Gynecologic Oncology Patients Research Articles

Use of a patient engagement technology platform improves gynecologic oncology patient outcomes in the perioperative setting (001)

Objectives: Technology can now be used through patient engagement platforms (PEPs) to allow patients to interact with their healthcare providers in order to increase education, assess and manage symptoms, monitor outcomes, and address questions/concerns. The objective of this study was to evaluate the impact of a mobile health patient engagement platform (PEP) on postoperative outcomes among gynecologic oncology patients undergoing surgery on an enhanced recovery protocol (ERP). Methods: All gynecologic oncology patients undergoing surgery on the ERP were approached from July 2019 to May 2021. The patients were enrolled in a PEP, which can be accessed by computer, tablet, or smartphone and provide enhanced pre and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbid conditions and were asked to complete daily health checks in the postoperative period. Patients reporting problems in the health check were given personalized education for minor problems or prompted to call the healthcare team for more serious issues. Age, race, body mass index (BMI), Carlson comorbidity index (CCI), surgical complexity, insurance status, length-of-stay (LOS), re-admission rates, surgical site infections, and use of the PEP were evaluated. Analysis was performed using SPSS v.26. Results: A total of 682 women met inclusion criteria during the study time. Of them, 347 were in the PEP group and 335 were in the control group (ERP only group). Patients in the PEP group had a significantly lower LOS (2.9 vs 3.6 days; p<0.01) and lower re-admission rate (4.3% vs 8.6%; p<0.01) than the control group. There was no difference in surgical site infections (1.1 vs 0.9%; p=0.4). Demographics and other factors, including race, BMI, CCI, gynecologic cancer diagnosis, surgical complexity, and insurance status, were not different between the PEP and control groups. Conclusions: The use of PEP in our gynecologic oncology patient population decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors. Furthermore, there was a 50% reduction in re-admission rates in the PEP group. The use of PEP allows healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care. Objectives: Technology can now be used through patient engagement platforms (PEPs) to allow patients to interact with their healthcare providers in order to increase education, assess and manage symptoms, monitor outcomes, and address questions/concerns. The objective of this study was to evaluate the impact of a mobile health patient engagement platform (PEP) on postoperative outcomes among gynecologic oncology patients undergoing surgery on an enhanced recovery protocol (ERP). Methods: All gynecologic oncology patients undergoing surgery on the ERP were approached from July 2019 to May 2021. The patients were enrolled in a PEP, which can be accessed by computer, tablet, or smartphone and provide enhanced pre and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbid conditions and were asked to complete daily health checks in the postoperative period. Patients reporting problems in the health check were given personalized education for minor problems or prompted to call the healthcare team for more serious issues. Age, race, body mass index (BMI), Carlson comorbidity index (CCI), surgical complexity, insurance status, length-of-stay (LOS), re-admission rates, surgical site infections, and use of the PEP were evaluated. Analysis was performed using SPSS v.26. Results: A total of 682 women met inclusion criteria during the study time. Of them, 347 were in the PEP group and 335 were in the control group (ERP only group). Patients in the PEP group had a significantly lower LOS (2.9 vs 3.6 days; p<0.01) and lower re-admission rate (4.3% vs 8.6%; p<0.01) than the control group. There was no difference in surgical site infections (1.1 vs 0.9%; p=0.4). Demographics and other factors, including race, BMI, CCI, gynecologic cancer diagnosis, surgical complexity, and insurance status, were not different between the PEP and control groups. Conclusions: The use of PEP in our gynecologic oncology patient population decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors. Furthermore, there was a 50% reduction in re-admission rates in the PEP group. The use of PEP allows healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes (006)

