Gynecologic Cancer Care Research Articles

Gynecologic Oncology in the Department of Defense.

Gynecologic oncology existed within the Department of Defense (DOD) prior to its recognition as a separate subspecialty of obstetrics and gynecology. Military gynecologic oncologists were among the founders of the specialty and continue a tradition of leadership and engagement within the field at the national and international level. The full range of gynecologic oncology services is located at the military's largest medical centers, acknowledging the team approach with multiple subspecialties necessary to provide the highest standard of modern gynecologic cancer care. Gynecologic oncologists within the military receive training on par or exceeding that of their civilian counterparts, and their education extends beyond traditional training to prepare them for the unique challenges within military medicine as well. The clinical offerings from these practitioners and their facilities are state of the art, and each offers the full spectrum of care inclusive of surgery and chemotherapy. Closely coupled with expert clinical care is medical education and comprehensive cancer research. The gynecologic oncology research conducted by the DOD spans the scientific spectrum from basic laboratory investigations, to translational and molecular analyses, to all phases of clinical trials. This discussion will examine gynecologic oncology services in the DOD inclusive of infrastructure, personnel and training, clinical care and outcomes, as well as research contributions.

Does gynaecological cancer care meet the needs of Indigenous Australian women? Qualitative interviews with patients and care providers

BackgroundThere is a disparity in the burden of gynaecological cancer for Indigenous women compared with non-Indigenous women in Australia. Understanding how Indigenous women currently experience gynaecological cancer care services and factors that impact on their engagement with care is critical. This study explored Indigenous Australian women’s experience of gynaecological cancer care at a major metropolitan hospital in Queensland.MethodsIndigenous women receiving care at a major metropolitan Queensland hospital for investigation or diagnosis of gynaecological cancer were invited to participate in a larger longitudinal study exploring women’s experiences of gynaecological cancer care. This component was an in-depth, qualitative interview exploring the women’s experiences of hospital care at approximately three-month post initial referral. A peer-approach was used to interview women. Hospital-based care providers involved in the care of Indigenous gynaecological cancer patients were invited to be interviewed. Interviews were transcribed and thematically analysed using an interpretative phenomenological approach enabling a multi-layered, contextualised understanding of the patients' experience and their interaction with tertiary cancer services.ResultsEight Indigenous patients and 18 care providers were interviewed. Analysis of all interviews revealed four broad issues affecting Indigenous patients’ early experiences of care: (1) navigating the system, impacted by timely diagnosis, access to support services and follow up; (2) communication and decision-making, patients’ decision-making, efficacy of doctor-patient communication, and patients’ knowledge about cancer; (3) coping with treatment demands, was impacted by emotional stress, access to services and support by hospital staff; and (4) feeling welcome and safe in the hospital, impacted by patients’ relationship with care providers and their access to culturally-safe services. The combination of factors impacting these women’s’ experience of gynaecological care commonly left these women at breaking point, often with limited access to information, resources or support.ConclusionsOur findings revealed that experiences of cancer care for Indigenous women are overlain by challenges associated with late referral, misdiagnosis, miscommunication, lack of information, logistics in accessing treatment and services and system cultural insensitivities. Our findings offer insights that can inform cancer care provision to more effectively support Indigenous women accessing gynaecological cancer services.

Exploring traditional and complementary medicine use by Indigenous Australian women undergoing gynaecological cancer investigations

BackgroundIndigenous Australian women experience worse gynaecological cancer outcomes than non-Indigenous women. While traditional and complementary medicine (T&CM) is increasingly used by cancer patients alongside conventional treatments, little is known about T&CM use by Indigenous women. This study aimed to explore the beliefs, attitudes and experiences related to T&CM use and disclosure among Indigenous women undergoing gynaecological cancer investigations. MethodsA mixed-methods design explored T&CM use among Indigenous women who presented for gynaecological cancer investigation at an urban Queensland hospital (September 2016 and January 2018). ResultsFourteen women participated. The reported use (86%) and perceived value of T&CM was high among the participants, however, women reported major challenges in communicating with healthcare providers about T&CM, commonly associated with trust and rapport. ConclusionsThese findings highlight the need for strategies to facilitate culturally-appropriate doctor-patient communication around T&CM to foster trust and transparency in gynaecological cancer care for Indigenous women.

