Gynecologic Oncology Service Research Articles

Data-driven education improves patient blood management: A pilot study

Abstract Introduction: We sought to increase the use of a restrictive transfusion protocol through clinician education and a standard approach to Patient Blood Management (PBM) in our gynecologic oncology service. Optimal PBM requires the consistent application of evidence-based, restrictive transfusion guidelines, however the use of restrictive transfusion is understudied in surgical oncology populations. We hypothesized that provider specific education that includes data derived from their own clinical practice would result in improved compliance current evidence-based transfusion guidelines. Methods: We created an educational activity that described evidence-based restrictive transfusion guidelines followed by data showing providers their own clinical transfusion practice where compliance with restrictive guidelines was poor. After the education, a plan to improve compliance was developed and put into place. Comparison of transfusion practices and complication/morbidity rates before and after the education was performed. Results: During the 18 months post-education the number of RBC units transfused decreased from 316 152, a 57% reduction and monthly transfusion events were reduced by 42% from 12 to 7 per month. The percent of transfusions with a pretransfusion hemoglobin less than 7 g/dL increased from 40% to 56%. The percent of transfusions with a hemoglobin less than 8 g/dL increased to 90%. Finally, the use of single unit transfusions increased from 49 to 85%, a major contributor to the reduction in units transfused. Conclusion: We created a service-specific educational intervention that improved compliance with evidence-based restrictive transfusion practice. This intervention improved provider compliance with lower transfusion thresholds and increased the use of single-unit transfusions.

Adnexal Torsion of a 28 cm Paratubal Cyst: A Case Report

Objective: To report a rare case of a 28 cm left adnexal torsion requiring surgical intervention including detorsion and salpingectomy Methods: Case report. Results: An 18-year-old nulliparous female with morbid obesity presented to the emergency department complaining of one week of sharp right lower quadrant pain with nausea and vomiting that had acutely worsened. Vital signs were notable for tachycardia, but otherwise within normal ranges. She had a significant leukocytosis. Her pregnancy test was negative. A CT abdomen/pelvis was obtained that demonstrated a large multiloculated complex cystic mass measuring 28.5 x 19.8 x 13.3 cm with possible origin from the ovaries that could represent a serous cystadenoma. Additionally, the scan was remarkable for a heterogeneous and enlarged left ovary measuring 7.6 x 5.9 x 7.2 cm, surrounded by free fluid and mesenteric edema. On examination, she did not demonstrate any surgical abdomen findings. Her pain improved with pain medication. She was admitted, tumor markers obtained, and an ultrasound ordered. The ultrasound demonstrated normal appearing right ovary with present doppler flow and a simple cyst measuring 6.6 x 5.1 x 6.1 cm. The left adnexa was noted to have a complex versus solid mass with unclear boundaries of the ovary. Also noted on the ultrasound were two large simple midline cysts measuring 10.5 x 9.1 x 11.8 cm inferiorly and 18.2 x 15.5 x 17.2 cm superiorly. No free fluid was seen within the right upper quadrant on ultrasound. The view of the left upper quadrant was suboptimal. Due to these findings, Gynecologic Oncology service was also consulted and after discussion, decision made to proceed urgently to diagnostic laparoscopy with robotic assisted cystectomy versus oophorectomy. Upon laparoscopic entry into the abdomen, a large necrotic-appearing left adnexal mass was visualized coming from the left fallopian tube. Both the left fallopian tube and left ovary were necrotic, with the left ovary being torsed numerous times. After resection of the large left fallopian tube and cyst, the left ovary was detorsed, and the decision was made to leave the ovary in situ. It still appeared necrotic, but its blood supply was intact. There was a large simple paratubal cyst on the right fallopian tube that was also drained and excised. Postoperatively, her right lower quadrant pain resolved, and she was discharged on post-operative day 1. She prescribed a two-week course of doxycycline and metronidazole as pelvic inflammatory disease could not be ruled out. At outpatient follow-up, she was asymptomatic and ready to begin working again. Her pathology report confirmed a large left paratubal cyst with associated findings of ischemia due to torsion and a large right paratubal cyst. Conclusions: Adnexal torsion is a rare gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support, which can negatively impact fertility. Prompt diagnosis is key, but definitive diagnosis is only by direct visualization. The differential diagnosis for acute onset of severe pelvic pain with nausea and vomiting is broad and includes ectopic pregnancy, pelvic inflammatory disease, endometriosis, ruptured ovarian cyst, urologic issues and gastrointestinal issues. Commonly, ultrasound is used to help evaluate a possible torsion with several classic findings that were not noted in this case, other than a mass. The two best known risk factors for adnexal torsion are a mobile ovarian mass and a history of prior torsion. Although large ovarian masses greater than 5 cm are more likely to cause torsion, some experts hypothesize that very large masses are less likely to torse given the constraints of the pelvis. However, such was not the case here. Additionally, it has been observed that adnexal torsion typically affects the right adnexa due to theoretical protection from the descending colon on the left. Given that the case presented did not have any of the typical imaging findings for adnexal torsion and that her pain was on the right but the torsion on the left, it is important to maintain a high level of suspicion when evaluating patients with acute onset pelvic pain of any location with nausea and vomiting.