Objectives: Race and ethnicity data are not routinely reported in the auditing of Enhanced recovery after surgery (ERAS) pathways. Given known racial disparities in outcomes among gynecologic oncology patients, the purpose of this study was to compare differences in ERAS metrics by race. Methods: A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to July 2021. Demographic factors and compliance with preoperative, intraoperative, and postoperative ERAS metrics were compared by race using t-test and Chi-square analyses. Postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and re-admission within 30 days were also compared by race using Chi-square and multivariate logistic regressions (adjusted for age, body mass index, and diagnosis). Results: Of 1015 patients identified (83.9% White, 16.1% non-White), 94.2% underwent laparotomy. Non-White women were younger (54.3 years ± 13.5 vs 60.8 years ± 13.3, p<0.001) and less likely to speak English (76.1% vs 97.1%, p<0.001). Fewer non-White women had ovarian cancer than White women (45.4% vs 58.6%, p<0.002). Fewer non-White women received preadmission ERAS education (71.2% vs 79.8%, p=0.014) and fewer received oral bowel preparation (33.1% vs 47.1%) compared to White women. However, there were no differences in rates of preoperative nutritional assessment, carbohydrate loading, antibiotic prophylaxis prior to incision, or thrombosis prophylaxis by race. Intraoperative and postoperative metrics did not differ by race, including surgical approach, blood loss, length of incision, core body temperature, intravenous crystalloid and blood products given, length of operation, length of stay, resection site drainage, use of a nasogastric tube, and mobilization on the day of surgery. A higher percentage of non-White patients experienced complications during their primary stay than White patients (34.4% vs 26.5%, p=0.041, see Table 1). When analyzed by complication type, non-White women had more anesthesia complications (5.5% vs 1.8%, p=0.004), hypotension (5.5% vs 1.2%, p<0.001), and surgical complications (11.7% vs 7.0%, p=0.044) compared to White women. However, no differences were noted in complications after the primary stay, 30-day survival, reoperation, ICU transfer, or readmission. On multivariate logistic regression, non-White women were more likely to experience complications during the primary stay (OR: 1.8, 95% CI: 1.2-2.6, p=0.007) after adjusting for confounders. Objectives: Race and ethnicity data are not routinely reported in the auditing of Enhanced recovery after surgery (ERAS) pathways. Given known racial disparities in outcomes among gynecologic oncology patients, the purpose of this study was to compare differences in ERAS metrics by race. Methods: A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to July 2021. Demographic factors and compliance with preoperative, intraoperative, and postoperative ERAS metrics were compared by race using t-test and Chi-square analyses. Postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and re-admission within 30 days were also compared by race using Chi-square and multivariate logistic regressions (adjusted for age, body mass index, and diagnosis). Results: Of 1015 patients identified (83.9% White, 16.1% non-White), 94.2% underwent laparotomy. Non-White women were younger (54.3 years ± 13.5 vs 60.8 years ± 13.3, p<0.001) and less likely to speak English (76.1% vs 97.1%, p<0.001). Fewer non-White women had ovarian cancer than White women (45.4% vs 58.6%, p<0.002). Fewer non-White women received preadmission ERAS education (71.2% vs 79.8%, p=0.014) and fewer received oral bowel preparation (33.1% vs 47.1%) compared to White women. However, there were no differences in rates of preoperative nutritional assessment, carbohydrate loading, antibiotic prophylaxis prior to incision, or thrombosis prophylaxis by race. Intraoperative and postoperative metrics did not differ by race, including surgical approach, blood loss, length of incision, core body temperature, intravenous crystalloid and blood products given, length of operation, length of stay, resection site drainage, use of a nasogastric tube, and mobilization on the day of surgery. A higher percentage of non-White patients experienced complications during their primary stay than White patients (34.4% vs 26.5%, p=0.041, see Table 1). When analyzed by complication type, non-White women had more anesthesia complications (5.5% vs 1.8%, p=0.004), hypotension (5.5% vs 1.2%, p<0.001), and surgical complications (11.7% vs 7.0%, p=0.044) compared to White women. However, no differences were noted in complications after the primary stay, 30-day survival, reoperation, ICU transfer, or readmission. On multivariate logistic regression, non-White women were more likely to experience complications during the primary stay (OR: 1.8, 95% CI: 1.2-2.6, p=0.007) after adjusting for confounders.

