious implications for future resource allocation for both seasonal and novel pandemic influenza outbreak and understanding the immunologic deficits as a result of chemotherapy may improve patient care.

Metastatic cholangiocarcinoma to the ovary: a case series.

Metastases to the ovary can be a challenging diagnostic dilemma as they often present similarly to a primary ovarian cancer, and there are many potential sites of origin. We present a case series of 5 patients with known cholangiocarcinoma recurrent in the ovary after completion of initial multimodality therapy including surgical resection of the primary tumor followed by adjuvant chemotherapy.

Physical activity and lower limb lymphedema among uterine cancer survivors.

PURPOSE: Physical activity (PA) is known to provide physical and mental health benefits to uterine cancer survivors. However, it is unknown if PA is associated with lower limb lymphedema (LLL), an accumulation of protein-rich fluid in the lower limbs. Therefore, we sought to examine the association between PA and LLL in uterine cancer survivors, with a focus on walking. METHODS: We conducted a cross-sectional study using mailed surveys among uterine cancer survivors who received care at a university-based cancer center. We asked about PA, walking, and LLL symptoms using validated self-report questionnaires. PA was calculated using MET-hours per week, and walking was calculated using blocks per day. RESULTS: The response rate to our survey was 43%. Among the 213 uterine cancer survivors in our survey, 36% were classified as having LLL. Compared with participants who reported <3 MET · h · wk of PA, participants who reported ≥ 18.0 MET · h · wk of PA had an odds ratio of LLL of 0.32 (95% confidence interval, 0.15-0.69; P trend = 0.003). Stratified analyses suggested the association between PA and LLL existed only among women with body mass index (BMI) <30 kg · m (P trend = 0.007) compared with women with BMI ≥ 30 kg · m (P trend = 0.47). Compared with participants who reported <4.0 blocks per day of walking, participants who reported ≥ 12 blocks per day of walking had an odds ratio of LLL of 0.19 (95% confidence interval, 0.09-0.43; P trend < 0.0001). Stratified analyses suggested the association between walking and LLL was similar among women with BMI <30 kg · m (P trend = 0.007) and women with BMI ≥ 30 kg · m (P trend = 0.03). CONCLUSION: Participation in higher levels of PA or walking is associated with reduced proportions of LLL in dose-response fashion. These findings should be interpreted as preliminary and should be investigated in future studies.

A review of dendritic cell therapy for cancer: progress and challenges.

Dendritic cells are the professional antigen-presenting cells of the innate immune system with the potential to generate robust antigen-specific T cell immune responses. Immunotherapeutic strategies have attempted to monopolize on this ability of dendritic cells to deliver antigens as a means of therapeutic vaccination in individuals with advanced malignancies. Since the publication of the first clinical trial in melanoma patients in 1995, therapeutic dendritic cell cancer vaccines have been extensively studied in numerous phase I and II trials. While advances have been encountered (especially with prostate cancer), there are still considerable challenges that need to be addressed in future clinical trials. In this review, we describe the current methodology and highlight trials which have contributed to the development of dendritic cell vaccines. We then review strategies to optimize dendritic cell vaccines in order to improve antitumor responses in cancer patients.

The prevalence of lymphedema symptoms among survivors of long-term cancer with or at risk for lower limb lymphedema.

OBJECTIVE: The aim of this study was to identify commonly reported symptoms in the lower limbs among those with or at risk for developing lower limb lymphedema (LLL). DESIGN: The authors surveyed survivors of long-term cancer using the Pennsylvania State Cancer Registry. They inquired about demographics, cancer treatment history, knowledge about LLL, and symptoms experienced since completing cancer treatment. They invited all participants for an in-person clinical assessment to better identify and characterize the symptoms associated with LLL. RESULTS: The response rate to the study survey was 57.2%. Among the 107 participants who answered the study survey, 37 (34.5%) reported one or more symptoms associated with LLL. Many reported a combination of symptoms that included difficulty walking (n = 37; 100%), aching (n = 32; 86%), puffiness (n = 28; 76%), and pain (n = 27; 73%) on one side of the body since cancer treatment. The in-person clinical assessment among a subsample of 17 participants revealed 10 participants with no evidence of LLL and 5 and 2 participants with grade 1 and 2 LLL, respectively. The in-person clinical assessment identified three cases of previously undiagnosed LLL. CONCLUSIONS: One third of the survivors of cancer surveyed reported experiencing new symptoms in the lower limbs since cancer treatment. Cases of symptomatic, undiagnosed LLL may exist in the population.

Bevacizumab-induced perforation of the gastrointestinal tract: clinical and radiographic findings in 11 patients.

AIM: To present the gastrointestinal (GI) complications associated with bevacizumab therapy and their findings on abdominal imaging studies. METHODS: A computerized search identified 11 patients with GI complications of bevacizumab therapy on abdominal CT (n = 11) and fluoroscopic GI contrast studies (n = 4) who met our study criteria (including five patients with ovarian cancer, five with colon cancer, and one with cervical cancer). The medical records and imaging studies were reviewed to determine the clinical and radiographic findings in these patients. RESULTS: All 11 patients had findings of GI perforation on CT, or CT and GI contrast studies. CT revealed a localized extraluminal collection containing gas, fluid, and/or contrast material in eight patients (73%) with focal perforation, and free abdominal air and fluid in three (27%) with free perforation The imaging studies also revealed seven fistulas, including two colovaginal, one rectovaginal, one enterocutaneous, one colocutaneous, one gastrocolic, and one colorectal fistula. Eight (73%) of the 11 patients died within 1 year of the development of GI perforation, and the perforation was felt to be the cause of death in four patients (36%). CONCLUSION: Abdominal CT and fluoroscopic GI contrast studies are useful imaging tests for the diagnosis of potentially life-threatening GI perforation as a complication of bevacizumab therapy. When GI perforation is detected on abdominal imaging studies, treatment with bevacizumab should immediately be discontinued.

Dendritic cell-based tumor vaccinations in epithelial ovarian cancer: a systematic review.

After decades of extensive research, epithelial ovarian cancer still remains a lethal disease. Multiple new studies have reported that the immune system plays a critical role in the growth and spread of ovarian carcinoma. This review summarizes the development of dendritic cell (DC) vaccinations specific for ovarian cancer. So far, DC-based vaccines have induced effective antitumor responses in animal models, but only limited results from human clinical trials are available. Although DC-based immunotherapy has proven to be clinically safe and efficient at inducing tumor-specific immune responses, its clear role in the therapy of ovarian cancer still needs to be clarified. The relatively disappointing low-response rates in early clinical trials point to the need for the development of more effective and personalized DC-based anticancer vaccines. This article reviews the basic mechanisms, limitations and future directions of DC-based anti-ovarian cancer vaccine development.