Gynecologic Oncology Population Research Articles

Abstract A006: Performance of the laparoscopic hysterectomy readmission score among diverse women with endometrial cancer

Abstract Introduction: Readmission following cancer-directed surgery is an important quality metric. The laparoscopic hysterectomy readmission score (LHRS) was developed to identify women for whom same day discharge after minimally invasive surgery was suitable, with low readmission risk. Our single-institution cohort study supported the hypothesis that the LHRS was associated with increased readmission odds in a gynecologic oncology population; however, this analysis was limited by the racial homogeneity of the cohort. In addition, an assessment of discrimination of the LHRS has not been performed. Therefore, we evaluated readmission odds and performance associated with the LHRS among women with endometrial cancer (EC) overall and by race/ethnicity. Methods: Using data from the National Surgical Quality Improvement Program (NSQIP), we calculated the LHRS by assigning one point to the following six variables (diabetes, severe chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery of two hours or longer) and two points for any postoperative complication occurring prior to discharge (range: 0-8). We dichotomized LHRS (<3, ≥3) and examined odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day readmission odds using logistic regression in the overall study population and stratified by race/ethnicity (White, Black, Hispanic, Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native). Discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUC) in the overall study population and by race/ethnicity. Results: In this study of 27,981 EC patients diagnosed between 2014 and 2020, overall readmission was low (3.1%). The majority of women were White (80%), followed by Black (7.6%), Hispanic (6.0%), Asian (4.9%), Native Hawaiian/Pacific Islander (1.1%), and American Indian/Alaska Native (0.4%). Overall, readmission odds were higher among those with LHRS ≥3 vs. <3 (OR=3.10, 95% CI=2.31, 4.15) with similar associations in race/ethnicity-stratified models. In the overall study population, the AUC was not much better than chance (0.52, 95% CI=0.51, 0.53). AUCs of the LHRS stratified by race/ethnicity were: 0.52, (95% CI=0.51, 0.53), 0.53 (95% CI=0.51, 0.56), 0.53 (95% CI=0.50, 0.58), 0.49 (95% CI=0.491, 0.50), 0.49 (95% CI=0.47, 0.49), and 0.65 (95% CI=0.47, 0.99) among White, Black, Hispanic, Asian, Native Hawaiian/Pacific Islander, and American Indian/Alaskan Native women, respectively. Discussion: We observed higher readmission odds associated with higher LHRS in the overall cohort of EC patients and among race/ethnicity subgroups. Performance metrics for the LHRS generally demonstrated low predictive ability. Citation Format: Jennifer A. Sinnott, Caitlin E. Meade, Michelle D.S. Lightfoot, David A. Barrington, Casey M. Cosgrove, Laura M. Chambers, Ashley S. Felix. Performance of the laparoscopic hysterectomy readmission score among diverse women with endometrial cancer [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr A006.

The FARGO study: Frailty assessment for risk prediction in gynecologic oncology.