Optimizing prehabilitation in gynecologic oncology (476)

<b>Objectives:</b> Prehabilitation, or therapy implemented prior to surgery, has demonstrated an improved return to physical baseline in colorectal, surgical oncology, and urologic literature but has never been evaluated specifically in gynecologic oncology patients. The intervention generally involves physical therapy (PT); however, reduced stress and anxiety have been noted with the addition of cognitive- behavioral therapy (CBT). Extrapolating from improved outcomes in other surgical literature, we sought to identify the optimal therapy program in gynecologic oncology. We hypothesize that women receiving trimodal treatment with PT, CBT, and nutrition counseling will have earlier physical recovering and higher quality of life (QOL) scores compared to unimodal PT alone. <b>Methods:</b> Women aged 18-90 years undergoing surgery for known or suspected gynecologic malignancy were enrolled. All patients underwent PT assessments at baseline (preoperative), four and eight weeks postoperative. Trimodal patients also had CBT stress reduction and dietician counseling at the same schedule. QOL was assessed with the Functional Assessment of Cancer Therapy-General (FACT- G) at baseline and eight weeks postoperative. Nutritional status was assessed with the Patient-Generated Subjective Global Assessment at baseline and eight weeks. Each patient, therefore, served as her own PT and QOL control. An anonymous survey was completed at the study conclusion. <b>Results:</b> To date, 42 patients have enrolled; 15 withdrew secondary to canceled surgery or scheduling/financial constraints, whereas 17 (five unimodal, 12 trimodal) have mature data for analysis. Patients undergoing unimodal therapy had a significant improvement in PG-SGA scores 5.0 ± 3.4 to 2.0 ± 1.9 (p<0.05) compared to trimodal patients (2.8 ± 2.4 to 1.7 ± 0.9, p=0.39) though they started at poorer scores. Trimodal patients had a significant improvement in QOL scores (81.7 ± 15.5 to 92.0 ± 9.0, p < 0.05) compared to unimodal patients (82.5 ± 23.7 to 6.8 ± 17.9, p=0.43). PT assessments included a 6-Minute Walk Test (6MWT), Timed Up and Go (TUG), Hand Grip Strength (HGS), and 30-Second Sit to Stand (30CST). Overall, at least a trend toward improvement in all PT assessments was noted other than unimodal stable HGS with the greater trimodal trend and significant TUG improvement in both groups at eight weeks (p < 0.05). All patients who completed the anonymous survey reported a helpful experience, with more trimodal patients reporting benefit in surgery expectations (100% vs 71%, p=0.18), faster strength recovery (88% vs 71%, p=0.57), and stress reduction (100% vs 86%, p=0.44). <b>Conclusions:</b> Prehabilitation is feasible and positively received by gynecologic oncology patients regardless of treatment method. Trimodal is associated with reduced stress and improved QOL. Further study enrollment may delineate an optimal group though centers seeking to apply such programs may find any prehabilitation to provide a positive, meaningful patient experience.

Safety and efficacy of percutaneous liver ablation in gynecologic oncology patients with oligometastatic disease (543)

