Gynecologic Oncology Patients Research Articles

Assessing sleep quality in gynecologic oncology patients after surgery

<h3>Objectives:</h3> High quality sleep is important for maintaining immune function, wound healing, and physical and emotional well-being. Our objective was to determine the quality of sleep in women admitted for post-operative recovery after surgical management for a suspected gynecologic malignancy. <h3>Methods:</h3> We surveyed women who were admitted to the hospital for at least one midnight after undergoing a surgical procedure for a suspected gynecologic malignancy between September 2020 and October 2020. The Pittsburgh Sleep Quality Index (19 item self-report questionnaire) was used to assess baseline sleep quality in the month prior to the planned procedure. The Richards-Campbell Sleep Questionnaire (5 item self-report survey) was used to assess nightly sleep quality during the subject's hospitalization. A chart review was also completed to assess for patient or surgical factors associated with poor sleep. <h3>Results:</h3> Twenty-three patients met the study criteria, of which 20 (87%) agreed to participate. The mean age was 58 (SD = 15), the mean BMI was 32.2 (SD = 8.3). Eighty percent of patients underwent surgery for confirmed malignancy, with uterine cancer (30%) and ovarian cancer (25) comprising the majority of diagnoses. The median admission length was 2 days interquartile range (IQR = 1-4.5), fifty percent of patients underwent an open procedure. Based on Pittsburgh Sleep Quality Index (PSQI) results, 15 patients (75%) reported poor sleep quality in the month prior to their surgery. The total RCSQ score was the worst on the first post-operative day (38.3, SD=28.3). Sleep quality improved on post-operative day 2 (67.3, SD=12.2), but then declined over the remainder of the hospitalization. <h3>Conclusions:</h3> Sleep quality is poor in women hospitalized after surgery with gynecologic oncologists. Sleep is an under recognized factor in optimizing postoperative recovery. The high prevalence of poor sleep during hospital-based post-operative recovery among gynecologic oncology patients warrants the development of evidence-based interventions for improving sleep and sleep quality.

Barriers to clinical trial enrollment among gynecologic oncology patients at a National Cancer Institute Comprehensive Cancer Center

<h3>Objectives:</h3> The objective of this retrospective review was to assess barriers to successful clinical trial enrollment among gynecologic cancer patients at a comprehensive cancer center. <h3>Methods:</h3> A retrospective chart review was performed of all new patients and established patients requiring treatment changes seen in a clinic setting by physicians in the gynecologic oncology department at a national cancer institute between July 1, 2019, and June 30, 2020. Demographic information collected for each patient included age, race, language, distance from the cancer center, insurance type, marital status, education, performance status and medical history. Demographic factors were compared between patients who enrolled in trials and those who were deemed eligible for clinical trials but did not enroll. Patients who did not enroll in a clinical trial were stratified by the reason for not enrolling as physician factor, patient factor, trial factor, and screening failure. Data was collected in a secure REDCap database. Data was analyzed using the Wilcoxon rank sum test and Fisher's exact test. <h3>Results:</h3> 960 records were reviewed and 165 patients were found to be eligible for a clinical trial at the time of their visit. 35 of these 165 patients (21.2%) enrolled in a clinical trial. Among patients who did not enroll in a clinical trial, the reasons for not doing so were due to a physician factor (71/130 or 55%), patient factor (42/130 or 32%), screening failure (13/130 or 10%), or a trial factor (4/130 or 3%). There were no significant differences in demographics between patients who enrolled in trials and those who did not. Patients who did not enroll secondary to a physician factor differed significantly from those enrolled or attempted to enroll in age and insurance type. Patients who did not enroll secondary to a physician factor were older when compared to those who enrolled or attempted to enroll in a clinical trial but failed the screening process (median of 70 vs 61.5 years old, p=0.014). They were also more likely to have Medicare and less likely to have private insurance (p=0.044). Patients who did not enroll secondary to a patient factor did not appear to differ significantly from patients who did enroll or who failed screening. Although patients who did not enroll secondary to a patient factor lived a mean distance almost twice as far away as those who enrolled or attempted to enroll (mean of 184 vs 91 miles), this was not statistically significant (p=0.107). <h3>Conclusions:</h3> Based on a one year time span of retrospective review, including the COVID 19 pandemic time, physician factor and concern for a patient's age appears to be the biggest barrier to clinical trial enrollment. Exploring additional reasons behind physicians' reluctance to enroll patients in trials may be the key to increasing clinical trial enrollment of eligible patients.

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.

Factors contributing to treatment delays among Medicaid-insured patients with gynecologic malignancies during COVID-19 in New York City

