Surviving and thriving: What do survivors of gynecologic cancer want?

The purpose of this study was to characterize survivorship concerns and survivorship program preferences among gynecologic cancer survivors. Women treated for gynecologic malignancy at our cancer center were surveyed from 1/2019 to 10/2020 on concerns and preferences using a 5-point Likert scale. Descriptive analysis and multivariable logistic regression were performed to describe survivors' concerns/preferences. The most frequent survivorship concerns were fear of cancer recurrence (49.6%), desire to lose weight (40.0%), and long-term side effects (30.7%). The highest ranked survivorship program components included assistance with nutrition (36.5%), weight loss (30.4%), and stress reduction (29.0%). Older patients (≥64 y) were less likely to report concern with losing weight (OR 0.26, p < 0.05), sex life (OR 0.18, p < 0.01), and strain in family relationships (OR 0.27, p < 0.05) compared with younger patients. Compared with ovarian/fallopian tube/primary peritoneal cancer survivors, endometrial cancer survivors were less likely to desire nutritional education (OR 0.06, p < 0.01). Participants with advanced cancer were less likely to desire assistance with weight loss than those with early stage cancer (OR 0.23, p < 0.05). A significant portion of gynecologic cancer survivors reported a fear of cancer recurrence. Assistance with nutrition and weight loss were the most desired survivorship program components. Variation in patient preferences and differences among clinical subgroups highlight the need for tailored survivorship care.

Clinical outcomes in ovarian cancer patients receiving three versus more cycles of chemotherapy after neoadjuvant treatment and interval cytoreductive surgery.

OBJECTIVES: To compare clinical outcomes for stage IIIC and IV ovarian cancer patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery followed by up to three versus more cycles of post-operative chemotherapy. METHODS: We conducted a multi-institution retrospective cohort study of patients treated from January 2005 to February 2016 with neoadjuvant platinum-based therapy followed by interval surgery and post-operative chemotherapy. The following were exclusion criteria: more than four cycles of neoadjuvant chemotherapy, bevacizumab with neoadjuvant chemotherapy, non-platinum therapy, prior chemotherapy, and elevated CA125 values after three post-operative chemotherapy cycles. Progression-free and overall survival and toxicity profiles were compared between groups receiving up to three cycles versus more that three cycles post-operatively. RESULTS: A total of 100 patients met inclusion criteria: 41 received up to three cycles and 59 received more than three cycles. The groups were similar in terms of age, body mass index, performance status, tumor histology, optimal cytoreduction rates, and median number of neoadjuvant chemotherapy cycles. Median progression-free survival was 14 vs 16.6 months in those receiving up to three cycles versus more than three cycles, respectively (HR 0.99, 95% CI 0.58 to 1.68, p=0.97). Similarly, median overall survival was not different at 47.1 vs 69.4 months, respectively (HR 1.96, 95% CI 0.87 to 4.42, p=0.10). There were no differences in grade 2 or higher chemotherapy-related toxicities. CONCLUSIONS: Extending post-operative chemotherapy beyond three cycles in patients receiving neoadjuvant chemotherapy and interval cytoreductive surgery with normalization of CA125 levels was not associated with improved survival or greater toxicity. Future study in a larger cohort is warranted to define optimal length of cytotoxic treatment.

Pubovesical sling for residual incontinence after successful vesicovaginal fistula closure: a new approach to an old procedure.

INTRODUCTION AND HYPOTHESIS: For decades, the pubovesical (PV) sling has been in the armamentarium of the fistula surgeon for treating persistent urinary incontinence after successful fistula closure. We report our early experience with slings, and then also introduce a new "tight" PV sling technique for management of post-fistula urethral leak. Our hypothesis is that performance of tight slings might result in improved continence for women with persistent urinary incontinence after obstetric fistula closure. METHODS: Data from 120 patients in whom some type of sling procedure had been performed between 1996 and 2012 were extracted and labeled as "early slings." Beginning in October 2014, more complete data were recorded and a more uniform approach was undertaken in 40 patients. Data were extracted from their charts and recorded as "tight slings." This information was analyzed using Chi-squared analysis. RESULTS: Tight slings were more successful in patients who had less severe fibrosis and who had a shorter time since initial injury. Thirty percent of women who underwent tight slings had improved continence at follow-up. CONCLUSION: Persistent urinary incontinence despite successful surgical closure of obstetrical fistula remains a difficult problem. Tight slings may be warranted in an attempt to avoid urinary diversion.

Venous Thromboembolism in Patients Receiving Extended Pharmacologic Prophylaxis After Robotic Surgery for Endometrial Cancer.