<b>Objectives:</b> To describe the safety and efficacy of percutaneous liver ablation (PA) performed by interventional radiology (IR) in gynecologic oncology patients with liver-dominant oligometastatic disease. <b>Methods:</b> This retrospective cohort included all adult women (>21 years) with a gynecologic malignancy who underwent PA for liverdominant oligometastatic disease from August 2016 to June 2021 at our institution. Age, Charlson comorbidity index (CCI), diagnosis, performance status (PS), prior cancer therapies, technical details of PA, complications, tumor response (complete, stable disease, and progression), and recurrence were evaluated. Descriptive statistics were performed using SPSS v. 26. <b>Results:</b> Thirteen women (median age: 63 [range: 45-77]; median CCI: 8 [range: 6-11]; median PS=0 [range: 0-2]) were included who underwent 21 PAs. Eight patients (61.5%) had recurrent ovarian cancer, while five patients (38.5%) had recurrent endometrial cancer. All patients had liver-dominant, oligometastatic disease with treated tumors ranging from 1.3-4.5cm. The median number of procedures was one (range: 1-4). Three women had multiple procedures. Patients most commonly underwent microwave ablation (<i>n</i>=17/21; 81%) or cryoablation (<i>n</i>=4/21; 19%). Patients had received a median of three anticancer therapies (range: 1-6) prior to PA in addition to primary surgery, with the most common being chemotherapy. About 66.7% of PA procedures (<i>n</i>=14/21) resulted in a complete response to treatment. Three procedures (14.3%) resulted in stable disease. Thus, 17/21 procedures (81%) resulted in local control. Four patients (19%) had disease progression in the liver consisting of new metastases not targeted during the PA ablation procedure. Eight out of 13 patients (61.5%) had no further evidence of liver metastases during their disease or treatment course. There were two major complications: a grade 3 liver abscess requiring drain placement and IV antibiotics and a grade 3 pneumothorax requiring chest tube placement. Two minor complications included a perihepatic hematoma (grade 1) and an asymptomatic pneumothorax (grade 1). PA did not result in any complication with permanent sequelae or grade 4 or 5 adverse events. <b>Conclusions:</b> PA is an effective therapeutic option for gynecologic oncology patients with liver-dominant oligometastatic disease. More than 80% of procedures result in disease control, and two-thirds of procedures achieve a complete response with an acceptable safety profile. This image-guided, minimally-invasive procedure provides an additional tool for managing oligometastatic disease in the liver for appropriately-selected patients. A multi-disciplinary approach is crucial in treating these complex patients.

Peri-operative cardiac events in patient undergoing surgery for gynecologic malignancies are associated with long-term cardiovascular outcomes (489)

Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data on women with gynecologic cancer. Cancer and CV disease have significant pathophysiologic overlap, and both independently increase the risk of the other. Cancer patients have a 5-fold increased risk of major stroke or myocardial infarction, and patients who have perioperative cardiac events in noncardiac surgeries have significantly increased mortality. We aimed to characterize the incidence of perioperative events and long-term outcomes in women undergoing surgery for gynecologic malignancy. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days of surgery) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were white, 35.3% were Black, and 1.2% were Asian. Fifty-four (31.0%) patients experienced a perioperative CV event. Arrhythmia was most common (23.6%), followed by heart failure exacerbation (4.6%) and NSTEMI (4.6%). Of these patients, 35.2% had not been identified to be at increased cardiac risk preoperatively. Among the patients who had a perioperative event, 46.7% were diagnosed with a new chronic CV condition. After 30 days of follow-up, 45.4% of patients had a new CV event: arrhythmia was most common (17.8%), followed by heart failure exacerbation (16.7%) and stroke/ TIA (5.2%). Of these patients, 33 were diagnosed with at least one chronic CV condition, including heart failure (51.5%), atrial fibrillation (30.3%), CAD (6.1%), and pulmonary hypertension (6.1%). Fifteen patients who had perioperative events had a subsequent CV event. Conclusions: Perioperative cardiac events related to surgery for gynecologic malignancy, though rare, may represent a sentinel event for CV health and represent an opportunity for early intervention. Almost half of the patients with a CV event were diagnosed with a new chronic CV condition, and almost one-third had a subsequent CV event. Additional studies should focus on the long-term sequelae of perioperative CV events in gynecologic oncology patients and their interaction with oncologic outcomes. Objectives: Cardiovascular (CV) disease is a leading cause of mortality in older women, but there is limited data on women with gynecologic cancer. Cancer and CV disease have significant pathophysiologic overlap, and both independently increase the risk of the other. Cancer patients have a 5-fold increased risk of major stroke or myocardial infarction, and patients who have perioperative cardiac events in noncardiac surgeries have significantly increased mortality. We aimed to characterize the incidence of perioperative events and long-term outcomes in women undergoing surgery for gynecologic malignancy. Methods: A retrospective cohort analysis was performed from January 1, 2013, to December 31, 2019, of all patients with gynecologic malignancies who had either a perioperative (within 30 days of surgery) or subsequent cardiac event. Events were abstracted from the electronic medical record using ICD codes. Demographic, medical history, comorbid conditions, oncologic course, and event-based data were analyzed using SAS 9.4. Results: One hundred seventy-four patients met the inclusion criteria; 76 (45.3%) had ovarian cancer, 69 (40.0%) had uterine cancer, and 23 (13.7%) had cervical/vulvovaginal cancer. The average age was 67.4 years, 63.0% were white, 35.3% were Black, and 1.2% were Asian. Fifty-four (31.0%) patients experienced a perioperative CV event. Arrhythmia was most common (23.6%), followed by heart failure exacerbation (4.6%) and NSTEMI (4.6%). Of these patients, 35.2% had not been identified to be at increased cardiac risk preoperatively. Among the patients who had a perioperative event, 46.7% were diagnosed with a new chronic CV condition. After 30 days of follow-up, 45.4% of patients had a new CV event: arrhythmia was most common (17.8%), followed by heart failure exacerbation (16.7%) and stroke/ TIA (5.2%). Of these patients, 33 were diagnosed with at least one chronic CV condition, including heart failure (51.5%), atrial fibrillation (30.3%), CAD (6.1%), and pulmonary hypertension (6.1%). Fifteen patients who had perioperative events had a subsequent CV event. Conclusions: Perioperative cardiac events related to surgery for gynecologic malignancy, though rare, may represent a sentinel event for CV health and represent an opportunity for early intervention. Almost half of the patients with a CV event were diagnosed with a new chronic CV condition, and almost one-third had a subsequent CV event. Additional studies should focus on the long-term sequelae of perioperative CV events in gynecologic oncology patients and their interaction with oncologic outcomes.