Objectives:When New York City (NYC) emerged as a COVID-19 epicenter, hospitals and clinicians were forced to quickly change practice models of health care delivery. We sought to determine the impact of COVID-19 on treatment delays that occurred during the peak of the pandemic among low-income gynecologic oncology patients in NYC.Methods:Medicaid-insured patients receiving gynecologic oncology care at two affiliated centers between March 15 and April 15, 2020 were identified for telephone interview. Eligible patients included those with precancerous or cancerous gynecologic diseases or hereditary breast and ovarian cancer (HBOC) syndromes. Demographics, clinical characteristics, and reasons for treatment delays were identified through self-report and confirmed with chart review at the time of interview and at 6-month follow up. Outcomes were classified as delays in the following: surgery, adjuvant treatment (chemotherapy/radiation), and surveillance visits.Results:Of the 158 eligible patients identified, 100 completed the interview. A total of 47 patients experienced an average treatment delay of 85.3 days (range: 7-210): surveillance visit (n=33), surgery (n=10), chemotherapy (n=3), radiation (n=1). Within this group, the median age was 58 years (range: 19-86). Self-identified race included: African-American (23.5%), Hispanic (31.9%), non-Hispanic White (17%), Asian (9.1%), Other (8.5%). The majority of patients (80.9%) had an annual income < $40,000. Clinically relevant surveillance delays occurred in 3 patients. A delayed diagnosis of vulvar cancer due to missed biopsy (follow up at 49 days) and 2 patients with delayed diagnosis of recurrent ovarian/primary peritoneal cancer; one died from disease and the other is undergoing chemotherapy. Surgical delays were identified in 10 patients: high grade cervical/vulvar dysplasia (n=3); endometrial intraepithelial neoplasia (EIN) (n=2); endometrial cancer (n=2); risk reducing surgery for HBOC syndromes (n=2); metastatic gastrointestinal adenocarcinoma to the ovary (n=1). Among the patients with endometrial cancer, one procedure delayed by 1 week was able to proceed and one transferred care. No upstaging of cancer diagnosis resulted from delays. Chemotherapy delays occurred in 3 patients with an average delay of 47.7 days. Of these patients, 2 were found to have progression of disease resulting in death (n=1) and decision to pursue hospice (n=1); one had a personal COVID-19 diagnosis. A delay in radiation treatment of 70 days was reported in 2.1% (n=1). A total of 9 patients were lost to follow up. Characteristics of patients lost to follow up include Hispanic/Latino race/ethnicity, essential worker, living with children in a high COVID-positive area (37.5%, n=3) or individuals who experienced a change in employment status (25%; n=2).Conclusions:COVID-19 resulted in significant treatment delays among Medicaid-insured gynecologic oncology patients. As we continue to minimize clinical encounters, interventions aimed at providing timely oncology care during the COVID-19 pandemic is essential to prevent widening disparities in low-income populations.

Gynecologic oncology and surgical oncology treatment modifications, cancellations or delays in response to the COVID-19 pandemic in public versus private cancer centers in North America

Objectives:The major shift in health-care resource utilization during the COVID-19 pandemic to support patients requiring mechanical ventilation and intensive care monitoring has led to unprecedented cancellations of elective surgeries and reductions of ambulatory clinic visits worldwide. The primary objective of this study is to determine whether the response to the pandemic resulted in modifications, cancellations or delays to the standard therapeutic algorithms for patients with gynecologic malignancies at tertiary, large-volume publicly funded Canadian cancer centers as compared to a privately funded American cancer center.Methods:This is a retrospective cohort study of all surgical oncology and gynecologic oncology cases performed in the province of Ontario and at the University Health Network/Princess Margaret Cancer Center (UHN/PMH) as a surrogate for treatment delays, compared to all gynecologic oncology patients treated at the Dana Farber Cancer Institute, Boston, MA, USA, between March 3, 2020-June 30, 2020. Descriptive statistics and treatment times were analysed using SPSS 25.0Results:In the province of Ontario, between March 15, 2020-October 25, 2020, there was a 19% overall decrease in surgical oncology volumes compared to the same time period the previous year (March 17, 2019-Oct 17, 2019). There was an increase of 96% in high priority surgical oncology cases and a 43% decrease in low priority cancer cases. Surgeries for gynecologic malignancies decreased by 8% in the province of Ontario as compared to the previous year. At UHN/PMH, a publicly funded tertiary cancer center in Ontario, there was a 59.8% reduction in surgical oncology volumes between March 09, 2020-May 04 2020, as compared to the previous year (March 04, 2019-April 29 2019). In comparison, at the Dana Farber Cancer Institute, a privately funded tertiary cancer center, there were 202 new gynecologic oncology patient referrals and 66 returning patients between March 3, 2020-June 30, 2020. The median time from referral to first consultation for new patients was 11 days (range 1-21) and the time to primary treatment was 31 days (range 5-157). New patients with ovarian malignancies had the shortest time to treatment of 22 days (range 5-157). There were no modifications made to the standard of care treatment plans for any patients and 5.7% of the patients had treatment delays.Conclusions:During the COVID-19 pandemic, the public Canadian healthcare system in the province of Ontario was subjected to a 19% reduction in surgical oncology volumes and 8% specifically for gynecologic oncology surgeries, while there was a 5.7% treatment delay for gynecologic oncology surgeries for a similar patient cohort treated at a tertiary cancer center in a privately funded health care system in the United States.

Implementation of a broader pre-operative antibiotic coverage and chlorhexidine irrigation associated with a lower postoperative surgical site infection