Publication trends in Gynecologic Oncology: A 45-year history

Objective: Production and publication of quality research is critical to advancements in gynecologic cancer prevention and care. Gynecologic Oncology has been the leading journal in the field since its first issue in 1972. This study sought to evaluate trends in categories of articles published in Gynecologic Oncology over time.

Improving the quality of care in a public hospital in Guatemala

Guatemala is located in Central America with an estimated population of 16.6 million people, of which 54% are women. Hospital General San Juan de Dios is one of the two major hospitals in our public health system and the only one that provides free gynecological cancer care to our population. After

Gynecologic radiation oncology patients report unmet needs regarding sexual health communication with providers.

Following radiation therapy (RT), women with gynecologic malignancies report high rates of sexual dysfunction, but little is known regarding sexual health communication between these patients and health-care providers. This study assessed these patients' beliefs/attitudes toward providers' sexual history taking. Surveys were administered to women who presented for follow-up care for gynecologic cancers in an academic radiation oncology department. The surveys assessed patient sexual health beliefs and inquiry preferences. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). Ordered logistic regressions were performed to assess for correlations between survey responses, FSFI, and demographic characteristics. Seventy-five subjects participated. Most (89.8%) had FSFI scores indicating sexual dysfunction. Most patients agreed that sexual function is an important component of overall health (78.7%) and that providers should inquire regularly (62.8%). Few (12.0%) reported embarrassment around provider discussions. Most (62.7%) preferred discussion with female providers, especially married patients (p = 0.03). Half (53.4%) agreed that sexual problems are an unavoidable part of aging, a view that was more common as education level decreased (p = 0.01). Most (62.7%) patients agreed that providers should regularly ask about their sexual history, with patients having significant differences in education level. Patients with low FSFI scores were less likely to report inquiry from their OB/Gyn (p = 0.03). Gynecologic cancer radiotherapy patients want to discuss sexual health, but report suboptimal provider inquiry. Patient views and experiences varied based on marital status, education level, and FSFI score. This work highlights the need for improved sexual health communication between cancer patients and providers.

Caregiving Is a Marathon, Not a Road Race: Reenvisioning Caregiver Support Services in Gynecologic Oncology.

As gynecologic cancer care shifts to the outpatient setting, caregivers are instrumental in helping patients navigate the demands of the disease and treatment. Through social media, we aimed to understand the needs of caregivers of patients with gynecologic cancers and support services necessary to meet these needs. On January 10, 2018, a monthly Twitter discussion session was hosted by the GYNecologic Cancer Social Media community (handle @GYNCSM) using the hashtag #GYNCSM. Five topics regarding caregiver needs and support were discussed. Basic descriptive statistics, including means and frequencies of tweets, and a content analysis of the tweets were performed. Forty-six participants posted a total of 471 tweets, with 1.725 million impressions. Four main themes of caregiver needs emerged, including accepting help from others, a need to care for themselves as caregivers, increased access to information and resources, and a need for the health care team to communicate with caregivers. Themes relating to barriers to obtaining support services included practical barriers, a lack of awareness, negative emotions, and a need to do it all themselves. Participants suggested that caregiver support programs include convenient resources, caregiver peer support programs, support for the "work" of caregiving, and support to improve the emotional and physical health of the caregiver. Experts, patients, and caregivers effectively engaged in social media to identify a wide range of needs of caregivers of women with gynecologic cancers. Further research is needed to identify specific support services that could meet the priority needs of a broader network of caregivers.

Sexual Health as Part of Gynecologic Cancer Care: What Do Patients Want?

