The psychosocial impact of cervical cancer among affected women and their partners.

This study aimed to assess the range and intensity of psychosocial concerns experienced by women with cervical cancer and their male partners. A cross-sectional survey assessed 26 couples where the woman had invasive cervical cancer stage I-IV, up to 2 years posttreatment, using a concerns questionnaire and widely used psychosocial questionnaires. Respondents indicated their concerns about the impact of the disease and treatment as well as general psychosocial impact. Women with cervical cancer and their male partners expressed equal intensities of concern regarding the illness and its treatment, rating sexuality, prognosis, and communication with the treatment team most highly in terms of current concerns. Couples where the patient had a more advanced stage of cancer expressed higher concerns than those with earlier stage disease. Although women with cervical cancer reported more fatigue and illness intrusiveness than their male partners, both experienced disruptions in relationships, intimacy, and instrumental life domains. With increased time posttreatment, concerns differed subtly between affected women and their male partners. Effective psychosocial support for cervical cancer must be provided for both the affected woman and her male partner. Support and information should address the most salient concerns of patients and partners as these evolve over significant clinical milestones.

Pseudomyxoma peritonei: a case series and review of the literature.

The purpose of this study was to use descriptive methodology to study the management of patients with pseudomyxoma peritonei (PMP) at the Princess Margaret Hospital. This is a case series of patients with a diagnosis of PMP treated between January 1, 1995 and December 31, 2001. A health record search using the morphology code for PMP was done and identified 70 patients. Additionally, an unrestricted Medline search was conducted between 1990 and 2002 for PMP. Eight cases of PMP were treated by the Gynecologic Oncology service at Princess Margaret Hospital during the study period. The patients ranged in age from 43 to 84 and presented with a pelvic mass and/or increasing abdominal girth. All but two patients underwent appendectomy as part of their surgery. Postoperative management was by gynecologic oncology for seven of eight patients. An appendiceal origin was confirmed for six patients and highly suspicious for one patient. The remaining patient underwent appendectomy, but it was not sufficiently sectioned for diagnosis. Chemotherapy was given to patients in a non-uniform fashion. Removal of mucinous tumors of the ovary should include appendectomy. Consultation from a general surgical oncologist should be sought where appendiceal origin is confirmed. Coding errors may occur in medical records at a frequency greater than is anticipated.

How important is removal of the parametrium at surgery for carcinoma of the cervix?

OBJECTIVES: The aims of this study were (1) to determine the incidence and factors predictive for pathologic parametrial involvement in clinical stage IA1/2 and IB1 cervical cancer after radical surgery and (2) to identify a population at low risk for pathologic parametrial involvement. METHODS: All patient information was collected prospectively and extracted from a cervical cancer radical surgery database. Selection criteria for surgery were generally based upon tumor size, with the cutoff for surgery between 3 and 4 cm. Parametrial involvement (PI) was defined as either positive parametrial lymph nodes (PMLN) or malignant cells in the parametrial tissue (PT) (including lymphovascular channels) by either contiguous or discontiguous spread. Statistical analysis included the chi2 test, the Wilcoxon rank test, and the Mantel-Haentzel test. RESULTS: Between July 1984 and January 2000, 842 patients underwent radical surgery for clinical stage IA1/2 and IB1 cervical cancer at our center. Forty-nine patients (6%) had positive pelvic lymph nodes. Thirty-three patients (4%) had pathologic PI, 8 in the PMLN and 25 in the PT (none had both). PI was associated with older age (42 vs 40 years, P < 0.04), larger tumor size (2.2 vs 1.8 cm, P < 0.04), higher incidence of capillary-lymphatic space invasion (85% vs 45%, P = 0.0004), tumor grades 2 and 3 (95% vs 65%, P = 0.001), greater depth of invasion (18.0 vs 5.0 mm, P < 0.001), and pelvic lymph node metastases (44% vs 5%, P < 0.0001). The incidence of PI in patients with tumor size < or =2 cm, negative pelvic lymph nodes, and depth of invasion < or =10 mm was 0.6%. CONCLUSION: Pathologic parametrial involvement in clinical stage IA1/2 and /IB1 cervical cancer is uncommon. Acknowledging that almost all patients with pelvic lymph node metastases and a high proportion of patients with tumor invasion >10 mm will receive adjuvant radiation regardless of the radicality of surgery, a population at low risk for pathologic parametrial involvement can be identified. These patients are worthy of consideration for studies of less radical surgery performed in conjunction with pelvic lymphadenectomy.