<h3>Objectives:</h3> Post-operative surgical site infections (SSI) cause major health and economic burden on the patients and the healthcare systems. Multiple risk factors such as obesity and medical comorbidities are known to increase the risk of SSI in gynecologic oncology patients. Commonly used preoperative antibiotic regimens focus on targeting the skin flora as described by the enhanced recovery protocols adopted by many hospitals. We sought to investigate the effect of the addition of metronidazole to the preoperative antibiotic regimen and the intraoperative pelvic irrigation with 0.05 % chlorhexidine gluconate (CHG) on the rate of SSI after a minimally invasive surgery in gynecologic oncology. <h3>Methods:</h3> After IRB approval, we collected data from June 2018 to January 2020 for patients who underwent minimally invasive gynecologic oncology surgery at Marshall University School of Medicine. Implementation of the infection control model (pre-operative Metronidazole + intraoperative CGH pelvic irrigation) started in July 2019. Demographic and medical data, as well as intraoperative and postoperative data, were collected. The rate of SSI was analyzed before and after adoption of the model. <h3>Results:</h3> A total of 508 patients underwent a minimally invasive gynecologic oncology procedure: 262 before the implementation of the infection control model and 318 afterward. The median age of the patients was 59 years old and the rate of comorbidities was equal between the groups. The rate of SSI before the implementation of the model (Group 1) was 2.29% (6/262) and the rate of SSI afterward (Group 2- post infection control model) was 0.94% (3/318). The most common bacteria isolated from the first group were gram-negative bacilli (Klebsiella and E. Coli) and anaerobes, while Group 2 had a single patient with Klebsiella infection, one Bacteroides species infection, and one MRSA infection. All of these infected patients required pelvic abscess drainage and hospital readmission for intravenous antibiotics, with an average of 2-day hospital stay. <h3>Conclusions:</h3> The addition of metronidazole to the preoperative antibiotics regimen and the intraoperative pelvic irrigation with 0.05 % CHG appears to decrease the rate of SSI after a minimally invasive gynecologic oncology surgery. This model merits further studying in order to validate these results.

Telemedicine and gynecologic oncology: caring for patients remotely during a global pandemic

<h3>Objectives:</h3> The objective of this project was to investigate care outcomes and patient satisfaction for gynecologic oncology patients participating in telemedicine visits conducted at the authors' institution during the COVID-19 pandemic. <h3>Methods:</h3> Telemedicine visits conducted between 3/23/2020 and 5/14/2020 were reviewed for demographic, clinical, and follow up data. To ascertain patient satisfaction, voluntary patient surveys were conducted by phone after their telemedicine visit using a validated survey used in other telemedicine studies. Physician and advanced practice provider (APP) satisfaction were surveyed at two clinical locations. Proportions compared using chi-square tests. Data analyzed using Stata SE statistical software. <h3>Results:</h3> From 3/23/2020-5/14/2020 there were a total of 281 telemedicine encounters. A total of 42 (15.0%) were new consults, 66 (23.5%) surveillance visits, 104 (37.0%) chemotherapy visits, 27 (9.6%) were postop visits, 30 (10.7%) were problem visits, and 12 (4.3%) were uncategorized visits. A total of 120 visits were for patients with ovarian cancer and 71 visits were for patients with uterine cancer. The remainder of the visits included patients with cervical cancer, vulvar/vaginal cancers, and benign conditions. A total of 11 visits were for patients on a clinical trial and 10/11 (90.9%) were able to continue on trial during this time period. With regards to imaging and labs for patients on trials, there were no protocol deviations. A total of 112 patients who completed telemedicine visits responded to a post visit survey. A total of 109 (97.3%) agreed or strongly agreed that their privacy was respected and 103 (92%) agreed or strongly agreed that their diagnosis and treatment options were adequately explained. A total of 83 (74.1%) of survey participants indicated that they preferred a mixture of telemedicine and in-person visits moving forward, 14 (12.5%) indicated they preferred only in-person visits moving forward and 15 (13.4%) indicated that they preferred only telemedicine visits moving forward. There were no significant differences between telephone and televideo visits with regard to patients agreeing or strongly agreeing that their diagnosis and treatment options were adequately explained (96.8% vs 86%, p=0.12). Similarly, patients agreed or strongly agreed that they could ask questions and seek clarification easily with both telephone and televideo visits (100% vs 94%, p=0.268). Additional patient perceived benefits of telemedicine are displayed in Figure 1. Approximately 80% of physicians and APPs at both clinical locations felt very satisfied or satisfied that clinical goals were achieved. <h3>Conclusions:</h3> Telemedicine has been underutilized in the care of women with gynecologic malignancies until the COVID-19 pandemic. Data from our institution demonstrate successful implementation of a telemedicine program that can be used for all visit types including for patients on clinical trials. Survey data indicate patients and providers view telemedicine favorably.

Impact of Enhanced Recovery After Surgery protocol on oncologic outcomes

<h3>Objectives:</h3> To determine if adherence to enhanced recovery after surgery (ERAS) protocol decreases the time to adjuvant therapy in gynecologic oncology patients undergoing laparotomy. <h3>Methods:</h3> After implementation of an ERAS program based on published guidelines at a single academic institution, women were identified over a 12-month period who underwent a planned exploratory laparotomy for suspected gynecologic malignancy and met criteria for adjuvant treatment. Prior to initiation of the ERAS program, pre-ERAS patients were identified by ICD-10 diagnosis codes and CPT laparotomy codes over a two-year period. Patient data was collected including demographics, adherence to ERAS protocols, type of and time to adjuvant treatment. The two groups were compared by mean difference using odds ratio and relative risk with 95% confidence interval. <h3>Results:</h3> We identified 52 women in the post-ERAS cohort and 99 in the pre-ERAS cohort who met criteria. Patient characteristics including disease site, type of adjuvant treatment, ASA, BMI, and length of surgery were similar between groups. Approximately one half of the patients had ovarian cancer, 54.0% in pre-ERAS and 50.8% in post-ERAS. There was a similar rate of chemotherapy as adjuvant treatment, 76.5% in pre ERAS and 76.9% in post ERAS. A total of 25 ERAS protocol elements were audited, and 10 were included for this analysis. The mean difference in time to adjuvant treatment between the 2 groups was 5.6 days (95% confidence interval 29.3- 36.8). Ovarian cancer patients underwent adjuvant treatment 10 days earlier in the pre-ERAS group compared to the post-ERAS group (95% confidence interval 31.3-43.1). <h3>Conclusions:</h3> After implementation and adherence to ERAS protocols, gynecologic cancer patients undergoing laparotomy returned to adjuvant oncologic therapy quicker than a pre-ERAS cohort, with ovarian cancer patients achieving a 10-day improvement in time to adjuvant chemotherapy. The entire post-ERAS group met the goal of 42 days from surgery to adjuvant treatment set out by SGO and the Commission on Cancer as an evidence based quality metric. Overall, our study demonstrated that gynecologic oncology patients undergoing laparotomy reach their next step in cancer treatment faster than a pre-ERAS program.