Sexual health is important to quality of life; however, the sexual health of gynecologic cancer patients is infrequently and inadequately addressed. We sought to understand patient experiences and preferences for sexual health care to help inform strategies for improvement. An anonymous, cross-sectional survey of outpatient gynecologic cancer patients at a large academic medical center was performed as part of a larger study examining patient and caregiver needs. The survey explored patient-provider discussions about sexuality across 3 domains (experiences, preferences, barriers) and 4 phases of cancer care (diagnosis, treatment, treatment completion, follow-up). Age, relationship status, sexual activity, and cancer type were recorded. Mean age was 63 years. Most patients had ovarian cancer (38%) or endometrial cancer (32%). Thirty-seven percent received treatment within the last month, 55% were in a relationship, and 35% were sexuality active. Thirty-four percent reported sexuality as somewhat or very important, whereas 27% felt that it was somewhat or very important to discuss. Importance of sexuality was associated with age, relationship status, and sexual activity but not cancer type. Fifty-seven percent reported never discussing sexuality. Age was associated with sexuality discussions, whereas relationship status, sexual activity, and cancer type were not. The most common barrier to discussion was patient discomfort. Follow-up was identified as the best time for discussion. Sexuality was most often discussed with a physician or advanced practice provider and usually brought up by the provider. Demographic predictors of importance of sexuality to the patient are age, relationship status, and sexual activity. Providers primarily use age as a proxy for importance of sexuality; however, relationship status and sexual activity may represent additional ways to screen for patients interested in discussing sexual health. Patient discomfort with discussing sexuality is the primary barrier to sexual health discussions, and awareness of this is key to developing effective approaches to providing sexual health care.

Survivorship care planning in gynecologic oncology\u2014perspectives from patients, caregivers, and health care providers

PurposeThis qualitative study sought to describe the challenges following treatment and the preferences regarding survivorship care among patients treated for gynecological cancer, their caregivers, and health care providers.MethodsBetween July and August 2017, in-depth semi-structured interviews regarding survivorship were conducted at a large academic hospital in the USA among patients who recently completed treatment (< 12 months) for a gynecological cancer (ovarian, endometrial, cervical, and vulvar) and their primary caregivers. A focus group was conducted among health care providers (oncologists, nurses, and fellows). Main themes were identified using descriptive content analysis.ResultsA total of 30 individuals participated in this study (13 patients, 9 caregivers, 8 health care providers). Almost all participants reported a desire for more information on how to address survivorship needs, specifically as they related to side effects, follow-up schedule, and psychological assistance. Despite this uniformly identified need for more information, preferences for survivorship care planning differed across cancer types and individuals, with respect to content, timing, and mode of delivery. Health care providers expressed challenges in communicating with patients about survivorship, a desire to shift post-treatment conversations to the goal of improving quality of life as opposed to focusing on disease recurrence, and an unmet need for disease specific and individualized survivorship care planning.ConclusionsPatients, caregivers, and health care providers each expressed a need for gynecologic cancer-tailored survivorship care resources.Implications for Cancer SurvivorsThe variation of disease types and patient and caregiver needs may require multi-faceted, individualized survivorship care planning.

Gynecologic Oncologists’ Perceptions of Palliative Care and Associated Barriers: A Survey of the Society of Gynecologic Oncology

Objectives: Gynecologic oncologists frequently care for patients at the end of life with the aid of palliative care (PC) specialists. Our primary objectives were to identify perceived barriers to integrating specialty PC into gynecologic cancer care. Materials and Methods: Members of the Society of Gynecologic Oncology (SGO) were invited to participate in an anonymous online survey. A Likert scale captured perceptions regarding primary and specialty PC, frequent barriers to use of PC, and potential interventions. Results: A total of 174 (16%) gynecologic oncologists completed the survey. The majority (75%) agreed or strongly agreed that PC should be integrated into cancer care at diagnosis of advanced or metastatic cancer. The most frequently perceived PC barriers included patients’ unrealistic expectations (54%), limited access to specialty PC (25%), poor reimbursement (25%), time constraints (22%), and concern of reducing hope or trust (21%). The most agreed upon potential intervention was increased access to outpatient PC (80%). Conclusions: According to this cohort of SGO members, families’ or patients’ unrealistic expectations are the most frequent barriers to specialty PC. Understanding this communication breakdown is critically important.