Oncologists' use of quality of life information: results of a survey of Eastern Cooperative Oncology Group physicians.

PURPOSE: Objectives of this study were to obtain data from Eastern Cooperative Oncology Group (ECOG) oncologists regarding their views on quality of life (QOL) information; perform psychometric testing on the MD-QOL questionnaire, develop a model to describe oncologists' willingness to use QOL information and propose data-based interventions to facilitate use of QOL information in clinical decision-making. METHODS: A self-administered questionnaire, MD-QOL, designed to assess physician perspective on QOL information was mailed to a random sample of 500 oncologists, members of ECOG; 271 responded. RESULTS: Oncologists' attitude, current behaviour, knowledge of QOL data, and reported willingness to use QOL can be measured using MD-QOL. The attitude, behaviour and willingness scales have high internal consistency. Physician attitude and behaviour account for 59% of the variance in the willingness to use QOL information. Demographic variables influencing physician responses were their primary income source and exposure to trials with a QOL component. CONCLUSIONS: This report of ECOG oncologists' views on QOL information suggests a model to describe relationship between physician willingness to use QOL information on the basis of their attitude and behaviour. Data-based interventions are proposed to influence the key variables and thus facilitate the incorporation of QOL data in clinical practice.

Changes in the demographics and perioperative care of stage IA(2)/IB(1) cervical cancer over the past 16 years.

OBJECTIVES: The aim of this study was to determine whether there have been any significant changes in the demographics and perioperative care of FIGO stage IA(2)/IB(1) cervical cancer over the past 16 years and, if so, to quantify them. METHODS: Since July 1984, all patients with FIGO stage IA(2)/IB(1) cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Selection for surgery has been unchanged over the past 16 years. Since March 1994 and November 1996, one surgeon has performed radical vaginal trachelectomy and laparoscopic assisted radical vaginal hysterectomy, respectively. Statistical analysis used Spearman's correlation analysis, the proportional hazards regression model of Cox, and the Mantel-Hanzel test was performed. Due to the number of statistical analyses, statistical significance was defined as P < 0.01. RESULTS: Eight hundred sixty-four patients have undergone radical surgery (784 radical hysterectomy, 42 radical vaginal trachelectomy, 32 radical vaginal hysterectomy, 6 radical abdominal trachelectomy) for FIGO stage IA(2)/IB(1) carcinoma of the cervix by members of our division since 1984. There have been no changes in the median age (40 years), tumor size (2.0 cm), incidence of capillary lymphatic space involvement (47%), or positive pelvic lymph nodes (6%) over the past 16 years. The median Quetelet index (24.6), depth of tumor invasion (squamous cell carcinomas only) (6.0 mm), and proportion of patients with comorbid conditions (17%) have increased over time (P = 0.001, P = 0.003, and P < 0.001, respectively). Pathologically, there has been an increase in the proportion of adenocarcinomas (28%) and a decrease in the proportion of grade 3 tumors (28%) (P < 0.001 and P < 0.001, respectively). The median operating time (2.8 h), hospital stay (7.0 days), blood loss (600 cc), allogeneic blood transfusion (23%), postoperative infections (13%), and noninfectious complications (6%) have all decreased (P < 0.001, P < 0.001, P < 0.001, P < 0.001, P < 0.001, and P = 0.002, respectively). There has been no change in the incidence of positive surgical margins (3%), adjuvant radiation (13%), or recurrence-free survival (2 and 5 years, 94 and 90%, respectively) after a median follow-up of 45 months. CONCLUSION: Despite no substantive changes in the selection criteria for surgery and the small time interval studied (16 years), almost all indices of operative and postoperative morbidity analyzed have decreased significantly. These changes have occurred without an increase in the use of adjuvant radiation or decrease in recurrence-free survival. Although little progress has been made in the cure rates associated with surgical management of FIGO stage IA(2)/IB(1) cervical cancer during this time interval, it appears that the morbidity of surgery has decreased.