The Surprise Question: a tool to estimate and identify factors associated with 12-month mortality for gynecological oncology patients in an outpatient setting

Objectives: Although prognostic accuracy is essential to timely initiation of end-of-life (EOL) planning, clinicians’ ability to predict prognosis is generally poor. The Surprise Question - ‘would you be surprised if this patient died in the next year’ - is a validated screening tool for use in oncology patients and highly predictive of 12-month mortality. Our primary objective was to determine the prognostic significance of the Surprise Question in patients with late stage or recurrent gynecologic malignancy. Our secondary objective was to identify potential risk factors associated with increased mortality during a 12-month interval. Methods: We performed an observational prospective cohort study assessing the prognostic significance of the Surprise Question in patients with late stage and/or recurrent gynecologic malignancy at Women and Infants Hospital in Providence, Rhode Island. All providers seeing patients with late stage gynecologic malignancies were consented and participated in the study. When a patient presented to the gynecologic oncology clinic, the attending physicians, fellows, and nurse practitioners answered the Surprise Question for each person on an iPad. Patient data was abstracted via chart review 12-months from Surprise Question answer with demographic, clinical, and EOL data being collected. Data analysis included log-rank, Fisher's exact, and Wilcoxon rank sum tests. Results: A total of 44 providers were consented to participate in the study. A set of 12-month follow-up data was evaluated for 299/299 participants, with providers using the Surprise Question to screen 37% “no” and 63% “yes”. At the 12-month mark, 39% of those screened “no” were deceased while 91% of those screened “yes” were alive. Kaplan-Meier curves show that survival proportions at 12-months were statistically significant between those screened “no” and “yes” (Log-rank test=p Download : Download high-res image (97KB) Download : Download full-size image Conclusions: Our results demonstrate that the Surprise Question can help identify patients at high-risk for mortality within the following 12-months when used in the outpatient setting for those with gynecologic malignancy. When patients screen ‘no’ to the Surprise Question, early emphasis on EOL planning may be deemed higher importance. Identification of risk factors associated with increased risk of mortality at 12-months (recurrent disease, hospitalization, radiation, poor performance status) can help guide treatment decisions and when to best initiate EOL conversations.

Opioid analgesics following surgery for gynecologic cancer patients at a university health center: have we altered our prescribing patterns in this patient population?

Objectives: Our objective was to analyze the effect of increased opioid prescribing regulations, implemented as an updated state law in July 2016, on the number of opioid tablets prescribed to postoperative gynecologic oncology patients at a state-funded university health center. Methods: This Institutional Review Board (IRB)-approved, retrospective review utilized several electronic health records systems and our referral list to identify patients who qualified. Patients were included in the study if they received surgery performed by a gynecologic oncologist for suspicious masses, premalignant or malignant conditions of the uterus, tubes, ovaries or cervix. The charts were divided into Before July 2016 and After July 2016. The number of opioids prescribed to patients at time of discharge was recorded when available. Qualitative data was collected including the prescription or recommendation for non-opioid analgesics within the discharge summary, and type of procedure conducted (open versus minimally invasive). Demographic information including age, ethnicity and insurance coverage was also recorded. The study was designed to detect a 25% decrease in opioid tablets prescribed after the regulation was implemented (alpha = 0.05, power 0.8). Comparisons were made between groups after a Kolmogorov-Smirnov and Shapiro-Wilk test determined that the data was not normally distributed. Therefore, we utilized Mann-Whitney U tests to compare number of opioid tabs prescribed and to compare median age between the Before and After July 2016 groups. We used Chi-Square and Fischer Exact tests to compare differences in ethnicity and non-opioid analgesic (NSAID) use between the Before and After July 2016 groups. Finally, we utilized a multivariate linear regression model to determine if ethnicity and NSAID use significantly impacted the number of opioid tablets prescribed. Statistical analyses were performed utilizing SPSS software version 25. Results: We identified a statistically significant, 50% decrease in the number of opioid tablets prescribed after gynecologic oncology surgeries after July 2016. As anticipated, we also saw fewer opioid tablets prescribed following minimally invasive procedures compared to open cases (p=0.007). When examining non-opioid analgesic data, we identified significantly more patients received a prescription for non-opioid analgesics in the After July 2016 group compared to the Before July 2016 group (p Conclusions: This study confirms there was a significant decrease in the number of opioid tablets prescribed to postoperative gynecologic oncology patients at discharge since July 2016 in our state-funded university hospital. The difference cannot be attributed to the change in the regulatory guidelines alone, but is temporally related to the updated provider requirements. These results reemphasize that minimally invasive surgery has a reduced number of prescribed opioids, inferring a decreased amount of postoperative analgesic requirements. Multi-institutional study is required with more patients to detail the factors involved in further decreasing opioid prescribing and use. It appears from these results that increasing regulatory oversight is an important variable in harnessing the opioid epidemic.