TPS12137 Background: Little is known about how to best predict postoperative outcomes and chemotherapy tolerance in an increasingly aging and complex gynecologic oncology (GO) population. Frailty is a multidimensional age-related and disease-related state of vulnerability to stressors due to reduced capacity of different physiological systems. Resource limitations are a barrier to routine adoption of frailty assessments through comprehensive clinical evaluations in daily practice. This highlights the relevance of studying potential biomarkers of frailty, which could complement or replace clinical assessments. Frailty has been associated with worse perioperative and oncologic outcomes in many subspecialties, however the literature in patients with gynecologic malignancies is very limited. Methods: The FARGO study is a multi-centre prospective cohort study of 280 patients aged ≥55 years-old undergoing surgery, with or without chemotherapy for a suspected or confirmed gynecologic malignancy. Patient recruitment will occur over 13 months. The over-arching goal is to evaluate the predictive value of frailty assessments in predicting surgical and chemotherapy outcomes. The two primary objectives are: 1) To evaluate the predictive value of preoperative frailty assessment based on the Frailty Phenotype (FP), compared to a perioperative cardiovascular risk assessment, in predicting the composite of all-cause death or new disability at 6 months after surgery 2) To create of a biobank to explore possible biomarkers of frailty, including mitochondrial DNA levels. Secondary objectives include to evaluate the predictive value of clinical and biomarker frailty assessment for 30-day postoperative complications, for chemotherapy tolerance and 1-year recurrence-free survival. Patients will undergo frailty and cardiovascular risk assessment prior to surgery and/or neoadjuvant chemotherapy. A trained clinical research assistant will measure frailty based on the clinical frailty scale (CFS) and the FP. The cardiovascular risk calculation will be based on the preoperative Revised Cardiac Risk Index, age, and occurrence of myocardial injury after non-cardiac surgery (MINS). Research personnel blinded to the frailty and cardiovascular risk assessment will evaluate study outcomes including death, disability, and clinical events at 30 days, 6 months, and 12 months after surgery. Disability will be measured with the WHODAS 2.0 (World Health Organization Disability Assessment Schedule), a validated patient-reported outcome measure. Pre-specified blood biomarkers will be measured. Our study emphasizes patient-centered outcomes (i.e. loss of independence, short and long-term disability) and system-level outcomes. Our findings may have important implications to assist in risk stratification and planning for oncologic treatments and perioperative care needs. Clinical trial information: will be added later .

A pilot evaluation of social needs among gynecologic oncology patients in inpatient versus outpatient settings

The WHO defines social determinants of health (SDoH) as the conditions in which we are born, grow, work, and live as well as other large systems that positively or negatively affect our health. Many healthcare systems currently lack the resources and strategies required to accurately assess and address SDoH. Action must be taken because studies have found that chronic diseases, including cancer, are affected by SDoH. The aim of this study is to identify the incidence of social needs in an inpatient gynecologic oncology population and its relation to patient demographics and clinical diagnostic data to guide and inform future intervention. Patients agreeing to participate in the study completed a needs assessment survey during their inpatient stay at the hospital between November 2020 to March 2021. The survey contained seven questions, six of which were questions screening for social needs including food and housing security, transportation means, financial stability, health literacy, and social support. Responses were considered positive if any degree of need was reported. Demographic and cancer diagnosis data were then collected and included zip code, race, cancer stage and age at diagnosis, treatment history, and number of hospital admissions and length of stay over the past 12 months. The most substantial reported needs across all gynecologic malignancies were social support (65%), health literacy (37%), and financial need (22%). Less need was reported in the categories of food (11%), housing (7%), and transportation (4%). SDoH have been studied in the outpatient gynecologic population and the needs seen in this study are similar to the needs of that population. However, there are likely different challenges and frequencies of unmet need in the different types of gynecologic cancers that may affect the stage at which their cancer is diagnosed as well as the number of hospital admissions related to their cancer care.

Postoperative venous thromboembolism risk stratification in patients with uterine cancer