Implementation of HER2 Testing in Endometrial Cancer, a Summary of Real-World Initial Experience in a Large Tertiary Cancer Center.

HER2-targeted therapies have transformed the management of advanced or recurrent serous endometrial cancer (EC), leading to an increased clinical demand for HER2 testing. Despite its adoption in select academic centers, the global extent of such tumor testing is unclear. In this study, we report on the initial two-year experience of HER2 testing at a major academic center with a reference gynecologic oncology service and biomarker reference laboratory. All patients who underwent HER2 testing based on physician discretion, reflex HER2 testing, and reference laboratory requests were included. From February 2021 to October 2023, HER2 testing was performed on 192 tumor tissue samples from 180 EC patients. Serous carcinoma constituted 52% of samples, reflecting diagnostic challenges and limited therapeutic options for advanced EC. HER2 positivity was found in 28% of all cases and 30% of p53-aberrant cases. An immunohistochemistry (IHC) score of 3+ was found in 15% of samples, while IHC 2+ was found in 45% (13% IHC 2+/ISH+ and 32% IHC 2+/ISH-). The newly identified 'HER2-low' category comprised 46% of the samples. Heterogeneity was noted in 42% of HER2-positive cases, with complex patterns in 3%. NGS and HER2 IHC-FISH showed a 24% discordance, attributed to intratumoral heterogeneity, tumor cellularity, a small number of amplified cells, and the HER2/CEP17 ratio near the cut-off. This study offers real-world insights into HER2 testing in EC, highlighting the challenges and underscoring the need for standardized guidelines in specimen handling, proficiency testing, and scoring criteria to enhance patient management and therapeutic decision-making.

Surgical, oncologic, and obstetric outcomes of radical trachelectomy in early-stage cervical cancer: results from a retrospective cohort study at Brazil National Cancer Institute.

to analyze oncological, obstetrical, and surgical results of young early-stage cervical cancer patients who underwent radical trachelectomy (RT) surgery and wished to maintain their fertility. a retrospective cohort study was carried out concerning cases attended at the Brazilian National Cancer Institute Gynecology Oncology Service. Patients who underwent RT between January 2005 and January 2021 were included. A total of 32 patients with median age of 32 years old, 62.5% of whom were nulliparous, were assessed. Concerning cancer type, 65.6% squamous cell carcinoma (SCC) cases, 31.2% adenocarcinoma cases and 3.1% adenosquamous carcinoma cases were verified. Stage IA2 was evidenced in 12.5% of the patients and stage IB < 4cm in 87.5%. Regarding surgical approaches, 68.25% of the patients underwent vaginal RT (VRT), 18.75%, abdominal RT (ART), 9.3%, the robotic radical trachelectomy (RORT) and 3.1%, video laparoscopy radical trachelectomy (VLRT). The median number of removed lymph nodes was 14, with only two detected as positive. Two cases of positive surgical margins were noted. A total of 3.1% intraoperative and 31.25% postoperative complications were observed, with cervical stenosis being the most common. The recurrence rate of the study was 3.1%, with a median follow-up time of 87 months, where 3.1% deaths occurred. The pregnancy rate of the study was 17.85% (5/28), with 54.5% evolving to live births and 45.5% evolving to abortion. Radical trachelectomy is a feasible procedure presenting good oncological results and acceptable pregnancy rates.