Trends in the intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

Trends in the intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

New EHR-integrated PRO module for electronic reporting and monitoring of symptoms improves care in the postoperative setting

<h3>Objectives:</h3> Post-operative morbidity can compromise patient outcome and require acute care services. Cancer patients who utilize the PRO-CTCAE - a standardized, validated method of capturing patient-reported outcomes (PROs) - to report their symptoms have been shown to reduce symptom burden, decrease the need for acute care, and preserve quality of life. Building off this work, a fully EHR-integrated PRO system capturing side effects from surgery could significantly improve health care delivery, particularly in rural populations which has been further challenged by the COVID-pandemic. <h3>Methods:</h3> Through the NCI's Moonshot-funded IMPACT consortium, Dartmouth-Hitchcock Medical Center (DHMC) in collaboration with 5 other health systems and Epic designed eSyM, an EHR-integrated electronic symptom management program based on the PRO-CTCAE questionnaire. eSyM was deployed at DHMC, a large rural academic medical cancer center, systems beginning in spring 2020, for gynecologic oncology patients having surgery. Prompts to complete questionnaires were disseminated via the standard DHMC Epic-based patient portal (MyChart) on a tapered schedule averaging approximately twice/week for 90 days after surgery. Each survey included at least 6 PRO-CTCAE symptom items including pain, nausea/vomiting, fatigue, anxiety, wound redness and discharge as well items assessing overall wellbeing and functional status. Composite scores were generated for each symptom: 0 for no symptoms, 1-2 for mild/moderate symptoms, and 3 for severe symptoms. Reported severe symptoms automatically prompted an alert message sent directly to nursing staff. <h3>Results:</h3> Over the past 90 days, 134 women were eligible to participate in eSyM. 101 women were sent automated eSyM questionnaires after surgery through their patient portal. 69 (68%) activated their portal account and 48 (70%) completed at least 1 questionnaire electronically to report symptoms. Women who used eSyM were younger than those who did not activate their account, 54 vs. 61 years (p=0.05). Women completed a mean of 5 questionnaires over a mean of 19 days after surgery. 20% of patients reported severe symptoms, of which pain was the most common. Women who used eSyM were less likely to require hospitalization in the 90 days after surgery than women who did not participate (p<0.005). Urgent care and ED visits following surgery were comparable between eSyM users and those never activated their account <h3>Conclusions:</h3> Women with activated portal accounts had high rates of eSyM utilization to report symptoms after surgery. eSyM users tended to be younger than women who did not activate their accounts. Amidst the COVID-19 pandemic, an electronic platform to report and monitor symptoms following surgery alleviates some of the some of the burdens placed upon the patient and health care systems with in-person care, especially in rural settings. Future areas of research will include more robust patient cohorts from other institutions utilizing eSyM, and an evaluation of health care outcomes, including symptom burden, acceptability and acute care needs associated with eSyM.

Can we talk? The association between language and preoperative wait times for gynecologic oncologic patients

<h3>Objectives:</h3> The literature shows that non-English speakers have challenges in the perioperative setting when compared to English speaking patients. There is a lack of research within the field of gynecologic oncology regarding how patients' preoperative wait time and preoperative experience is influenced by their primary spoken language. The purpose of this study is to compare perioperative wait times in gynecologic oncology for English and non-English speaking patients at large public and private institutions. <h3>Methods:</h3> This is a retrospective review of women who underwent elective surgery for a gynecologic malignancy at both a large public safety-net hospital or a large private hospital between January 2018 and September 2019. Data collection included demographic data, baseline health characteristics, pre-operative information including dates of outpatient visits and surgical date. Statistical analysis included two-tailed T tests and chi-square tests. <h3>Results:</h3> 211 charts were reviewed, with 184 patients included in the final analysis. Charlson comorbidity indices were similar for English and non-English speaking patients (p=0.39). The most common non-English spoken languages were Spanish (55%), Mandarin (8%), Cantonese (8%), Polish (7%), and Russian (4%). Overall, the mean wait time from booking appointment to surgery for English speaking patients was 25.5 days compared to 33.6 days in non-English speaking patients (p=0.12). The majority (90%) of the non-English speaking patients included in the analysis received their care at the public hospital (p<0.001). When the analysis was restricted to public hospital patients, mean wait times from booking appointment to surgery were 33.7 and 36.7 days for English and non-English speaking patients, respectively (p=0.7). At the private hospital, wait times from booking appointment to surgery were 19.0 and 14.7 days for English and non-English speaking patients, respectively (p=0.5). When comparing wait times for non-English speaking patients at the two institutions, patients waited significantly longer at the public hospital (p=0.008). <h3>Conclusions:</h3> Non-English speaking patients had an 8 day increase in perioperative wait times compared to English speaking patients. This increase is largely attributable to the increased wait time for all patients in the public hospital system when compared to the private hospital. Further investigation of the structural differences between the public and university hospital systems is warranted.