Uterine cancers are associated with a high risk for venous thromboembolisms. The American Society of Clinical Oncology practice guidelines recommend that all patients undergoing pelvic surgery for cancer should receive extended pharmacologic thromboprophylaxis with the duration being dependent on risk. However, risk stratification for patients with uterine cancer is not clearly defined. The Caprini score is the most widely used risk assessment model but it has been found to have limited use in the gynecologic oncology population. A modified Caprini score has been explored in other populations. The Khorana score is an additional risk assessment model that has not been studied in this context. Our objective was to evaluate the ability of a modified Caprini model and the Khorana score to risk stratify patients with uterine cancer for postoperative venous thromboembolisms within 90 days of surgery. Following institutional review board approval, a retrospective cohort study was performed, and all patients with uterine cancer who underwent a hysterectomy over a 4-year period were included. The Caprini and Khorana scores were calculated for each patient. The Caprini score cutoff for highest risk was evaluated at ≥7, ≥8, and ≥9 (modified Caprini) and the Khorana score cutoff was evaluated at ≥2 and ≥3. To determine the prognostic use of each score and other clinico-pathologic criteria related to the development of a venous thromboembolism, univariate analyses were performed using independent ttests, chi-square tests, or Fisher's exact tests; a multivariate analysis was performed using logistic regression. A total of 954 patients were included. The rate of venous thromboembolism development was 1.7% (16/954). A minimally invasive surgical approach was used in 90.5% (863/954) of patients. The mean Caprini score for patients with a venous thromboembolism was 10.3 compared with 8.1 for patients without a venous thromboembolism (95% confidence interval, 1.17-3.33; P<.0001). The mean Khorana score for the venous thromboembolism group was 2.4 vs 1.9 for those without (95% confidence interval, 0.04-0.82; P=.03). Both the Caprini and Khorana scores were found to be associated with venous thromboembolisms, but only a Caprini score with a cutoff of ≥8 or ≥9 was statistically significant (risk ratio, 31.25; 95% confidence interval, 1.88-519.49; risk ratio, 4.59; 95% confidence interval, 1.49-14.13, respectively), with high accuracy based on the area under the curve (0.75 and 0.68, respectively). Of the minimally invasive subgroup, 11.7% (101/863) of patients had same-day discharge with no postoperative thromboprophylaxis; none of these patients developed venous thromboembolisms. Despite extended prophylaxis among the laparotomy patients (30 days), the rate of venous thromboembolisms was more than 3 times that of the minimally invasive group (5.49% vs 1.7%). Advanced tumor stage and leukocytosis were noted to be independent risk factors for venous thromboembolisms. Our study suggests that using a modified Caprini score could help to identify the highest-risk patients who would benefit from prolonged thromboprophylaxis, could reduce the incidence of postoperative venous thromboembolisms, and could minimize the cost and harm of overtreatment. These findings need to be validated in a prospective manner, and further research is needed to determine the optimal duration of therapy.

Qualitative Interview Study of Gynecologic Oncologist Utilization of Recommended Same-Day Discharge Following Minimally Invasive Hysterectomy.

Recent investigations have supported the safety and benefits of discharging women on the same day following a minimally invasive hysterectomy (MIH) for both benign and malignant indications. Not all eligible candidates for same-day discharge (SDD) are discharged the same day, and patients undergoing an MIH for malignant indications have decreased the odds of receiving SDD despite established safety. The objective of this study was to use qualitative interviews to explore physician decision making regarding SDD after an MIH for malignant indications. Six qualitative interviews of gynecologic oncologists were analyzed using recurrent theme analysis for distinct themes in physician decision making regarding SDD. Results suggest that physician-perceived barriers to SDD include patient health characteristics, patient social characteristics, and hospital-system factors. Cited factors influencing SDD include patient travel, social support, practice setting (urban vs. rural) and staff comfort with the recommendation. Obstructive sleep apnea and post-surgical oxygenation appear to be a recurring reason for unplanned admission. The utilization of SDD after an MIH in the gynecologic oncology patient population is influenced by patient, physician, and system factors. Addressing the physician’s perceived barriers to SDD and catering recommendations to the gynecologic oncology population may increase utilization.

Who will be readmitted? Evaluation of the laparoscopic hysterectomy readmission score in a gynecologic oncology population undergoing robotic-assisted hysterectomy

ObjectivesThe laparoscopic hysterectomy readmission score (LHRS) was created to identify patients for whom same day discharge (SDD) after minimally invasive hysterectomy (MIH) may not be advisable and includes diabetes, chronic obstructive pulmonary disease, disseminated cancer, chronic steroid use, bleeding disorder, length of surgery, and any postoperative complication prior to discharge. We evaluated the performance of the score at predicting readmission in a gynecologic oncology population, and additionally sought to determine if any factors known prior to surgery could replace those that are not known until the time of surgery (operative time and postoperative complication). MethodsThis was a single-institution retrospective cohort study of women undergoing robotic hysterectomy by a gynecologic oncologist in 2018. Associations between pre-operative, operative and post-operative factors and 30-day readmission, SDD and postoperative complications were assessed using logistic regression. ResultsThe 30-day readmission rate among the 423 women in the cohort was 4.5% and 1.9% in those undergoing SDD. Readmission rates by LHRS were: score 1 (4.9%), score 2 (7.8%), score 3 (13.6%), score 4 (16.7%). Patients with a LHRS of ≥3 had higher odds of readmission compared to those with a lower score (OR 4.20, p = 0.02). Infectious morbidity accounted for the majority of postoperative complications, emergency room visits and readmissions. We did not identify preoperative factors to replace the intra- and post-operative factors used in the score. ConclusionsThe readmission rate following MIH is low, and a LHRS of ≥3 is associated with increased risk of readmission. Our findings support the applicability of the LHRS to a gynecologic oncology population; addressing risk factors for postoperative infection or closer follow up for patients with a LHRS ≥3 could reduce postoperative readmissions.