Colostomy for large bowel obstruction at the end of life: What do patients gain from palliative surgery? (598)

Colostomy for large bowel obstruction at the end of life: What do patients gain from palliative surgery? (598)

Narcotic waste in the operating room and immediately post operatively in gynecologic oncology surgery (118)

Narcotic waste in the operating room and immediately post operatively in gynecologic oncology surgery (118)

Gynecologic oncology patients living in rural areas less likely to utilize telemedicine services during the COVID-19 pandemic (054)

Objectives: The COVID-19 pandemic is an unprecedented event in the era of modern medicine and has resulted in a rapid shift in clinical care delivery to incorporate more telemedicine services. While there is a well-recognized need for the integration of telehealth into gynecologic oncology care, there are concerns about limitations of its use regarding access to and ability to use requisite technology. The purpose of this study was to characterize gynecologic oncology patients who utilized telemedicine as part of their cancer care during the pandemic in order to determine potential barriers and facilitators of telemedicine use.Methods: A single-institution retrospective chart review was performed of patients who participated in at least one telemedicine visit from March 1 to September 30, 2020, at an NCI-designated cancer center. Demographic factors were compared between telemedicine users and non-users using Fisher’s exact test for categorical values and the Wilcoxon rank-sum test for continuous variables.Results: A total of 2238 patients were seen during the study period. Of which, 193 patients participated in telemedicine visits, and 2045 patients did not participate in any telemedicine visit with gynecologic oncology providers (Table 1). The median age was 63 years in both groups, and 65% of users were older than 60 years versus 62% of non-users. There were no significant differences with respect to race and primary language; the majority were Caucasian and English-speakers. There was no difference in terms of insurance status; about 50% in each group were privately insured. Among the telemedicine users, 97% had private insurance or Medicaid/Medicare, compared to 93% of non-users. Among users, the median distance of the patient’s residence from the cancer center was 21 miles, with 36% living 50 miles or further and 28.5% living in rural zip codes as designated by the Federal Office of Rural Health Policy. Among non-users, the median distance was 24.5 miles, with 37% living 50 miles or further and 38% living in rural zip codes. The odds of using telemedicine for patients living in rural zip codes was 34.6% less than for patients living in non-rural zip codes (Odds Ratio: 0.654, 95% CI: 0.473-0.906).Conclusions: Telemedicine provides an important opportunity to reduce unnecessary patient exposure to healthcare settings and has the potential to decrease the financial toxicity and treatment burden associated with cancer care. Our findings suggest that telemedicine at our institution was accessible to patients of a wide range of ages, including a large percentage of older adults. While 37% of gynecologic oncology patients seen during this period lived in rural areas, we found that the odds of utilizing telemedicine were significantly lower among patients who lived in rural areas compared to those living in non-rural areas (p=0.0101). This highlights the importance of identifying barriers rural patients face in utilizing telemedicine services and developing strategies to improve their access.