A letter to your care providers: implementation and analysis of a letter-based advance care planning initiative for gynecologic oncology patients

<h3>Objectives:</h3> To determine the impact of a prospective, student-led, letter-based advance care planning (ACP) intervention on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. <h3>Methods:</h3> Retrospective analysis of patients admitted to the GO service at a single academic institution in 2019 showed that compliance with recommendations for ACP documentation was suboptimal. We initiated a quality improvement initiative from January through September 2020 to improve our compliance. Patients admitted to the GO service were given ACP packets with a letter-based advance directive (AD) worksheet modeled after the Stanford Letter Project. In January and February 2020, patients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. From March through September 2020, students were unavailable to facilitate in-person ACP conversations due to COVID-19 restrictions. Pre and post-intervention ACP documentation of patients admitted to the GO service were analyzed. Descriptive statistics were calculated, and associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. <h3>Results:</h3> Since implementation of the letter-based ACP intervention, 98 patients were admitted to the GO service. The majority of those admitted had cancer (n=60, 61%). Only 16 patients (16%) had an AD on admission, and 65 patients (66%) reported never having an ACP conversation. Of 82 patients without ADs, 71 (87%) received an ACP packet. Of those receiving packets, 8 (11%) requested more information about ACP and 6 (8%) participated in an ACP conversation with a student. At 9-month follow-up among patients receiving a packet, 9 patients added an AD to their EMR (13%), and 2 updated their AD (3%). After the intervention, AD completion in our population went from 16% to 26%. Among those receiving ACP packets, increasing age was associated with increased post-admission AD completion (OR 1.1, p=0.01). <h3>Conclusions:</h3> Completion of AD among patients continues to be low. Barriers to AD completion include patient and provider reluctance surrounding discussing these issues and difficulty with uploading these documents into the EMR. Letter-based ADs offer a unique method for introducing ACP earlier in cancer care and may lead to increased conversations about patient values and goals of care. More work is needed to improve occurrence and documentation of ACP conversations.

The show must go on: impact of the ban on elective surgery in New York City during the coronavirus outbreak on gynecologic oncology patient care

<h3>Objectives:</h3> To characterize the effect that a ban on elective surgery had for patients who were scheduled for surgery with a gynecologic oncologist during the first coronavirus disease 19 (COVID-19) outbreak in New York City. <h3>Methods:</h3> Patients who were scheduled to undergo surgery by a gynecologic oncologist at one of three campuses of a New York City based academic hospital during the ban on elective surgery between March 16, 2020 and June 15, 2020 were included. Patients with benign disease were excluded. Data on patient demographics, perioperative characteristics, nature of surgical delay, and post-operative treatment were abstracted from patient charts. Standard of care was considered met if surgical procedures occurred for suspected malignant and pre-invasive disease, or if an appropriate treatment plan and follow up was documented for malignant cases. Kruskal-Wallis and chi-square test of independence were performed with significance set at p<0.05. <h3>Results:</h3> A total of 196 patients were scheduled to undergo a surgical procedure during the ban on elective surgery, of which 146 were for malignant, suspected malignant or pre-invasive disease. The majority of cases (42.4%) occurred in patients with known malignancy, followed by suspected malignancy (37.7%) and pre-invasive disease (19.9%). Forty percent of patients experienced one or more surgical delay, 9.6% experienced 2 or more surgical delays and 1.4% experienced three or more surgical delays. Of patients who experienced surgical delays, 75.9% experienced hospital-initiated delays and 24.1% experienced patient-initiated delays. There were no differences between hospital versus patient initiated delays by White vs non-White race (p=0.167). Eight percent of delays were due to a patient with known or suspected COVID-19. The median time from surgical consultation to proposed date of surgery was 20 days for both known malignancy and suspected malignancy, and 34.5 days for pre-invasive disease (p=0.005). Similarly, the median time from surgical consultation to actual date surgery was 23 days for patients with known or suspected malignancy compared to 64 days for preinvasive disease (p=0.011). Of eight patients undergoing treatment for ovarian cancer, 50% underwent primary debulking and 50% underwent neoadjuvant chemotherapy. Among all scheduled cases, the standard of care was met in 89.7% of cases. Standard of care treatment was achieved with a documented alternative plan in 6.1% of cases and with a non-surgical plan in 3% of cases. <h3>Conclusions:</h3> During the ban on elective surgery in New York City during the first outbreak of the COVID-19 pandemic, many patients experienced minor surgical delays, but the majority of patients with known or suspected malignancies obtained appropriate, timely care. Ten percent of patients did not receive standard of care.

Outcomes of gynecologic oncology patients at an epicenter of the COVID-19 pandemic

Objectives:To describe the clinical course and associated mortality and morbidity of gynecologic cancer patients with COVID-19 infection with respect to cancer status, demographics, and comorbidities.Methods:An IRB approved prospective registry was initiated of all gynecologic oncology patients with COVID-19 infections at a health care system in New York City from March 1 to June 1 2020. Clinical and demographic data was abstracted from the electronic medical record. Univariate and multivariate regression analyses were performed to identify factors associated with development of an adverse event defined as the composite of death, intubation, or ICU admission.Results:In total, 57 gynecologic cancer patients with documented COVID-19 positivity were identified. The median age of identified patients was 68 years (range 32 - 91years). 29 patients (50.9%) required hospital admission and 28 (49.1%) patients required supplemental oxygen. 17 patients (30%) experienced an adverse event, defined as the composite of death, intubation, or ICU admission. Specifically 7 (12%) were intubated, 13 (23%) were admitted to the ICU, and 16 (27%) patients died from acute complications of COVID-19. All patients who were intubated and/or admitted to the ICU died from COVID-19 complications. Patients with elevated white blood cell count (WBC), absolute neutrophil count (ANC) and/or elevated prothrombin time (PT) were significantly more likely to experience an adverse event (WBC: 47 vs 12%, p=0.01; ANC: 37 vs 8%, p=0.04; PT: 61 vs 17%, p=0.04). On multivariable analysis, ECOG status of 1 or greater was associated with a 26-fold increase in the odds of an adverse event (OR=26, 95% CI: 2 - 415, p=0.02), and seven or more abnormal lab values was associated with a 305-fold increase in the odds of an adverse event (p=0.007). The presence of active cancer (n=33. 57.9%) or receipt of systemic therapy (n=18, 31.6%) was not associated with the development of an adverse event (p=0.205, p=0.81 respectively). Type of systemic therapy (chemotherapy, immunotherapy, radiation) was not associated with adverse event development.Conclusions:In this study, we analyzed the outcomes of gynceocologic oncology patients with COVID-19 infections at an urban New York City hospital. Over 50% of patients required hospital admission for COVID-19 related symptoms, with a case fatality rate of 27%. Age, active cancer status, or recent systemic therapy was not associated with subsequent intubation, ICU admission, or mortality, while performance status and multiple abnormal lab values were significant risk factors. Further characterization of associated poor prognostic factors is needed in order to formulate best oncologic practices during the COVID-19 pandemic.