Effects of a cognitive behavioral intervention on salivary cortisol levels in post-operative gynecologic oncology population: A randomized control trial

Effects of a cognitive behavioral intervention on salivary cortisol levels in post-operative gynecologic oncology population: A randomized control trial

Impact of Screening for Sexual Trauma in a Gynecologic Oncology Setting

Objectives: Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman’s risk of developing cancer, in particular cervical cancer. We analyzed the impact of screening for sexual abuse in a gynecologic oncology population. Methods: Patients were screened for sexual trauma in a gynecologic oncology clinic over 5 and a half years (April 1, 2011, to September 30, 2016) in this cohort study. The screening questions were selected by behavioral oncology physicians and integrated into the gynecologic history component of the new patient assessment. Patients who screened positive for a history of sexual abuse or intimate partner violence were offered a behavioral oncology referral. Providers were also questioned about the effect of screening on their practice. Results: Of the 1,423 consecutive patients screened for sexual trauma, a total of 164 patients (12%) disclosed a history of sexual abuse. Of the 133 patients who specified their age at the sexual trauma, the majority (107 [80%]) responded that they were a young child or early teen. Most patients (92%) declined counseling. Among individuals presenting with cancer, the distribution of cancer type was statistically different between those patients with and without a sexual trauma history (p = 0.0001). Conclusion: Screening for sexual trauma in a gynecologic oncologic population serves as a valuable opportunity to uncover a history of abuse that may increase a woman’s susceptibility to cancer. This study demonstrates that screening for sexual abuse in a gynecologic oncology setting may be integrated into new patient interviews with minimal disruption. Identification of an undisclosed sexual trauma history allows for an opportunity to offer counseling and minimize the emotional distress that may be precipitated by treatment and exams.

Use of an individualized algorithm for postoperative prescriptions in gynecologic oncology patients: prescribing practices, clinical encounters, and patient satisfaction

Objectives: There are multiple studies across surgical specialties documenting the prevalence and risks of opioid over-prescribing. Nonetheless, adequate pain control remains an important priority in the postoperative setting. There is a need for a standardized approach that balances the highly individual nature of pain with the patient and societal risks of opioid overprescribing. With this in mind, we set out to evaluate the impact of an individualized algorithm for postoperative prescriptions on opioid prescribing practices, pain-related post-discharge clinical encounters, and patient satisfaction. Methods: This was designed as a prospective cohort study conducted at a single tertiary-care comprehensive cancer center. The pre-intervention cohort included post-operative discharges from the gynecologic oncology service from July 1st through September 30th 2019. A personalized algorithm was designed and implemented starting on October 7th, 2019. Allowing for a period of implementation and normalization of this algorithm, the post-intervention cohort included post-operative patients from December 7th, 2019 until March 1st, 2020. The personalized algorithm included prescribing acetaminophen and ibuprofen to all patients unless there were contraindications, and opioid prescription based on a patient's length of stay and inpatient use of opioids. Patients with a /= 24 hours were provided a 5-day opioid pain medication supply calculated from their personal opioid use in the 24 hours prior to discharge. Data on post-operative encounters for pain medication refills were also collected. In addition, this intervention included restructuring the perioperative patient education and expectations. A detailed booklet about the perioperative experience was provided to each patient and reviewed at time of preoperative visit. Patient satisfaction pre- and post-intervention was prospectively assessed via written surveys at the post-operative visit. Survey results were compared between the groups. Results: A total of 107 pre-intervention and 90 post-intervention cases were assessed. Patient demographics and characteristics between the two cohorts were similar. The post-intervention group demonstrated a 25% reduction in the median number of opioids prescribed at discharge (p=0.16), mostly accounted for in the Conclusions: An individualized algorithm for post-operative discharge medication prescribing is a feasible concept in a gynecologic oncology population. Additional research is needed to explore an optimized algorithm.