OBJECTIVE: This study aims to determine the rate of postoperative venous thromboembolism (VTE) in endometrial cancer patients undergoing robotic hysterectomy with or without extended pharmacologic VTE prophylaxis. METHODS/MATERIALS: A retrospective chart review of women undergoing robotic hysterectomy with or without other procedures for endometrial cancer from January 2010 to February 2015 was conducted at 2 institutions. Charts were manually abstracted, and rates of VTE within 30 and 60 days after surgery were determined. Patients were then stratified by those who did and did not receive extended VTE prophylaxis. RESULTS: A total of 403 patients were included, of which 367 patients (91%) received extended pharmacologic prophylaxis and 36 patients (9%) did not. Low molecular weight heparin prescriptions ranged from 7 to 30 days. Patients receiving extended prophylaxis (EP) were older (63 ± 11 vs 57 ± 12; P = 0.004), more frequently underwent lymphadenectomy (67% vs 34%; P < 0.001), and had higher-grade tumors compared with patients not receiving EP. Overall 30-day and 60-day VTE rates were 0.7% and 1.2%, respectively. There were no significant differences in 30-day and 60-day VTE rates among patients that did and did not receive EP, although a trend toward lower VTE rates in the EP group was observed (30-day rates 0.5% vs 2.8% respectively, P = 0.25; 60-day rates 0.8% vs 5.6%, P = 0.07). CONCLUSIONS: In this study, 30-day and 60-day VTE rates after minimally invasive surgery for endometrial cancer were low. Rates were also similar to those of previous reports in this setting in which the majority of patients did not receive extended VTE prophylaxis. Given the consistent finding that postoperative VTE in this population is rare regardless of prophylaxis use and the variability in practice patterns for VTE prophylaxis, the development of best practice guidelines for EP use specific to this setting is warranted.

Effect of HIV infection on outcomes after surgical repair of genital fistula.

OBJECTIVE: To compare outcomes following surgical repair of genital fistula among Nigerian women with or without HIV. METHODS: A retrospective review was conducted of all genital fistula repair surgeries performed at Evangel Vesicovaginal Fistula Center in Jos, Nigeria, between January 1, 2004, and April 30, 2014. Patient characteristics, HIV status, genital fistula characteristics, and postoperative outcomes were assessed for between-group variance. The odds ratio (OR) and 95% confidence intervals (CIs) were the primary measures used for determining the association between HIV status and surgical outcomes. RESULTS: Of the 3313 surgeries recorded, 201 (6.1%) were performed among patients with HIV infection. No statistically significant between-group differences were found for patient or fistula characteristics. By contrast, failed vesicovaginal failure (VVF) closure was significantly more common among women infected with HIV than among their HIV-negative counterparts (OR 0.629, 95% CI 0.443-0.894). No between-group differences in failure rates were found for ureterovaginal or rectovaginal fistulas. CONCLUSION: Determining HIV status before surgery could aid prediction of outcomes among Nigerian women undergoing repair of VVF. Further studies are required to examine factors that might improve outcomes for women with HIV infection.

Bladder stones in vesicovaginal fistula: is concurrent repair an option? Experience with 87 patients.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the outcomes of a one-stage approach to bladder stones in the setting of a vesicovaginal fistula, performing fistula repair concurrently with stone extraction. METHODS: Retrospective review of urogenital fistula surgeries at Evangel VVF Center in Jos, Nigeria, between December 2003 and April 2014, identified 87 women with bladder stones accompanying their fistulas and 2,979 repaired without stones. Concurrent stone extraction and fistula repair were performed in 51 patients. Outcomes were compared with respect to fistula size, classification, and fibrosis. RESULTS: Women presenting with bladder stones were older and had larger fistulas than those without stones (P < 0.001). Additionally, their fistulas were more often classifiable as large and less often as high (P = 0.02), and were more fibrotic (P = 0.003). Twenty-six (51 %) patients with concurrent repair successfully became dry. Comparing results by classification, concurrent repair of high fistulas with stones was very likely to be successful (OR 8.8, 95% CI 1.0-78.2), whereas low fistulas were not (OR 0.2, 95% CI 0.02-0.7). Outcomes were similar to those of patients without stones, except for low fistulas, which were 5 times more likely to fail (P = 0.04). CONCLUSION: Concurrent closure of vesicovaginal fistula at the time of bladder stone extraction is possible and, in many respects, preferable to a staged approach, particularly among high or midvaginal fistulas.