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.

Developing a patient-centered opioid prescribing model: A prospective evaluation of opioid prescribing and utilization patterns among gynecologic oncology patients (581)

<b>Objectives:</b> The opioid epidemic is recognized as a public health crisis. Overprescribing opioids for postoperative pain management is commonly reported in surgical specialties, yet prescription guidelines are not well described after gynecologic oncology surgery. We sought to describe opioid prescribing and utilization patterns in gynecologic oncology patients to inform the development of a patient-centered opioid prescribing algorithm. <b>Methods:</b> This prospective cohort study recruited opioid naïve, gynecologic oncology patients undergoing hysterectomy. Demographic data, surgical data, inpatient opioid use, validated PROMIS pain inference questionnaires, and satisfaction surveys were collected. Medication diaries were collected at the 2- and 6-week postoperative visits. Outpatient postoperative opioid use was collected and converted to oral morphine milligram equivalents (MME). A retrospective chart view was completed to abstract details of the operation and the patient's inpatient opioid requirement. Descriptive statistics were used to quantify opioid prescribing and utilization patterns in MME. Wilcoxon rank-sum tests were used to compare opioid requirements by the surgical route. Nonparametric statistical methods were used to identify factors associated with outpatient narcotic use. An algorithm for future opioid prescribing was developed using the 95^th percentile of outpatient opioid use. <b>Results:</b> From January 2021 to July 2021, 65 women were recruited, with 57 completing follow-up data collection. The surgical approach was divided evenly with 49% open and 51% minimally invasive groups (MIS). The amounts of outpatient opioid prescription and use were lower in the MIS group compared to the open surgery group (p 0.011 and p 0.045, respectively). In the MIS group, the median prescribed opioids were 38 MME (IQR: 20-75 MME), equivalent to five pills of 5mg Oxycodone while median usage was 4 MME (IQR: 0-22), equivalent to one pill of 5mg Oxycodone. For the open group, 96 MME was prescribed (IQR: 38-150), equivalent to 20 pills, while usage was 31 MME (IQR: 0-82), equivalent to five pills. Twenty-four patients (42%) did not use any narcotics. Factors that correlated with postoperative opioid use included surgical procedure, estimated blood loss, the amount of narcotic taken during the last 24 hours as an inpatient, tobacco use, and patient's BMI. Patient reported high satisfaction with their preoperative teaching specific to pain control. Finally, 84% of patients had pain ratings on the PROMIS survey within normal limits at 6-week compared to a referent population. <b>Conclusions:</b> In this cohort, opioids were overprescribed for all patients, necessitating the need for more restrictive, personalized prescribing practices. As described in Figure 1, surgical route and last 24 hours inpatient MME can help delineate patient's opioid requirements and aid in the development of patient-centered guidelines for opioid prescribing in the postoperative period. Fig. 1

Cognitive behavioral therapy for weight management in gynecologic oncology (288)