The clinical utility of the Khorana score in determining risk for venous thromboembolism in patients with gynecologic cancer

Objectives: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with gynecologic cancer. The Khorana Score (KS) is a risk stratification tool for VTE that has been validated across multiple cancer types and ASCO recommends consideration of VTE chemoprophylaxis among cancer patients with KS of 2 or above. The best KS for initiating VTE chemoprophylaxis among gynecologic oncology patients has not previously been evaluated. The purpose of this study was to evaluate the clinical utility of the KS among patients with gynecologic cancer. Methods: A retrospective review was completed of all chemotherapy-naive patients who initiated treatment for gynecologic cancer at our institution between December 2019 and December 2020. Demographic, oncologic, clinical and laboratory data was collected. KS was calculated for all patients using previously specified parameters of cancer type, pre-chemotherapy leukocyte count >11, pre-chemotherapy hemoglobin 300 and BMI >35. Patients were also assessed for history of VTE during treatment and history of inpatient admission for therapeutic anticoagulation. Multivariate logistic regression analyses were completed to assess risk factors for VTE. Results: A total of 62 patients met inclusion criteria. Median age was 64 years. The majority of patients reported White race (82%), had ovarian cancer (39%), and advanced stage disease (57%). The majority of patients had a KS of 2 or above (52%). Median KS was 2 (Range= 1-4). During treatment, 7 (11.3%) of patients were diagnosed with VTE. The majority of VTE occurred in patients with KS of 3 or above (n=4, 57%). A logistic regression was performed to evaluate associations between age, stage, race, and KS on VTE diagnosis. Increasing KS was noted to be associated with increased risk of VTE (OR 4.9, p=0.01). When using a cut-off KS of 2 or greater, no significant increase in VTE was noted. However, when using a cut-off KS of 3 or greater, patients were 15 times more likely to have VTE (OR 15.2, p=0.04). Conclusions: Previous studies have reported that cancer patients with KS of ≥ 2 are at high risk for VTE with incidence as high as 10.2% within 6 months of starting chemotherapy. Clinical practice guidelines recommend consideration of VTE chemoprophylaxis for patients with KS ≥2 who are starting chemotherapy in the outpatient setting. In our gynecologic oncology population, KS ≥2 was not associated with increased VTE risk. The most notable increase was found in those with KS ≥3. These results suggest that KS of 3 may be a more appropriate cutoff to determine risk for VTE and guide clinical management regarding VTE prophylaxis in patients with gynecologic cancer.

Upstream oncology: identifying social determinants of health in a gynecologic oncology population

Introduction: Social determinants of health (SDoH) are the factors that affect a patient’s health quality and outcomes and contribute to health disparities. Evidence suggests that clinical care contributes only 20% to patients’ health outcomes, while the remainder is under the influence of upstream factors. The upstream approach to healthcare aims to address SDoH before they contribute to less ideal outcomes downstream. Several SDoH may contribute to outcomes for cancer patients. This Upstream Gynecologic Oncology Initiative seeks to identify which SDoH affect a population of patients with gynecologic malignancies. Hypothesis: This study hypothesizes that women receiving care for gynecologic malignancies are affected by specific SDoH among the categories of housing, food, transportation, finances, health literacy and social support. This study aims to identify the frequency of these six social factors among the outpatient gynecologic oncology population at the University of Iowa. Methods: This needs assessment is the first phase in a quality improvement project assessing the SDoH affecting women with gynecologic cancers. Two hundred twenty-two patients receiving outpatient care for gynecologic malignancies completed an anonymous needs assessment survey. Validated survey questions regarding housing, food, transportation, finances, health literacy and social support were used to identify needs. Responses were considered positive if any degree of need was reported. Results: Responses demonstrated the most substantial need in the categories of social support (32%), health literacy (28%) and financial stability (24%). Less need was reported in the categories of food (11%), transportation (5%) and housing (4%). Fifty-seven percent of women reported at least one social need among the six categories screened. Conclusion: Upstream SDoH, most notably social support, health literacy and financial stability are identified to be present and likely contributing to health quality, outcomes, and disparities within this gynecologic oncology patient population. Overall, these findings support the idea that SDoH should be assessed for each unique patient population - and for each patient receiving care for gynecologic cancer. While social support was the most frequently reported SDoH, many patients already received adequate help at home; suggesting that meaningful efforts should next be directed at improving health literacy in the population. Appreciation and assessment of SDoH potential to impact care and management should be used to design a routine screening tool for the study population and organize resources to address or mitigate the identified needs.