Same-day discharge after robotic hysterectomy for gynecologic malignancy: a study of cost analysis and resource utilization

Objectives: To determine impact and cost savings of a quality intervention involving enhanced patient, provider, and staff education focused on same day discharge after robotic assisted total hysterectomy, and/or bilateral salpingo-oophorectomy with sentinel and/or additional lymph node dissection. Methods: A quality project was undertaken at our institution to improve the rate of same day discharge after robotic assisted hysterectomy and to assess the resource utilization savings of such an intervention. Literature supports feasibility and safety of same day discharge for robotic assisted hysterectomies alone or with other procedures for benign and malignant indications. Complex robotic assisted hysterectomies include bilateral salpingo-oophorectomy plus sentinel or additional lymph node resection. We collected historical data via chart review for the 12 months of 2018 (Group A) to determine our baseline same day discharge rate for complex robotic hysterectomies. Faculty, outpatient clinic and perioperative clinic staff were provided with education regarding the same day discharge goal for complex robotic assisted hysterectomies for patients from a single institution in our gynecologic oncology practice. We then prospectively collected the outcome data on patients undergoing complex robotic hysterectomies for the subsequent 12 months in 2019 (Group B). We compared demographic, clinical factors, and factors of resource utilization such as time in surgery and recovery and length of admission. Descriptive statistics and t-test were utilized to compare the groups. Results: One hundred three patients underwent complex robotic assisted hysterectomy in 2018, and 5% (5 patients) were discharged home on the day of surgery (Group A). One hundred twelve patients underwent complex robotic assisted hysterectomy in 2019 (Group B), and 32% (36 patients) were discharged home on the day of surgery. There was no significant difference between mean age (62 vs 64) or BMI (37 vs 36) in the two cohorts, respectively. Median length of stay was 21 hours for patients that were not discharged on day of surgery and 3.5 hours for patients discharged day of surgery. Of the 41 total patients undergoing same day discharge (Group A + Group B), there was one urgent care visit, one ER visit and and no readmissions in 30 days post procedure. A savings of approximately $1975 per case when patient discharged day of surgery. By promoting same day discharge after robotic assisted hysterectomy, 648 in-patient care hours were saved during the 12 months post intervention. Conclusions: A low cost patient and provider education initiative to increase same day discharge after robotic hysterectomy in gynecologic oncology patients positively impacted cost and resource utilization without negatively impacting readmission rates and ER utilization. In 12 months, the same day discharge rate in one facility was increased from 5% to 32% of robotic hysterectomy cases.

Postoperative venous thromboembolism in gynecologic oncology patients undergoing minimally invasive surgery: does modality matter?

<h3>Objectives:</h3> Minimally invasive surgery (MIS) is increasingly utilized for gynecologic cancers. While rates of venous thromboembolism (VTE) after MIS are low overall, risk factors such as malignancy and prior pelvic surgery may increase risk of perioperative VTE. Various guidelines exist regarding extended chemoprophylaxis with low molecular weight heparin (LMWH) for VTE prevention. Our objective was to determine incidence of 30-day postoperative VTE in patients undergoing MIS for gynecologic malignancies and to determine differences in the incidence of VTE by MIS modality. <h3>Methods:</h3> We collected demographic and perioperative variables for all patients undergoing MIS (robot-assisted, multi-port laparoscopy, single-port laparoscopy) for gynecologic cancers between January 2014 and December 2018. Patients <18 years, with benign pathology, or on preoperative anticoagulation were excluded. Logistic regression, Chi-square, Fisher's exact test, and one-way ANOVA were performed to determine risk factors related to VTE occurrence. <h3>Results:</h3> We identified 818 patients who underwent MIS (median age 61, 97% non-Hispanic White, mean BMI 34 kg/m²). Most had Stage I disease (81.4%) and uterine cancer (81.6%). 99.9% received intraoperative unfractionated heparin (UFH) and 96.6% received immediate postoperative UFH. Three VTE events occurred within 30 days following surgery (0.3%). Twelve patients received extended chemoprophylaxis with LMWH (1.5%); 11 patients received a 28-day course while one patient received a 14-day course. VTE was diagnosed in a total of 17 patients within 18 months of surgery (2%, median time to VTE 12 months). Of those diagnosed with VTE, 11 patients underwent robot-assisted laparoscopy, 4 patients underwent multi-port laparoscopy and 2 patients underwent single-port laparoscopy. Incidence of VTE did not differ between MIS modalities (<i>p</i>=0.6). Patients with Stage III disease (<i>p</i><0.001) and longer operative time (<i>p</i>=0.04) were more likely to experience postoperative VTE. Age, smoking status, BMI, and cancer type were not significant risk factors for postoperative VTE. <h3>Conclusions:</h3> The incidence of postoperative VTE in patients with gynecologic cancers undergoing MIS is low and does not differ by modality. Extended chemoprophylaxis is unlikely to be beneficial in patients with gynecologic malignancies undergoing MIS procedures.