Use of IV Lidocaine Infusion Postoperatively Within the ERAS Surgical Population

PurposeThe aim of this project was to investigate whether opioid pain scores, postoperative opioid requirements, and postanesthesia care unit (PACU) length of stay were impacted when comparing a 24-hour intravenous lidocaine infusion versus postoperative discontinuation of the lidocaine infusion. DesignA retrospective chart review was used both before and after the discontinuation of postoperative lidocaine infusions for a quality improvement project. MethodsThe project was carried out in the adult surgery PACU setting at a level 1 trauma center between April 2021 and September 2021. The sample included 100 adult patients who fell under surgical specialties that used enhanced recovery after surgery protocol. After approval was obtained, data was collected via an electronic chart review using an evaluation tool created by the project team. FindingsBetween the five surgical specialties used for this review, the PACU length of stay variable was reduced only in the gynecology oncology service (P= .041). Additionally, the postoperative opioid requirements were significantly reduced in the surgical oncology service (P = .02). Comparing the groups as a whole, 50 participants who had a 24-hour continuous lidocaine infusion and 50 participants whose lidocaine infusion was discontinued before PACU admission had no statistically significant values with pain scores, postoperative opioid requirements, and PACU length of stay. ConclusionsResults indicate that a 24-hour lidocaine infusion did not impact this patient population’s pain scores, postoperative opioid requirements, or PACU length of stay.

Mapping of Radiation Oncology and Gynecologic Oncology Services Available to Treat the Growing Burden of Cervical Cancer in Africa

To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer. We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases. Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively. We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

Ferric derisomaltose and Outcomes in the Recovery of Gynecologic oncology: ERAS (Enhanced Recovery After Surgery) (FORGE) – a protocol for a pilot randomised double-blinded parallel-group placebo-controlled study of the feasibility and efficacy of intravenous ferric derisomaltose to correct preoperative iron-deficiency anaemia in patients undergoing gynaecological oncology surgery

IntroductionIron-deficiency anaemia is common in gynaecological oncology patients. Blood transfusions are immunosuppressive and carry immediate and long-term risks. Oral iron replacement remains the standard of care but requires prolonged treatment...

Experience of cytoreduction with peritonectomy and hyperthermic intraperitoneal chemotherapy in ovarian cancer

Currently, epithelial ovarian cancer is diagnosed in advanced stages (EC IIIC) in 75-80% of cases worldwide. In this group of patients treatment with neoadjuvant chemotherapy is started, followed by interval cytoreduction of residual disease and even require peritonectomy with application of hyperthermic intraperitoneal chemotherapy (HIPEC). To identify the overall survival and progression-free survival associated with peritonectomy, in patients with peritoneal carcinomatosis secondary to ovarian cancer treated in the oncology gynecology service from January 2009 to January 2019 at the UMAE Hospital de Oncología Centro Médico Nacional Siglo XXI. Observational, descriptive, cross-sectional, retrospective study, information was obtained from the clinical file of patients treated with peritonectomy with the use of hyperthermic intraperitoneal chemotherapy in the gynecological oncology service from January 2009 to January 2019 at the UMAE Hospital de Oncología Centro Médico Nacional Siglo XXI. Information was obtained from a total of 36 patients (n=100%), 36.1% received intraperitoneal chemotherapy and 63.8% underwent cytoreduction without the application of intraoperative chemotherapy. The most frequently used drug was cisplatin followed by mitomycin. There was no statistical significance when comparing both groups, however there was a trend in favor of the use of intraoperative chemotherapy by obtaining a greater number of months in terms of overall survival. Peritonectomy with hyperthermic intraperitoneal chemotherapy is an option in selected patients with advanced stage ovarian cancer in primary and recurrent surgery, as well as in patients with platinum-resistant ovarian cancer.

Stress, anxiety, and illness perception in patients experiencing delay in operative care due to the COVID-19 pandemic

BackgroundAmid the height of the COVID-19 pandemic in the US, the US Surgeon General ordered hospitals and healthcare systems to stop all elective surgical procedures. The aim of our study was to evaluate the additional mental health impact of surgical delay on patients awaiting surgery for benign, pre-malignant and malignant conditions within the context of the COVID-19 pandemic. Study designAll patients over the age of 18 awaiting surgery for benign, pre-malignant or malignant conditions within the gynecologic oncology, surgical oncology and colorectal services across Northwell Health were eligible for participation. Upon successful enrollment, participants completed a baseline questionnaire consisting of the Generalized Anxiety Disorder Questionnaire, the Penn State Worry Questionnaire, and Brief-Illness Patient Questionnaire. ResultsThe surgical delay was considered moderately to extremely concerning by 72 % of survey respondents, with one third indicating the highest (10/10) level of concern. Fifty-five percent of patients with a pre-operatively suspected/confirmed cancer or pre-malignant condition demonstrated mild to severe anxiety in their completion of the GAD-7 scale. The average time awaiting surgery was 117 days (range 8–292); and 63 % of respondents indicated that the delay had a moderate to severe impact on their daily life. ConclusionsPatients awaiting surgery for confirmed, suspected or pre-malignant conditions expressed decreased sense of control and increased levels of distress compared to patients awaiting procedures for benign conditions (p < 0.05, 95 % CI [-2.65, -0.08]). Future research will focus on the effects of COVID-19 related delays in operative care on clinical outcomes, including cancer morbidity and mortality.