Chemotherapy discontinuation processes in a gynecologic oncology population

ObjectiveWe sought to categorize the processes by which gynecologic oncology patients stop chemotherapy and to evaluate associations between these processes and end-of-life outcome metrics. MethodsA cohort of patients with metastatic or recurrent gynecologic cancer in an outpatient setting from January 2016 to May 2018 was identified. All deceased patients in this cohort were included for analysis. Processes of discontinuing chemotherapy were categorized as: 1) definitive decision inpatient; 2) definitive decision outpatient; 3) delayed decision (eg: treatment break and never resumed chemotherapy); 4) no decision. Associations between patient characteristics and clinical outcomes of those who made a definitive outpatient decision versus those who made any other type of decision were assessed. Results220 patients were identified; 205 patients were deceased at time of analysis. Of these, 36.6% made a definitive decision to stop chemotherapy as an outpatient, while 41.5% never made a decision to discontinue chemotherapy. Making a definitive decision as an outpatient, when compared to all other decision types, was associated with significantly lower incidence of death in the hospital (5.6% vs 21.1%, p < 0.004) and hospitalization within 30 days of death (20.8% vs 56.6%, p < 0.001), and significantly increased median time from last chemotherapy to death (135.5 vs 62 days, p < 0.001). ConclusionOnly one in three women in this cohort of patients deceased from gynecologic cancer made a definitive decision to discontinue chemotherapy in an outpatient setting, and this process was associated with improved end-of-life outcomes. Future efforts should examine the impact of interventions designed to increase the proportion of patients who transition away from chemotherapy via shared decision making in the outpatient setting.

Adherence to Oral Anticancer Therapeutics in the Gynecologic Oncology Population.

To gain a better understanding of gynecologic oncology patient adherence to oral anticancer agents through both a cross-sectional survey of adherence and qualitative interviews with patients and clinicians regarding their experience with these medications. Eligible participants completed a survey for this cross-sectional study that included an assessment of adherence, distress, quality of life, and health literacy. Any woman taking an oral anticancer agent for a gynecologic malignancy at a tertiary academic medical center for 30 days or more was eligible. Semi-structured qualitative interviews (n=14) were then conducted to explore experiences with oral anticancer agents. We also conducted a qualitative group interview with physicians and nurse practitioners. One hundred women taking oral anticancer agents were enrolled. Fifty-four percent reported perfect adherence to their medication, 21% reported equivocal adherence (demonstrating at least one nonadherent behavior in the previous 7 days), and 25% reported nonadherence (demonstrating more than one nonadherent behavior in the previous 7 days). Qualitative analysis identified five major themes: ease of use compared with traditional therapy; the mental burden of self-administrated medication; perceived importance of the medication; management of side effects; and the desire for consistent physician communication. Common misperceptions expressed in the health care professional interviews included high adherence to oral medications and a belief that cost was the biggest barrier to adherence. Almost half of the patients surveyed reported equivocal or nonadherence to their oral anticancer agent. The qualitative interviews identified several important themes, many of which were not recognized by physicians and nurse practitioners. These findings highlight the need for patient and health care professional interventions to improve patient adherence.