Holistic sexuality post gynaecological cancer treatment: A review of recent literature

Background: Sexual difficulties post gynaecological cancer treatment are commonplace and can impact multiple aspects of a woman’s life. Yet, health care practitioners remain reluctant to discuss sexuality from a holistic perspective with their patients.Aim: This article reviewed the literature on sexuality post gynaecological cancer treatment from the last 10 years. The aim was to understand research trends as well as identify gaps in the field.Methods: The review was framed using the neo-theoretical framework of sexuality. A comprehensive literature search, using the electronic databases EBSCOHost, Ovid, Clinical Key and PubMed, was conducted for articles concentrating on sexuality after gynaecological cancer treatment, published from 2007 to 2017 in English.Results: The results showed that the majority of the literature still approaches sexuality post treatment from a biomedical perspective with a focus on physical sexual functioning. However, there has been a slight shift towards understanding sexuality from a comprehensive standpoint, although there is a dearth of research relating to the psychological and relational aspects of sexuality.Conclusion: Comprehensive sexuality post treatment should be given further consideration in South Africa, and our unique socio-cultural context ought to be taken into consideration. Additionally, interventions at multiple levels should be explored, such as broadening sexual health training within the medical curriculum, considering the development of holistic cancer clinics and widening the scope of research relating to gynaecological cancer care.

Access to gynecologic oncology care and the network adequacy standard.

Federal regulations do not require insurance plans to cover gynecologic oncologists in network; consequently, women enrolled in 27% of plans nationwide lack access to high‐quality gynecologic cancer care. This gap in coverage must be closed.See also pages 2680‐3.

Society of Gynecologic Oncology Future of Physician Payment Reform Task Force report: The Endometrial Cancer Alternative Payment Model (ECAP)

Health care in the United States is in the midst of a significant transformation from a “fee for service” to a “fee for value” based model. The Medicare Access and CHIP Reauthorization Act of 2015 has only accelerated this transition. Anticipating these reforms, the Society of Gynecologic Oncology developed the Future of Physician Payment Reform Task Force (PPRTF) in 2015 to develop strategies to ensure fair value based reimbursement policies for gynecologic cancer care. The PPRTF elected as a first task to develop an Alternative Payment Model for thesurgical management of low risk endometrial cancer. The history, rationale, and conceptual framework for the development of an Endometrial Cancer Alternative Payment Model are described in this white paper, as well as directions forfuture efforts.

Survivorship care planning in gynecologic oncology: Perspectives from patients, caregivers, and health care providers.

63 Background: More than a decade after the widespread recommendation of survivorship care plans (SCPs), evidence-based content and processes for providing survivorship care planning in gynecologic oncology remain undefined. This qualitative study sought to characterize the challenges experienced in care after treatment of gynecological cancer and preferences for survivorship care planning among patients, their caregivers and health care providers. Methods: Between July and August 2017, in-depth semi-structured interviews were conducted at a large academic hospital in the United States among patients that recently ended treatment ( &lt; 12 months) of a gynecological cancer (ovarian, endometrial, cervical and vulvar), their caregivers, and health care providers (oncologists, nurses and fellows). Main themes were identified using descriptive content analysis. Results: A total of 30 individuals participated in this study (13 patients, 9 caregivers, 8 health care providers). The vast majority of patients and caregivers (91%) expressed satisfaction for survivorship care, although all reported that remaining needs and ongoing issues remained unaddressed (i.e. distressing symptoms and mood). Almost all (95%) reported a desire for more information on how to address these needs, including issues related to side effects (59%), follow-up planning (32%), and psychological assistance (23%). Preferences for survivorship care planning differed across individuals, with respect to content, timing, and mode of delivery. Some patients did not want a SCP at all (14%). Health care providers expressed that they 1) experience challenges in communicating with patients about survivorship, 2) want to shift the focus to improving quality of life as opposed to focusing on likely disease recurrence, 3) do not currently provide formal SCPs, 4) want disease specific and tailored SCPs to support their survivorship care. Conclusions: Patients, caregivers and health care providers express a need for resources to support survivorship care in gynecologic oncology. The variation of disease types and patient and caregiver needs in this field requires multi-faceted, tailored survivorship care planning.