Determining Health Literacy Level of Women with Gynecological Cancer and Affecting Factors

Aim: This study was conducted to determine the health literacy levels of women with gynecological cancer and the affecting factors. Method: The sample of this descriptive and cross-sectional study consisted of 128 women who volunteered to participate in the study and were treated in the gynecological oncology service of the Oncology Center of a Training and Research Hospital in Izmir between January and June 2021. Data were collected by face-to-face interview method using a questionnaire and HLS. Results: In the study, the mean age of women with gynecological cancer is 60.81±11.18. The mean total score of the women's HLS is 94.38±13.91. The factors that are found to be significantly (p&amp;lt;0.05) associated with the level of health literacy are the education level of the women, the number of children, the employment status, and the number of hospital admissions in a year. In the study, the type of gynecological cancer, the number of regimens, the type of treatment, the duration of the disease, the age of onset of the disease, and the period without treatment were not associated with health literacy (p&amp;gt;0.05). Conclusion: In the study, it was concluded that the health literacy level of women was sufficient, the factors affecting health literacy were generally socio-demographic variables, and the disease characteristics and health behaviors did not affect the health literacy level.

War and Siege Halt Gynecologic Oncology Services for Women in the Tigray Region of Ethiopia

This essay urges action in the aftermath of a war that destroyed the health care system, specifically women’s cervical cancer screening and treatment, in Tigray.

PO37 Presentation Time: 4:45 PM: Standardizing an Inpatient Order Set for Patients Undergoing Inpatient Brachytherapy for Gynecologic Oncology Patients

<h3>Purpose</h3> Brachytherapy, also known as internal radiation therapy, is often use for treatment of cervical, uterine and vaginal cancers using intracavitary (e.g. tandem and ring), interstitial (e.g. Syed), or hybrid (e.g. intracavitary applicators with interstitial needles) applicators. Currently, there is little consensus or formal society guidance on management of patients receiving brachytherapy in an inpatient setting. We performed a pre- and post-implementation study of an order set created as a qualitive improvement initiative to standardize admission orders for all patients admitted to the gynecologic oncology service for brachytherapy. <h3>Materials Methods</h3> We reviewed electronic medical records of all patients at a single urban, academic institution who received brachytherapy associated with an overnight stay 6 months prior to and after implementation of the order set, (pre-order set period: 8/2020-1/2021, post-order set period: 2/2021-7/2021). The order set had pre-selected orders to facilitate ease and uniformity with admission orders. Compliance of order set use was assessed in the following categories: ancillary and nursing orders (head of bed elevation, speech and swallow evaluation), medications (pain, anti-diarrheal), laboratory examination, and venous thromboembolism prophylaxis. This project was undertaken as a Quality Improvement Initiative and as such was not formally reviewed by Institutional Review Board. <h3>Results</h3> Thirty patients received brachytherapy associated with an overnight stay for a gynecologic malignancy during the evaluation period with 18 (60%) patients in the pre-order set period and 12 (40%) in the post-order set period. Mean age of the patients was 56 years. Patients demographics were 53% (n=16) white, 37% (n=11) black, and 6% (n=2) identified as other race. Cancer diagnoses were 67% (n=20) cervical, 20% (n=6) vaginal, 10% (n=3) uterine - cuff recurrence, and 3% (n=1) vulvar. Orders for head of bed elevation no higher than 15 degrees increased from 89% (n=16) in the pre-order set period to 100% (n=12) in the post-order set period. Speech and swallow evaluation by speech language pathologists increased from 39% (n=11) in the pre-order set period to 75% (n=9). In the post-order set period, 97% of patients had baseline admission labs ordered, 97% of patients had all recommended medications ordered and 100% of patients had an order for venous thromboembolism prophylaxis. 29% (n=5) of patients in the pre-order set group had a safety event, while 8% (n=1) in the post-order set group had a safety event. <h3>Conclusions</h3> While there are no current society-level recommendations for management of brachytherapy patients associated with an overnight stay, utilization of an order set enhances compliance to core elements of quality overnight admission. Further investigation is needed to see if such order sets improve patient safety, satisfaction, and efficiency over a longer study period.