Prescribed medical cannabis in women with gynecologic malignancies: A single-institution survey-based study

Research within a gynecologic oncology population has lagged behind the uptake in use of medical cannabis for symptom control. This study seeks to evaluate patient experience with prescribed medical cannabis obtained through licensed dispensaries in women with gynecologic malignancies.A 43-item survey exploring patient experience with medical cannabis was administered to women with gynecologic malignancies who used medical cannabis prescribed by a gynecologic oncologist.Thirty-six eligible patients were approached for consent, and 31 patients returned completed surveys (86%). Ninety-three percent had advanced or recurrent disease; 74% were receiving chemotherapy or immunotherapy. Eighty-three percent reported medical cannabis provided relief from cancer or treatment-related symptoms including decreased appetite (41%), insomnia (41%), neuropathy (41%), anxiety (35%), nausea (29%), joint pain (29%), bone pain (29%), abdominal pain (25%), and depression (19%). Eighty percent of patients reported medical cannabis worked the same or better than other traditional medications for management of their cancer or treatment-related symptoms, and 83% reported medical cannabis had an equivalent or better side effect profile. Of the subset of patients using medical cannabis for pain, 63% reported a reduction in opioid use.Patients perceive that medical cannabis was useful for relief of cancer and treatment-related symptoms, suggesting medical cannabis may be a reasonable alternative or adjunct therapy. Medical cannabis was well tolerated and may have the potential to improve neuropathic pain and decrease opioid use.

Thirty-day outcomes after gynecologic oncology surgery: A single-center experience of enhanced recovery after surgery pathways.

The purpose of the study is to evaluate the impact of an enhanced recovery after surgery (ERAS) program implemented in a Gynecologic Oncology population undergoing a laparotomy at a Canadian tertiary care center. Prospectively collected data, using the American College of Surgeons' National Surgical Quality Improvement Program dataset (ACS NSQIP), was used to compare 30-day postoperative outcomes of gynecologic oncology patients undergoing a laparotomy before and after the 2018 implementation of an ERAS program in a Canadian regional cancer center. Patient demographics, surgical variables and postoperative outcomes of 187 patients undergoing surgery in 2019 were compared with those of 441 patients undergoing surgery between January 2016 and December 2017. Student's t, Mann-Whitney U and Chi-square tests, as well as multivariate linear and logistic regressions were used to evaluate baseline characteristics and 30-day postoperative complications. Length of stay was significantly shortened in the study population after introducing the ERAS protocol, from a mean of 4.7 (SD=3.8) days to a mean of 3.8 (SD=3.2) days (P=.0001). The overall complication rate decreased from 24.3% to 16% (P=.02). Significant decreases in the rates of postoperative infections (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI]0.31-0.99) and cardiovascular complications (adjusted OR0.27, 95% CI0.09-0.79) were noted, without a significant increase in readmission rate (adjusted OR 0.50, 95% CI 0.21-1.07). Introducing an ERAS program for gynecologic oncology patients undergoing laparotomy was effective in shortening length of stay and the overall complication rate without a significant increase in readmission. Advocacy for broader implementation of ERAS among gynecologic oncology services and ongoing discussion on challenges and opportunities in the implementation process are warranted to improve patient outcomes and experiences.

Preliminary prospective quality of life and clinical outcomes with an opiate restrictive enhanced recovery protocol in a gynecologic oncology population

Objective: The impact of enhanced recovery after surgery (ERAS) protocols on quality of life (QOL) is not well defined. We describe initial clinical and QOL outcomes following an enhanced ERAS protocol that relies upon opiate-sparing anesthesia.

Upstream Gynecology: Identifying Social Determinants of Health in a Gynecologic Oncology Population [40H

INTRODUCTION: Social determinants of health (SDoH) are factors that affect a patient’s health quality and outcomes. Evidence suggests that clinical care contributes only 20% to patient outcomes, while the remainder is under the influence of upstream factors. The upstream approach to healthcare aims to address SDoH before they contribute to less ideal outcomes downstream. Several social determinants of health may contribute to outcomes for cancer patients. This Upstream Gynecologic Oncology Initiative seeks to identify which SDoH affect patients with gynecologic malignancies. METHODS: This needs assessment is the first step in a quality improvement project assessing the SDoH affecting women with gynecologic cancers. Female patients receiving care for gynecologic malignancies were invited to complete an anonymous needs assessment survey. Validated survey questions regarding housing, food, transportation, finances, health literacy and social support were used to identify needs. Data collected is being used to further develop a routine screening tool and to organize resources specific to the identified needs. RESULTS: Results demonstrate the relative prevalence of existing SDoH needs upstream of clinical care within this unique gynecologic oncology patient population. Results from the study population are also compared to prevalence among the general population of this institution's state. CONCLUSION: Upstream SDoH are identified to be present and likely contributing to health quality and outcomes within this gynecologic oncology patient population. Appreciation and assessment of their potential to impact care and management can be used to design a routine screening tool for the study population and organize resources to address or mitigate the identified needs.