Urinary diversion for patients with inoperable obstetric vesicovaginal fistula: the Jos, Nigeria experience.

INTRODUCTION: Repair of obstetric urinary fistula may result in successful fistula closure, but often incontinence persists. Our goal was to review our experience with continent urinary diversion in our patients with inoperable vesicovaginal fistula (VVF). METHODS: The database of patients who underwent urinary diversion at ECWA Evangel VVF Centre in Jos, Nigeria, between 1996 and 2012, was reviewed. Complications and surgical outcomes were noted. The earlier patients (1996-2002) and the later patients (2003-2012) were compared. RESULTS: Urinary diversions were performed on 118 patients. Compared with the earlier patients, the later patients more often underwent modified Mainz II diversions, had similar complication rates, but had better outcomes. The use of ureteric catheters intraoperatively and the performance of modified Mainz II pouch were associated with a better outcome. Overall perioperative mortality was 2.5 %. CONCLUSIONS: Urinary diversion is feasible in a low-resource setting. Use of modified Mainz II pouch diversion and intraoperative ureteric catheters were associated with a better outcome. Urinary diversion should be undertaken only after the careful counseling of each patient, and by an experienced surgeon.

Patterns and utility of routine surveillance in high grade endometrial cancer.

OBJECTIVE: To evaluate surveillance methods and their utility in detecting recurrence of disease in a high grade endometrial cancer population. METHODS: We performed a multi-institutional retrospective chart review of women diagnosed with high grade endometrial cancer between the years 2000 and 2011. Surveillance data was abstracted and analyzed. Surveillance method leading to detection of recurrence was identified and compared by stage of disease and site of recurrence. RESULTS: Two hundred and fifty-four patients met the criteria for inclusion. Vaginal cytology was performed in the majority of early stage patients, but was utilized less in advanced stage patients. CA-125 and CT imaging were used more frequently in advanced stage patients compared to early stage. Thirty-six percent of patients experienced a recurrence and the majority of initial recurrences (76%) had a distant component. Modalities that detected cancer recurrences were: symptoms (56%), physical exam (18%), surveillance CT (15%), CA-125 (10%), and vaginal cytology (1%). All local recurrences were detected by symptoms or physical exam findings. While the majority of loco-regional and distant recurrences (68%) were detected by symptoms or physical exam, 28% were detected by surveillance CT scan or CA 125. One loco-regional recurrence was identified by vaginal cytology but no recurrences with a distant component detected by this modality. CONCLUSIONS: Symptoms and physical examination identify the majority of high grade endometrial cancer recurrences, while vaginal cytology is the least likely surveillance modality to identify a recurrence. The role of CT and CA-125 surveillance outside of a clinical trial needs to be further reviewed.

The effect of neighborhood disadvantage on the racial disparity in ovarian cancer-specific survival in a large hospital-based study in cook county, illinois.

This paper examines the effect of neighborhood disadvantage on racial disparities in ovarian cancer-specific survival. Despite treatment advances for ovarian cancer, survival remains shorter for African-American compared to White women. Neighborhood disadvantage is implicated in racial disparities across a variety of health outcomes and may contribute to racial disparities in ovarian cancer-specific survival. Data were obtained from 581 women (100 African-American and 481 White) diagnosed with epithelial ovarian cancer between June 1, 1994, and December 31, 1998 in Cook County, IL, USA, which includes the city of Chicago. Neighborhood disadvantage score at the time of diagnosis was calculated for each woman based on Browning and Cagney's index of concentrated disadvantage. Cox proportional hazard models measured the association of self-identified African-American race with ovarian cancer-specific survival after adjusting for age, tumor characteristics, surgical debulking, and neighborhood disadvantage. There was a statistically significant negative association (-0.645) between ovarian cancer-specific survival and neighborhood disadvantage (p = 0.008). After adjusting for age and tumor characteristics, African-American women were more likely than Whites to die of ovarian cancer (HR = 1.59, p = 0.003). After accounting for neighborhood disadvantage, this risk was attenuated (HR = 1.32, p = 0.10). These findings demonstrate that neighborhood disadvantage is associated with ovarian cancer-specific survival and may contribute to the racial disparity in survival.

The association between neighborhood socioeconomic status and ovarian cancer tumor characteristics.