A Letter to Your Care Providers: Implementation and Analysis of a Letter-based Advance Care Planning Initiative for Gynecologic Oncology Patients.

To determine the impact of a letter-based advance care planning (ACP) healthcare improvement (HI) initiative on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. An HI initiative was implemented from January to December 2020 to improve ACP documentation among GO inpatients. Patients admitted to the GO service were given ACP packets with a letter-based ACP worksheet. GO inpatients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. ACP documentation rates in the EMR (electronic medical record) pre- and post-intervention were evaluated. Descriptive statistics were calculated. Associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. There were 172 patients admitted in 2019 (pre-implementation cohort). Of these, 45/172 patients (26%) had an advance directive (AD) documented in their electronic medical record (EMR). Following the implementation of the ACP HI in 2020, 55/168 patients (33%) had an AD documented in their EMR. This was a 7% absolute increase and 27% relative increase from pre-intervention AD documentation rates. Increasing age was associated with an increased likelihood of having an AD in the chart (p = 0.004). Married women were less likely to have an AD in their chart (p = 0.05). An HI utilizing a letter-based ACP packet given to GO inpatients improved AD documentation in the EMR. This HI offers a unique method for introducing ACP to patients. More work is needed to improve the occurrence and documentation of ACP conversations.

Prevaccine Human Papillomavirus Status in Invasive and Intraepithelial Lesions of the Vulva in New Zealand Women.

The human papillomavirus (HPV) vaccine, introduced in New Zealand (NZ) in 2008, is predicted to substantially lower the incidence of HPV-associated precancers and cancers. The aim of this study is to estimate the proportion of vulvar intraepithelial neoplasia (VIN) lesions and invasive vulvar squamous cell carcinomas (SCCV) attributable to HPV in NZ women treated by the Auckland Regional Gynecological Oncology Service, covering an estimated 50% of the NZ population. Polymerase chain reaction and reverse hybridization were used to analyze retrospective histologically proven SCCV from 1990 to 2007 and VIN lesions from 2000 to 2007 for HPV content and genotype in a collaborative study with the Catalan Institute of Oncology. Immunohistochemistry for p16INK4a was performed on SCCV, which were attributed to HPV if both tested positive. Polymerase chain reaction testing for HPV content and genotype was performed on 66 VIN lesions (all high-grade squamous intraepithelial lesions) and 189 SCCV. In addition, p16 immunohistochemistry was performed on 168 of the 189 SCCV (88.9%) tested for HPV-DNA. Overall, 61 SCCV cases (36.3%) were attributed to HPV (HPV+/p16+), and 89 SCCV cases (53%) were considered to have developed independently of HPV (HPV-/p16-). Known high-risk HPV genotypes were present in 96.8% of HPV-DNA-positive vulvar high-grade squamous intraepithelial lesions and 98.4% of HPV-attributable SCCV. Human papillomavirus 16 represented the most common genotype in both. Overall, the HPV vaccine is likely to substantially alter the profile of SCCV in our region. The results provide a baseline assessment of the HPV status of vulvar neoplasia before the introduction of the HPV vaccine.

Efficacy and safety of a restrictive blood transfusion protocol in gynecologic surgical patients

ObjectivesThis study sought to compare differences in blood transfusion and surgical complication rates before and after the implementation of a restrictive blood transfusion protocol. MethodsOn July 1, 2018, our institution implemented a restrictive blood transfusion protocol utilizing a hemoglobin trigger of less than 7 g/dL. Retrospective chart review was completed to review patients undergoing major abdominal surgery by the gynecology and gynecologic oncology services 18 months before, and after initiation of the transfusion protocol. Outcomes included number of patients, units transfused and postoperative complication rates. Complications included reoperation on the day of admission, surgical site infections, wound disruptions, pulmonary, renal, central nervous system, and cardiovascular complications, as well as deep venous thromboses, readmissions, and 30-day mortality. ResultsThere were 290 people in the pre- and 449 patients in the post-protocol group. A similar number of patients received blood transfusions in both groups (9.3% versus 10.6% p = 0.57). However, significantly fewer units of blood were given post-protocol initiation. For every patient who received a transfusion pre-protocol, 2.66 units were administered compared to 1.2 units after the protocol was initiated (p = 0.003). All postoperative complications were not significantly different between groups (p > 0.05). Individual postoperative complications were combined and analyzed using a clustered approach to detect rates of complications more conservatively. Both the 7-system (5.1% versus 4.9%, p = 0.90) and 8-system (5.5% versus 4.9%, p = 0.72) clustered analyses were not significantly different before and after the initiation of the transfusion protocol. ConclusionsA restrictive transfusion protocol is effective in decreasing the number of units of blood transfused without affecting postoperative complication rates in gynecologic surgery patients.