Use of an opioid disposal bag for leftover pills in gynecologic oncology patients undergoing surgery

Objectives: To evaluate the effects of an environmentally-friendly drug deactivation bag on opioid disposal in gynecologic oncology patients undergoing surgery. Methods: This descriptive study included gynecology oncology patients undergoing any surgical procedure requiring an opioid prescription from 3/2020-9/2020. Patients were managed on a restrictive opioid prescribing algorithm (ROPA) and given an opioid disposal bag at their preoperative visit. The carbon drug deactivation bag used neutralizes the opioid medication and is environmentally friendly making it disposable in the trash. Patients were educated preoperatively about pain management goals, the disposal bag, and the ROPA. Patients were asked to complete a survey at their postoperative visit evaluating patient satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics v.25. Results: 140 patients were asked to complete the survey. The response rate was 78.5% (110 patients). The most common procedures were exploratory laparotomy (36.3%) and laparoscopic hysterectomy (32.7%). Ovarian and endometrial cancer were the most frequent diagnoses (17.2% and 27.3%, respectively). 91.8% of patients filled their opioid prescription and 47 (42.7%) had leftover pain medications. 55.3% of patients with leftover medications used the deactivation bag to dispose of them, 12.8% flushed or threw them away, and 31.9% did not dispose of them. Leftover opioid pill amounts included: Conclusions: Despite a restrictive opioid prescribing practice, 40% of patients had leftover opioids. Over half of these patients used the opioid disposal bag to discard their leftover pills. The disposal bag was most commonly used by patients undergoing exploratory laparotomy given the larger number of opioid pills prescribed at discharge. The use of a drug deactivation bag is unlikely to be beneficial in patients undergoing minor outpatient surgery.

Family health history of gynecologic oncology patients: can we do better?

<h3>Objectives:</h3> Despite a growing understanding of familial cancer, multiple studies demonstrate that the quality of family health history (FHH) as currently collected in a clinic setting is inadequate to assess disease risk. Proposed challenges in FHH collection include lack of patient preparation, lack of FHH standardization, and time requirement (especially during the COVID-19 pandemic with intentional minimization of office time). Prior to implementation of a web-based application for FHH collection, we aimed to review the quality of collected FHH in a gynecologic oncology clinic and to determine if any patient factors affect FHH collection. <h3>Methods:</h3> This was a single institution retrospective study of FHH collection for new patient appointments at a gynecologic oncology outpatient practice between 4/2019-7/2019. FHH was collected verbally during the patient face-to-face interview. FHH was evaluated for the following, previously published, quality measures on a point system: 1) Three generations, 2) Relative gender, 3) Relative lineage (maternal vs paternal), 4) Pertinent negatives (absence of hereditary cancers), 5) Age of relatives' cancer diagnosis, and for deceased relatives, 6) Age of death and 7) Cause of death. <h3>Results:</h3> Among the 200 evaluable patients, 185 (92.5%) had FHH documented in the medical record. The median age was 52 years (range 23-93). Eighty-nine (44.5%) included three generations, 154 (77%) relatives' gender, 109 (54.5%) relatives' lineage, and 77 (38.5%) pertinent negatives (Figure 1). Among 147 patients reporting a history of cancer in their family, 23 (15.6%) included age of relatives' cancer diagnosis. Among 75 patients listing deceased relatives, 13 (17.3%) included age of death and 48 (64%) cause of death. Age and personal cancer diagnosis were not associated with quality of FHH. Patients with family history of cancer scored higher in quality of FHH than those without family history (median=3.0 [IQR 3.0; 4.0] vs. 1.0 [0.0; 2.0], <i>P</i><0.001) and were more likely to have inclusion of three generations (57.1% vs. 9.4%, <i>P</i><0.001). Forty-three patients (21.5%) had previously undergone genetic testing and these patients had higher FHH scores than those without prior genetic testing (3.0 [3.0; 4.0] vs. 3.0 [1.0; 4.0], P=0.01) and were more likely to include age of relatives' cancer diagnosis (27.0% vs. 11.0%, <i>P</i>=0.04), age of relatives' death (35.7% vs. 13.1%, P=0.04), and cause of relatives' death (92.3% vs. 58.1%, P=0.02). Overall, patients with higher quality FHH had increased likelihood of being referred to genetic assessment (4.0 [3.0; 4.75] vs. 3.0 [1.0; 4.0], P=0.002). <h3>Conclusions:</h3> Our data are consistent with the literature suggesting that standard collection of family history may not adequately capture all measures of a high quality oncologic FHH. Patients without prior genetic testing and no family history of cancer had the lowest scores for FHH quality and might benefit from a web-based FHH collection tool, allowing them to contact relatives for more information prior to an office visit and permitting better patient preparation and efficiency. In light of the COVID-19 pandemic, tools that minimize inoffice time are increasingly important. A prospective evaluation of a web-based FHH collection tool to address these issues is ongoing.