Quality-of-life information and clinical practice: the oncologist's perspective.

OBJECTIVE: To collect information from a group of Canadian oncologists about their perspectives on quality of life (QOL) and QOL information. DESIGN: A self-administered questionnaire (MD-QOL) containing 75 items with a 4-point Likert categorical response scale was administered by mail using Dillman survey methodology to all staff oncologists at a single institution. SETTING: A large Canadian cancer care centre (Princess Margaret Hospital, Toronto). MAIN OUTCOME MEASURES: Oncologists' knowledge, attitude, current behaviour and intended willingness to use QOL information. RESULTS: Of 67 eligible respondents 54 replied (80% response rate). In all, 74% felt that QOL can be quantified, and 95% felt that it gives information distinct from performance status measures. A total of 87% felt that published QOL data are useful for individual patient care, but 69% indicated that, at present, they would be more likely to base their recommendations on personal experience rather than on published literature. Of the respondents, 57% felt that decisions were made more difficult when QOL issues are considered. CONCLUSIONS: The surveyed oncologists support the relevance and importance of QOL information. Data from this study were used to develop a predictive model to assess oncologists' willingness to use QOL information; the model is being tested in other studies.

A preliminary survey of oncologists' perceptions of quality of life information.

Quality of life (QOL) of cancer patients has become the focus of increasing research in oncology, and a frequently measured endpoint in clinical trials. Very little attention has been paid to the perspective of physicians on quality of life information, and its role in clinical decision-making. This report describes the findings of research focused on exploring the perspectives of physicians about quality of life information that is available for cancer patients. On the basis of qualitative data gathered through in-depth interviews with 60 oncologists in the first phase of this project, we have developed a self-administered questionnaire (MD-QOL survey) designed to assess oncologists' views on QOL. This survey was administered to an international group of gynecologic oncologists. The objectives of this study were to assess the face validity of the initial items in the MD-QOL, to expand the pool of items, and to assess the feasibility of utilizing a self-administered questionnaire to assess physicians' perspectives on QOL information. Twenty-eight oncologists responded to the questionnaire. The majority of respondents felt that QOL can be measured and that it should be measured from the patient's own perspective. Half of the physicians felt that currently available QOL information is useful in clinical practice. Ninety-three percent of respondents felt that the greatest benefit of QOL information is 'being able to treat the whole patient'. Forty one percent of respondents felt that length of survival is more important to patients than quality of life. However, only 7% of the respondents felt that the primary job of physicians is to save lives, and that QOL should not be a predominant concern for physicians. The inclusion of QOL in randomized trials was perceived as encouraging both patient and physician participation. The results of this survey are being used to further explore these critical issues.

Physicians' perspective on quality of life: an exploratory study of oncologists.

There is an implicit assumption that physicians incorporate quality of life (QOL) information in clinical decision-making. However, very limited data exists on how physicians view QOL information and how they actually use it. To explore this issue, an in-depth study was conducted using a semi-structured interview guide, with 60 oncologists in Canada and the USA. While the majority of respondents perceived QOL as important they reported a tendency to use it informally and not in all situations. Key findings include the belief expressed by 88% of respondents that the term QOL could be defined, although they differed in their definitions. Although 85% stated that QOL can be formally measured, only a third perceived that the current instruments provide valid and reliable data. Respondents noted a number of significant benefits and drawbacks of using QOL data in their clinical practice that had not been previously noted in the literature. For example, its use as an endpoint in clinical trials was generally perceived to enhance both physician and patient participation. A drawback noted was that including QOL might adversely affect the decision-making process. These findings have been used to develop a self-administered questionnaire (MD-QOL) which will test the generalizability of these findings.

Laparoscopic ovarian transposition.