PURPOSE: Higher pathologic grade, suboptimal debulking surgery, and late-stage are markers of more aggressive and advanced ovarian cancer. Neighborhood socioeconomic status (SES) has been associated with more aggressive and advanced tumors for other cancer sites, and this may also be true for ovarian cancer. METHODS: We examined the association between neighborhood SES and ovarian cancer tumor characteristics using data on 581 women diagnosed with epithelial ovarian cancer in Cook County, Illinois. Two complementary measures (concentrated disadvantage and concentrated affluence) were used to estimate neighborhood SES. Prevalence differences and 95 % confidence intervals were estimated in logistic regression models adjusted for age and race. RESULTS: Greater disadvantage was associated with higher grade tumors (p = 0.03) and suboptimal debulking (p = 0.05) and marginally associated with later tumor stage (p = 0.20). Greater affluence was inversely associated with stage at diagnosis (p = 0.004) and suboptimal debulking (p = 0.03) and (marginally) with tumor grade (p = 0.21). CONCLUSION: Our findings suggest that lower SES, estimated by neighborhood SES, is associated with ovarian cancer tumor characteristics indicative of more advanced and aggressive disease.

Obstetric fistula: the ECWA Evangel VVF Center surgical experience from Jos, Nigeria.

INTRODUCTION AND HYPOTHESIS: The objectives of this study are to analyze the surgical outcomes of women undergoing obstetric fistula repair operations at the ECWA Evangel VVF Center, Jos, Nigeria, and to identify factors associated with postoperative urinary continence. METHODS: Sociodemographic and clinical data were abstracted retrospectively from the Center's database for patients who underwent vesicovaginal fistula (VVF) repair operations. These data were compared with clinical outcome ("wet" or "dry") at the time of hospital discharge. RESULTS: From August 1998 to April 2004, 1,084 fistula repair operations were performed on 926 patients. A vaginal approach was used in 90.1% of cases, and postsurgical continence was achieved in 70.5% of patients. Continence was more likely in patients with an intact urethra, an upper or midvaginal fistula, and less fibrosis than in those patients who remained wet. CONCLUSIONS: Two thirds of patients with obstetric fistulas can be cured, with complete restoration of continence and low surgical morbidity, using a transvaginal surgical approach.

The combination of monthly carboplatin and weekly paclitaxel is highly active for the treatment of recurrent ovarian cancer.

OBJECTIVES: To evaluate the response rate and toxicity of a regimen comprised of monthly carboplatin and weekly paclitaxel for recurrent ovarian cancer. METHODS: We performed a retrospective chart review of patients with recurrent ovarian cancer treated between 2001 and 2006 at a single institution with carboplatin AUC 5 (day 1), and paclitaxel 80 mg/m(2) (days 1, 8, 15) of a 28-day cycle. Primary endpoints were response rate, progression-free survival and overall survival. RESULTS: Twenty patients were treated with this regimen from 2001 to 2006. Stage ranged from stages IC to IV. All received intravenous platinum and taxane as their initial therapy. Histologic subtypes included papillary serous (17), carcinosarcoma (1), and clear cell (2). The median number of prior regimens was 1 (range 1-3). The overall response rate was 85.0% (15 complete responses, 2 partial responses). Patients with tumors categorized as platinum sensitive had a response rate of 93.3% (14/15) and those with tumors deemed platinum resistant had a response rate of 60.0% (3/5). The median survival has not yet been reached after a median follow-up of 28 months. Neutropenia was the only grade 3/4 toxicity, occurring in 7 patients (35.0%). Platinum hypersensitivity reactions occurred in 5 patients (25.0%) who all successfully continued treatment using a carboplatin desensitization protocol. CONCLUSIONS: A monthly carboplatin and weekly paclitaxel regimen is highly active for women with recurrent platinum-sensitive and platinum-resistant epithelial ovarian cancer. The regimen is well tolerated. This pilot series demonstrates the potential for this regimen as treatment of choice among doublet first salvage regimens for patients with recurrent epithelial ovarian cancer, thus warranting multi-institutional study.

The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria.

OBJECTIVE: The purpose of this study was to describe the characteristics of women with obstetric vesicovaginal fistulas at a hospital in north central Nigeria. STUDY DESIGN: A retrospective record review was conducted of all women who were seen with vesicovaginal fistulas at Evangel Hospital in Jos, Plateau State, Nigeria, between January 1992 and June 1999. RESULTS: A total of 932 fistula cases were identified, of which 899 cases (96.5%) were associated temporally with labor and delivery. The "typical patient" was small and short (44 kg and <150 cm); had been married early (15.5 years) but was now divorced or separated; was uneducated, poor, and from a rural area; had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus. CONCLUSION: Obstetric vesicovaginal fistula is extremely common in north central Nigeria. A complex interaction that involves multiple biologic and socioeconomic factors appears to predispose young women to this devastating childbirth injury.