Should we consider panel-based pharmacogenetic testing in gynecologic oncology patients? (224)

Objectives: Pharmacogenetic (PGx) testing identifies variations in genes that help predict efficacy, risk of side effects, and appropriate doses of certain medications. Evidence-based guidelines from the Clinical Pharmacogenetic Implementation Consortium (CPIC) facilitate the application of PGx testing in clinical practice. Antiemetics, NSAIDs, and opioids, which are metabolized via cytochrome p450 enzymes, are commonly prescribed medications for gynecologic oncology patients. This study aimed to evaluate the prescribing rate for medications impacted by PGx variants by gynecologic oncologists. Methods: The study design was a cross-sectional retrospective review. The electronic medical record was queried for unique prescriptions orders placed by gynecologic oncologists at a single academic institution for CPIC level A/B medications between July 15, 2018- July 14, 2021. The frequencies of actionable phenotypes for PGx genes were estimated using the European phenotype frequencies provided by CPIC. The projected prevalence of drug-gene interactions (DGI) was estimated by multiplying prescription drug counts by phenotype frequencies. Results: A total of 10,624 patients were treated by the gynecologic oncology service and 86% were ordered at least one CPIC level A medication. The top five CPIC level A medications were ondansetron (n=6807, 64%), ibuprofen (n=5815, 55%), omeprazole (n=1929, 18%), tramadol (n=1450, 14%), and lansoprazole (n=1395, 13%). The top drug classes impacted by PGx were antiemetics (64%), NSAIDs (63%), proton pump inhibitors (PPIs) (44%) and opioids (14%). DGIs projected to have clinical consequence include: ibuprofen/CYP2C9 (n=989, 9%), ondansetron/CYP2D6 (n=204, 2%), omeprazole/CYP2C19 (n=136, 1%), lansoprazole/CYP2C19 (n=98, 1%) and tramadol/CYP2D6 (n=87, 1%). Additionally, 1015 patients with genetic results were identified in the Penn Medicine BioBank for further clinical follow-up to assess efficacy and adverse drug reactions. Conclusions: CPIC level A medications are commonly prescribed for gynecologic oncology patients. Implementation of multi-gene panels containing CYP2D6, CYP2C9, and CYP2C19 for the guidance of commonly prescribed antiemetics, analgesics, and PPIs would be of greatest benefit in this population. Further research is necessary to evaluate side effects and drug responses for patients with PGx variants in this patient population. Objectives: Pharmacogenetic (PGx) testing identifies variations in genes that help predict efficacy, risk of side effects, and appropriate doses of certain medications. Evidence-based guidelines from the Clinical Pharmacogenetic Implementation Consortium (CPIC) facilitate the application of PGx testing in clinical practice. Antiemetics, NSAIDs, and opioids, which are metabolized via cytochrome p450 enzymes, are commonly prescribed medications for gynecologic oncology patients. This study aimed to evaluate the prescribing rate for medications impacted by PGx variants by gynecologic oncologists. Methods: The study design was a cross-sectional retrospective review. The electronic medical record was queried for unique prescriptions orders placed by gynecologic oncologists at a single academic institution for CPIC level A/B medications between July 15, 2018- July 14, 2021. The frequencies of actionable phenotypes for PGx genes were estimated using the European phenotype frequencies provided by CPIC. The projected prevalence of drug-gene interactions (DGI) was estimated by multiplying prescription drug counts by phenotype frequencies. Results: A total of 10,624 patients were treated by the gynecologic oncology service and 86% were ordered at least one CPIC level A medication. The top five CPIC level A medications were ondansetron (n=6807, 64%), ibuprofen (n=5815, 55%), omeprazole (n=1929, 18%), tramadol (n=1450, 14%), and lansoprazole (n=1395, 13%). The top drug classes impacted by PGx were antiemetics (64%), NSAIDs (63%), proton pump inhibitors (PPIs) (44%) and opioids (14%). DGIs projected to have clinical consequence include: ibuprofen/CYP2C9 (n=989, 9%), ondansetron/CYP2D6 (n=204, 2%), omeprazole/CYP2C19 (n=136, 1%), lansoprazole/CYP2C19 (n=98, 1%) and tramadol/CYP2D6 (n=87, 1%). Additionally, 1015 patients with genetic results were identified in the Penn Medicine BioBank for further clinical follow-up to assess efficacy and adverse drug reactions. Conclusions: CPIC level A medications are commonly prescribed for gynecologic oncology patients. Implementation of multi-gene panels containing CYP2D6, CYP2C9, and CYP2C19 for the guidance of commonly prescribed antiemetics, analgesics, and PPIs would be of greatest benefit in this population. Further research is necessary to evaluate side effects and drug responses for patients with PGx variants in this patient population.