Hereditary gynaecologic cancers in Nepal: a proposed model of care to serve high risk populations in developing countries

BackgroundEndometrial, ovarian and breast cancers are paradigms for global health disparity. Women living in the developing world continue to present in later stages of disease and have fewer options for treatment than those in developed countries. Risk reducing surgery is of proven benefit for women at high risk of gynaecological cancer. There is no specific model for identification and management of such women in the developing world.MethodsWe have integrated data from our published audit of a major gynaecological oncology centre at Royal Hospital for Women in Australia, with data from our survey and a focus group discussion of Nepalese gynaecological health care professionals regarding genetic testing, and findings from the literature. These data have been used to identify current barriers to multidisciplinary gynaecological oncology care in developing nations, and to develop a model to integrate hereditary cancer services into cancer care in Nepal, as a paradigm for other developing nations.ResultsThe ability to identify women with hereditary gynaecological cancer in developing nations is influenced by their late presentation (if active management is declined or not appropriate), limited access to specialised services and cultural and financial barriers. In order to include genetic assessment in multidisciplinary gynaecological cancer care, education needs to be provided to all levels of health care providers to enable reporting of family history, and appropriate ordering of investigations. Training of genetic counsellors is needed to assist in the interpretation of results and extending care to unaffected at-risk relatives. Novel approaches will be required to overcome geographic and financial barriers, including mainstreaming of genetic testing, telephone counselling, use of mouth swabs and utilisation of international laboratories.ConclusionWomen in Nepal have yet to receive benefits from the advances in early cancer diagnosis and management. There is a potential of extending the benefits of hereditary cancer diagnosis in Nepal due to the rapid fall in the cost of genetic testing and the ability to collect DNA from a buccal swab through appropriate training of the gynaecological carers.

Coordinating Care Across Health Care Systems for Veterans With Gynecologic Malignancies: A Qualitative Analysis.

Veterans concurrently using both Veterans Affairs (VA) and community providers and facilities have increased coordination needs related to bridging their care across health care settings. Women Veterans commonly require a combination of VA and community care if they have women-specific specialty care needs, such as gynecologic malignancies. We assessed VA women's health providers' and administrators' perceptions of coordination challenges for Veterans' gynecologic cancer care, and potential approaches for addressing these challenges. We carried out semistructured qualitative interviews with field-based key informants (VA gynecologists, women's health medical directors, and other staff directly involved in women's health care coordination) at 15 VA facilities. Transcripts were summarized in a template to capture key points. Themes were identified and iteratively revised (inductively/deductively) via a collaborative decision-making process utilizing matrices to compare content across interviews. Key informants (n=23) noted that services for patients with gynecologic cancers are provided through a combination of VA and community care with wide variation in care arrangements by facility. Care coordination challenges included care fragmentation, lack of role clarity and care tracking, and difficulties associated with VA and community provider communication, patient communication, patient records exchange, and authorizations. Care coordination roles suggested for addressing challenges included: care tracker, provider point-of-contact, patient liaison, and records administrator. Experiences in coordinating care for women Veterans with gynecologic malignancies receiving concurrent VA and community cancer care reveal challenges inherent in delivering care across health care systems, as well as potential approaches for addressing them.

Ovarian Cancer Knowledge in Women and Providers Following Education with Inside Knowledge Campaign Materials.