Preservation of ovarian function is both safe and feasible in many young women with pelvic malignancies. Techniques utilized to transpose the ovaries to date have uniformly required a laparotomy either at the time of surgical treatment or as a separate operation in patients about to undergo pelvic radiotherapy. We report our preliminary results in 3 patients who underwent laparoscopic ovarian transposition and pelvic lymphadenectomy as part of an experimental protocol using intracavitary radiation alone in patients with small node negative stage 1B cervical carcinoma desiring preservation of fertility. Dose calculations were performed to estimate the amount of radiation each transposed ovary received from the intracavitary radiation, as well as the dosage that would have been received had external pelvic (4500 cGy) with or without para-aortic nodal irradiation (4500 cGy) been required. The mean estimated distance each ovary was transposed was 14.4 cm for the right ovary and 14.3 cm for the left ovary. Operative times ranged from 2.75-4.0 hours, and the blood loss 100-300 mls. Post-operative hospital stays ranged from 1-2 days, and no complications were encountered. Two of the 3 patients are menstruating regularly 25-32 months after completion of treatment with serum FSH in the normal premenopausal range. Based on the above distances, the mean dose of radiation each transposed ovary received was estimated to be 126 cGy, whereas the range in dosage of radiation each ovary would have received had external pelvic +/- para-aortic nodal irradiation been required was 135-190 cGy, and 230-310 cGy respectively. One patient has become menopausal after her transposed ovaries slipped back into the pelvis. Laparoscopic ovarian transpositions can be performed. This procedure is technically easy to perform for those surgeons skilled in laparoscopic surgery and its preliminary morbidity appears to be low. More experience, longer followup, and refinement in the methods of ovarian transfixation are required.

Clinical review of adult granulosa cell tumors of the ovary.

Granulosa cell tumors are uncommon neoplasms that are characterized by their long natural history and for their tendency to recur years after an apparent clinical cure. As such they are difficult tumors to study. In the majority of cases, the initial therapy is surgical although the extent of the necessary procedure remains controversial. The role for any adjuvant therapy after complete resection remains to be established. In patients with advanced disease, combination chemotherapy consisting of cisplatinum/vinblastine/bleomycin has the highest identified response rates. In patients with recurrent or metastatic disease therapy is palliative and has not yet been standardized. Treatments therefore need to be individualized.

Etiology, epidemiology, risk and prognostic factors, screening, and imaging of gynecologic cancers.

This review presents some of the articles published over the past year pertaining to the etiology, epidemiology, risk and prognostic factors, screening, and imaging techniques of gynecologic cancer. The most significant advances in this period were made in the area of the genetics of gynecologic cancers and the factors that control tumor growth. New technologies are being developed in this area, which may eventually produce therapies aimed at controlling gynecologic cancers at the genetic or cellular level. Research continues for ideal screening tests for noncervical gynecologic cancers. Continuing advances were made in imaging techniques, eg, magnetic resonance imaging, which can now display very high-resolution pictures of cancers in vivo, but this technology is limited by both cost and insufficient studies proving its value.

Changing concepts in the management of vulvar cancer.

Vulvar carcinoma varies widely in its clinical presentations and prognosis. The reviewed literature outlines the achievements of conventional surgery, radiation, or chemoradiation therapy in its management. Currently therapeutic concepts are evolving. New treatment strategies replacing the uniform use of radical vulvectomy and bilateral groin dissection are proposed. These strategies are tailored to the clinical and pathological disease extent and location and integrate the possible therapeutic advantages of both surgery and chemoradiation. The testing and use of the proposed multimodality therapy protocols require the expertise of gynecologic, radiation, and medical oncologists. This approach should lead to improved anatomic and functional preservation in early disease and improved locoregional in advanced disease.

Current therapy for dysgerminoma of the ovary.