Measuring health disparity index in gynecologic oncology (281)

<b>Objectives:</b> A health disparity index (HDI) can be used to regularly assess quality metrics by race and ethnicity. Our objective was to describe the implementation of the HDI for gynecology oncology patients at a tertiary-care academic center. <b>Methods:</b> We systematically collected reportable quality events for gynecologic oncologic patients at a single academic institution over a one-year period, July 2020 - June 2021, who were presented at the department's bimonthly morbidity and mortality quality forum. Reportable events were mainly postoperative complications and were predefined as death within 30 days, transfusion of greater than four units of blood products, hospital stay greater than 15 days, unplanned transfer to the intensive care unit, unanticipated return to the operating room, re-admission within 30 days, venous thromboembolic event, operative injury, surgical site infection, and estimated blood loss greater than 750 mL for benign cases. The calculation below was used to compare events in Black patients compared to White patients. The race was self-reported and extracted from the electronic medical record. For the purposes of this calculation, reportable events were considered binary (i.e., patients either had or did not have a reportable event). A Chi-square test was used to compare the two populations. An HDI of 1 describes equal morbidity in White and Black patients, HDI <1 greater morbidity in White patients, and HDI >1 greater morbidity in Black patients. <b>Results:</b> A total of 458 patients underwent surgery with the gynecologic oncology service from July 2020 to June 2021 at The Hospital of the University of Pennsylvania. Sixty-two percent (<i>n</i>=284) identified as White, 29.7% (<i>n</i>=136) identified as Black, and 8.3% (<i>n</i>=38) identified as a race or ethnicity that was not White or Black. There were 73 reported events captured in the safety net reporting application. Of those 73 events, 33% (<i>n</i>=24) were for Black patients, 60% (<i>n</i>=44) were white patients, while the remaining 7% (<i>n</i>=5) were for all remaining patients. The proportion of Black patients with a reportable event was 17.6% (24/136), with a 95% CI of 11.6-25.1. The proportion of White patients with a reportable event was 15.5% (44/284), with a 95% CI of 11.5-20.2. The HDI presented at individual quality forums ranged from 0.50 to 5.1 over a 12-month period. The mean HDI is 1.14 with a 95% CI of 0.72-1.79 (p=0.57). <b>Conclusions:</b> From July 2020 to June 2021, the HDI was greater than 1 for our gynecologic oncology patients, indicating that a disparity in surgical and medical outcomes was present at a large urban academic institution. The wide range, as well as statistically non-significant p-value, is likely attributable to the small cohort. Using this HDI, our department is undertaking innovative quality improvement efforts to close the health disparity gap seen amongst gynecologic oncology patients.

Tailored opioid prescribing in gynecologic oncology: Michigan prescription opioid reduction tool (MiPORT) (292)