Because no effective methods for preventing or screening for ovarian cancer exist, symptom recognition is integral to its early detection. The Centers for Disease Control and Prevention's Inside Knowledge: Get the Facts about Gynecologic Cancer campaign was developed to raise awareness and educate women and providers about risk factors, symptoms, recommended screening, and prevention strategies for the five main gynecologic cancers, including ovarian cancer. Inside Knowledge campaign materials were utilized by CDC's National Comprehensive Cancer Control Program grantees to educate women and providers about gynecologic cancer from 2014 to 2015. Grantees recruited participants and held educational sessions using Inside Knowledge materials. Questionnaires were given before and after the sessions to assess changes in awareness, confidence, and behavioral intentions around gynecologic cancer information and analyzed in 2016. This analysis focused on an assessment of changes related to ovarian cancer information. Participants' knowledge increased after educational sessions. Among women, there were increases in correctly identifying that the Papanicolaou (Pap) test does not screen for ovarian cancer (89.2%) and that genetic testing is available (77.9%). There was a lower increase in knowledge that HPV is not a cause of ovarian cancer (56.4%). Providers and women reported significant increases in their confidence in their ability to talk to each other about gynecologic cancer post-session. Ovarian cancer awareness, confidence, and related behaviors increased in participants exposed to Inside Knowledge materials. Using these materials to increase knowledge could lead to more empowered patients, better provider-patient communications, and improved care for gynecologic cancers, including ovarian cancer.

Lymphedema following gynecological cancer: Results from a prospective, longitudinal cohort study on prevalence, incidence and risk factors

ObjectiveCancer-related lymphedema is a debilitating condition that adversely influences function, health and quality of life. The purpose of this study was to assess the prevalence, incidence, and risk factors of lower-limb lymphedema pre- through to 24months post-surgery for gynecological cancer. MethodsA clinic-based sample of women (n=408) with gynecological cancer participated in a prospective, longitudinal study (2008–2011) using self-reported measures (swelling in one or both legs) and objectively measured lymphedema (bioimpedance spectroscopy) at baseline (pre-surgery), six weeks–three months, 6–12months, and 15–24months post-surgery. ResultsAt pre-surgery, 15% of women self-reported lymphedema and 27% had measurable evidence of lymphedema. By 24months post-surgery, incidence of new self-reported or measured lymphedema was 45% and 37%, respectively. Three-quarters of these new cases presented by 12-months post-treatment. While lymphedema was transient for some women, 60% had persistent lymphedema. More extensive lymph node dissection, receipt of chemotherapy and radiation therapy, increasing body mass index, insufficient levels of physical activity, diagnosis of vulvar/vaginal cancer and presence of pre-treatment lymphedema were identified as potential risk factors (p<0.05). ConclusionFindings support the need for integration of pre-surgical assessment, and prospective, post-treatment surveillance of lymphedema into gynecological cancer care. Future research exploring the role of maintaining healthy body weight, regular physical activity and education about early detection of lymphedema to improve gynecological cancer survivorship is warranted.

Using the National Comprehensive Cancer Network guidelines and levels of evidence to prioritize research focus in gynecologic cancer care

Using the National Comprehensive Cancer Network guidelines and levels of evidence to prioritize research focus in gynecologic cancer care

A qualitative study of doctors' and nurses' barriers to communicating with seriously ill patients about their dependent children.

Research indicates that health personnel caring for seriously ill patients with dependent children aged 0 to 18years often avoid discussing with them the challenges of being a family with a parent in treatment. Children of seriously ill patients risk serious trauma and emotional difficulty later in life and depend on adult support to minimize these consequences. Patients suffer anxiety about supporting their children during their illness. Because of their potentially pivotal role in supporting patients in enabling parent-child communication, we examined HP's structural and emotional barriers to communicating with patients about their children. The study was based on 49 semi-structured, in-depth interviews with doctors and nurses working with haematology, gynaecological cancer, and neurointensive care. Both interviews and analysis addressed emotional and structural barriers, drawing on the theoretical framework of Maturana's domains. The study found structural barriers (eg, lack of space in the medical recording system, professional code, time pressure, and lack of training) and emotional barriers (eg, the painful nature of the situation and the perceived need of keeping professional distance). We found that emotional barriers tended to grow when structural barriers were not addressed. Our study indicates (1) the need to use templates and manual procedures to gather and process information about children in medical records; (2) the need for managerial backing for addressing children of seriously ill patients and time spent on it; and (3) the need for future HP training programmes to include how to implement procedures and how to address all barriers.