It is important that therapy of ovarian dysgerminoma be optimized because of the young age of women affected and the threat that therapy may pose to fertility. Our understanding of dysgerminoma has improved, so that treatment schemes with better therapeutic ratio may now be used. Approximately 65% of patients present with stage IA disease. For those wishing to preserve fertility, conservative surgery with close clinical, radiologic, and serologic follow-up is the treatment of choice, with chemotherapy for relapse. Cure rates should approach 100%, and fertility is usually preserved. Intra-abdominal relapse in those not wishing to preserve fertility should be treated with modest-dose pelvic and abdominal irradiation. For those patients with disease presenting in stages IB, II, and III who wish to maintain fertility, unilateral oophorectomy followed by combination chemotherapy may be curative and spare ovarian function. Otherwise, complete surgery, followed by abdominopelvic radiation therapy, is recommended. This treatment produces less morbidity than chemotherapy and will cure approximately two-thirds of patients. Chemotherapy should be used for salvage of subsequent relapse. Both radiation and chemotherapy are highly effective treatment modalities for dysgerminoma. This information, coupled with better understanding of the patterns of disease spread and improved ability to identify nondysgerminomatous elements using serum tumor markers, means that a more conservative approach can be taken to management without compromising the chance of cure. Cure rates for dysgerminoma should now approach the role of 97% achieved in the comparable tumor, testicular seminoma.

Pelvic exenteration.

Exenteration, or complete excision of the pelvic viscera, is an ultra-radical surgical procedure intended for curative treatment of the patient with advanced pelvic malignancy--primary or recurrent. At the time of introduction of this procedure, enthusiasm for its use was marred by the high incidence of serious surgical morbidity and mortality, which approached the five-year survival rate. With more careful physiological and psychological selection of patients, concentration of this kind of procedure in centres familiar with its use, improved urinary conduit techniques and careful attention to covering the pelvic floor with omentum and/or synthetic materials, the morbidity and mortality rate has been significantly reduced thus making exenteration a more acceptable treatment option to a wider spectrum of patients. More sophisticated haemodynamic monitoring, both intra- and postoperatively, intravenous hyperalimentation, prophylactic antibiotics and low-dose heparin are undoubtedly important adjuncts to the improvements in surgical technique and judgment. Psychosexual 'rehabilitation' in the broadest sense must be an integral part of patient care for those undergoing exenteration and in most instances necessitates involvement of the patient's partner. Exenteration has only a very limited role in palliation and all attempts should be made to avoid this procedure when cure is clearly not a possibility.

Vinblastine, bleomycin, and cisplatin in malignant germ cell tumors of the ovary.

Fourteen patients with malignant ovarian germ cell tumors were treated with vinblastine, bleomycin, and cisplatin. A complete clinical response was achieved in all 14 patients; however, 1 patient had small macroscopic disease present at second-look laparotomy. One patient died of bleomycin pulmonary toxicity. The remaining 13 patients are alive and free of disease from 20 months to 8 years and 8 months after initial diagnosis. Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels were monitored in all patients and were found to be reliable indicators of response to treatment and disease status. The uninvolved ovary was preserved in seven patients without compromising the response to treatment, and one patient subsequently became pregnant. Vinblastine, bleomycin, and cisplatin chemotherapy appears to be a safe, effective combination and is recommended as the primary treatment of choice in the management of patients with malignant ovarian germ cell tumors.

Adenocarcinoma in a cecal neovagina--complication of irradiation: report of a case and review of literature.

A 42-year-old woman is presented with her fifth primary pelvic carcinoma, occurring in an irradiated cecal neovagina. Previously reported neovaginal carcinomas are reviewed. The possible etiologies are examined. This is the first case of radiation-induced carcinoma arising in a cecal neovagina. Long-term follow-up is important in all patients with neovaginas.

Appendicitis masking as recurrent squamous cell carcinoma of the cervix.

The diagnosis of pelvic recurrent squamous cell carcinoma of the cervix is made on the basis of clinical assessment and radiologic confirmation. Occasionally the diagnosis is confused with sequelae of radiation therapy. The authors describe the symptoms and signs of appendicitis mimicking recurrent squamous cell carcinoma in a 43-year-old female. A 10-year search of the literature has failed to detect another case report or review. The authors believe that, if there is ever any doubt as to the diagnosis of pelvic recurrent squamous cell cancer, exploratory laparotomy and biopsies are warranted for confirmation.

Stage I endometrial adenocarcinoma: treatment results in 835 patients.

A 16-year review of 835 patients with Stage I adenocarcinoma of the uterus revealed histologic grade and depth of myometrial invasion to be salient prognostic factors. Sixteen percent of patients developed recurrent disease and despite aggressive treatment, only 10% of these survived. Preoperative or postoperative radium decreased the incidence of vault recurrence.