<b>Objectives:</b> To evaluate the implementation of a Gynecologic Oncology quality-improvement intervention aimed at tailoring opioid prescriptions to meet individual patient needs whilst not overprescribing. <b>Methods:</b> Our previously published opioid prescribing algorithm was implemented on January 1, 2021. This opioid reduction tool accounts for patient age, risk factors for opioid usage (history of anxiety, depression, substance abuse, chronic pain, or current opioid use), surgical modality, and inpatient opioid usage. This tool was used preoperatively to generate individualized opioid prescriptions for patients who underwent minimally invasive surgery or laparotomy by the Gynecologic Oncology service. Patients completed a 30-day postoperative standard questionnaire regarding the number of opioid pills used and any opioid refill requests. Opioid refill requests were cross-referenced with the state department's automated prescription system. Patients were identified in our institution's prospectively curated quality improvement surgical database from January 1, 2021, through July 31, 2021. Patients were included if they received the 5 mg oxycodone pills as per the standardized opioid prescribing algorithm. Prescriber compliance was defined as not prescribing more than the predicted patient needs determined by the opioid calculator. An excessive prescription was defined as the patient reporting more than three pills remaining after 30 days. <b>Results:</b> Two-hundred and thirteen patients were included in the analysis, where 56% (<i>n</i>=119) underwent laparoscopy, and 44% (<i>n</i>=94) underwent laparotomy. Eighty-three patients (39%) had at least one risk factor for opioid usage. The median number of opioid pills prescribed following laparotomy was 6 (range: 0-16), and the median after laparoscopy was three pills (range: 0-15). The rate of prescriber compliance was 87% (<i>n</i>=185/213). Of the 28 patients who received a higher number of opioid pills than what was recommended by the opioid calculator, 19 (68%) patients received only 1-3 pills more than the recommended amount. Four patients received larger amounts (10 pills) early in the implementation of the program and five larger prescriptions due to patient requests. The 30-day opioid refill request rate was 8% (<i>n</i>=17/213). Of the patients who received a larger prescription, 14% (<i>n</i>=4/28) received an opioid refill within 30 days. Thirty-four (21%) patients had more than three pills remaining after 30 days (excessive prescription rate). <b>Conclusions:</b> Using this tailored opioid calculator led to a high pre-scriber compliance rate and a low refill request rate while limiting the number of excessive opioid prescriptions.

Feasibility of combining pelvic reconstruction with gynecologic oncology-related surgery.

At our institution, every patient seen by the gynecologic oncology service is screened for pelvic floor dysfunction. This study was aimed at determining if a combined surgical approach by gynecologic oncology and urogynecology services at our institution was feasible and safe for this patient population. We performed a retrospective review of patients undergoing combined surgery by gynecologic oncology and urogynecology services at our institution from 2013 to 2021. Perioperative variables, postoperative adverse events, and long-term outcomes were assessed, and descriptive statistics were performed. From 20 December 2013 to 29 January 2021, a total of 102 patients underwent concurrent surgical repair of pelvic organ prolapse and/or stress urinary incontinence. Seventy-three patients (71.6%) had normal/benign pathologic conditions, and 29 (28.4%) had premalignant/malignant pathologic conditions. Ten patients (9.8%) had a postoperative complication, including reoperation for exposed midurethral sling (4.9%), urinary retention requiring midurethral sling release (2.9%), reoperation for hemoperitoneum (1.0%), and anemia requiring blood transfusion (1.0%). Nine complications occurred in patients with benign/normal pathologic conditions (12.3%), and one complication occurred in patients with pre-malignant/malignant pathologic conditions (3.4%). In our single-institution experience, concurrent gynecologic oncology and pelvic floor reconstructive surgery were safe and feasible in combination with no reported major morbidity events.

Side-to-end reanastomosis after low-anterior resection (STELAR): Outcomes, feasibility, and description of procedure performed by a gynecologic oncology service.

Low anterior rectosigmoid resection for a gynecologic disease is usually performed in concert with other procedures and can result in significant morbidity should anastomotic complication occur. This study examined surgical outcomes of side-to-end reanastomosis after low anterior resection (STELAR) performed by gynecologic oncology service. This is a case series examining consecutive patients who underwent STELAR for gynecologic indications by a single gynecologic oncology group from 2009 to 2018. Prospectively collected institutional surgical database was searched for STELAR, and standard descriptive statistics were used to describe intraoperative and postoperative complications specific to reanastomosis. A total of 69 women underwent STELAR, with median age and body mass index of 54 years and 24 kg/m2 , respectively. 63.8% of patients had ovarian cancer and 84.4% had stage III-IV disease. The median estimated blood loss was 875 ml. Four (5.8%) women underwent protective loop colostomy at the time of STELAR. Postoperatively, there was 1 (1.4%) case of abscess formation within 30 days and 1 (1.4%) case of anastomotic leak 5 weeks after STELAR that required reoperation and diversion. No cases of fistula were clinically identified. Side-to-end reanastomosis may be a safe and feasible procedure to accomplish low rectosigmoid anastomosis in women with gynecologic disease.