2534 Opioid Use and Misuse among Gynecologic Oncology Patients

Study Objective To determine opioid and benzodiazepine prescribing practices in the gynecologic oncology population and determine if this patient population is at risk for narcotic abuse. Design This was an IRB-approved, retrospective study of opioid and benzodiazepine prescriptions for cervical, ovarian (including fallopian tube and primary peritoneal), and uterine cancer patients within a single healthcare system from January 2016 to August 2018. Demographics and prescription details were extracted from the electronic medical record. Setting A tertiary care academic nonprofit healthcare system. Patients or Participants Patients with ovarian, uterine, or cervical cancer that received an opioid or benzodiazepine prescription. Interventions N/A Measurements and Main Results 6407 prescriptions for opioids/benzodiazepines were dispensed to 3586 patients over a total of 5931 prescribing encounters for cervical (n=1965, 33%), ovarian (n=1801, 30%), or uterine cancers (n=2165, 37%). The setting for prescription distribution was 50.9% outpatient, 25.6% inpatient, and 21% emergency center. Cervical cancer patients were more likely to have received a prescription in an emergency center (p Conclusion Opioid prescribing patterns differed for cervical, ovarian, and uterine cancer patients. Patients with cervical cancer were more likely to have risk factors present for opioid and benzodiazepine misuse, abuse, and diversion.

Outpatient desensitization is an effective and safe management option for platinum hypersensitivity reactions: A single institution experience

Objective: Platinum hypersensitivity reactions (HSR) occur at a rate of approximately 1% of all platinum administrations and can range in severity from mild to life-threatening. There is increasing interest in platinum desensitization (PD) protocols. Here, we report our expanded experience with outpatient PD in our gynecologic oncology population.

Therapy discontinuation processes in a gynecologic oncology population.

11611 Background: The decision to discontinue anti-cancer therapies in oncology patients is a complex one and may occur in several unique ways. We sought to understand the processes of therapy discontinuation in a gynecologic oncology population and to discern possible changes in the distribution of these processes after implementation of a palliative care (PC) quality improvement project. Methods: Women with incurable gynecologic malignancies seen in the outpatient setting at an academic center were identified with the recommendation for ‘goals of care’ discussion within 3 visits following identification. Processes of discontinuing chemotherapy for this population were assessed and categorized into 1 of 4 categories: definitive outpatient decision, definitive inpatient decision, interruption by hospitalization, treatment holiday, and “no decision.” Retrospective chart review identified a similar cohort of women prior to the implementation of our PC intervention. Univariate analyses were conducted to determine associations between characteristics and binary outcome of definitive outpatient decision versus all other decision processes. Results: 90/102 (88%) pre-intervention subjects and 83/157 (53%) post-intervention subjects had died at time of analysis. Of the total deceased cohort, 59/173 (34%) made a definitive decision to stop therapy in the outpatient setting. After implementation of the PC initiative, there was a trend towards fewer women identified as having made “no decision” (18.1% vs 30%). Those who made a definitive outpatient decision were less likely to die within 30 days of hospitalization than those who did not (OR 0.16 [95% CI 0.07,0.390], p &lt; 0.0001). Conclusions: Discontinuation of therapy is a nuanced concept in gynecologic oncology patients that can be stratified into several processes. While our data demonstrates a possible increase in active decision-making with the PC initiative, a majority of patients near the end of life still did not make definitive therapy cessation decisions. This reveals an urgent need for the development of initiatives to enhance patient engagement and shared decision making for women near the end of life.