<b>Objectives:</b> Obesity is an epidemic in gynecologic oncology, leading to an increased risk of surgical complications and poor cancer outcomes. Cognitive-behavioral therapy (CBT) is an effective weight loss strategy. We aimed to determine whether group CBT is an effective weight loss tool when offered in an outpatient gynecologic oncology setting. <b>Methods:</b> We established a CBT-based weight management intervention for gynecologic oncology patients at an NCI-designated cancer center. The intervention was a 12-week group-based weight loss program offered to patients from the gynecologic oncology clinic with body mass indices (BMI) between 25-50 kg/m². Sessions were free of charge, led by a psychologist and dietitian, and transitioned from in-person to tele-visits due to the COVID-19 pandemic. The program combined nutritional education, lifestyle changes, and CBT approaches, with 12 weekly group visits followed by three monthly individual follow-up visits. Each participant was given a goal weight loss of 7% total body weight (TBW). Retrospective data were collected from patients enrolled in the intervention from September 2019 through March 2021. Paired t-tests were performed to compare the pre-program and ending weights for all participants. Weight loss data were tested for normality using the Shapiro-Wilk test. <b>Results:</b> A total of 29 patients were enrolled in four cohorts during the study timeframe. Fifty-nine percent of participants were White, 38% were Black. The mean age among participants was 56 years, and the mean BMI was 41 kg/m². Most participants had a history of endometrial hyperplasia or malignancy (58%) and had stage I disease (59%). Among the participants, 22 (76%) completed the program. The average weight loss among all participants during the 12-week program was 5.6 pounds (CI: -8.9- -2.1, p=0.002), equivalent to an average 2% change in TBW. Among the 22 participants who completed the program, the average weight loss was 7.4 pounds (CI: -11.1- -3.8, p <0.001), equivalent to an average 3% change in TBW. Weight loss was sustained at the 6-month mark, with an average change in TBW of 2-3% when comparing weight at 6 months to pre-program weight. <b>Conclusions:</b> This CBT-based weight loss intervention was feasible and acceptable to gynecologic oncology patients. While the average weight loss fell short of the goal of 7% TBW, the 2-3% change in TBW achieved on average with this intervention was stable over six months. Additionally, retention within the intervention was high and maintained during COVID-19 with tele-visits. Given that weight loss plateaued when transitioning from weekly to monthly sessions, our findings suggest that longer, more intensive treatment may be needed to promote sustainable weight loss among gynecologic oncology patients. Collaboration between psychologists, oncology dietitians, and gynecologic oncologists, with continued support for psychologists and dieticians at cancer centers, is critical to the success of such programs. CBT is a feasible behavioral intervention to add further multidisciplinary efforts to tackle the complexity of obesity in cancer survivors. Table 1

An initiative to improve adherence to guidelines for thromboprophylaxis among high-risk gynecologic oncology patients receiving outpatient chemotherapy (293)

Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population. Objectives: Pharmacologic thromboprophylaxis is recommended for high-risk gynecologic oncology patients with a Khorana score (KS) ≥ 2 receiving outpatient chemotherapy. Our objective was to evaluate the impact of a quality improvement (QI) project designed to increase KS calculation and documentation of thromboprophylaxis eligibility for patients initiating outpatient chemotherapy. Methods: In January 2021, the Society of Gynecologic Oncology endorsed guidelines recommending thromboprophylaxis for gynecologic oncology patients with a KS ≥ 2 receiving outpatient chemotherapy. The primary barriers to the implementation of these guidelines at the author’s institution included provider awareness, KS calculation, and documentation of eligibility. Starting June 2021, a KS calculator and associated thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Eligible patients included those with gynecologic malignancies initiating a new chemotherapy regimen from January to September 2021. The percentages of patients for whom KS and thromboprophylaxis eligibility were documented at the start of the first cycle pre- and post-QI initiative were compared using the Chi-square test. The percentages of eligible patients who were offered and initiated thromboprophylaxis (apixaban 2.5 mg twice daily) in accordance with the algorithm were also assessed. Results: There were 119 total new chemotherapy cases identified in the study time frame: 61 pre-QI (51.3%) and 58 post-QI (48.7%). Of these, 34.4% (21/61) and 34.5% (20/58) were eligible for thromboprophylaxis pre- and post-QI, respectively. Table 1 demonstrates percentages of patients for whom KS calculation and thromboprophylaxis eligibility were documented prior to cycle 1 initiation. There was a statistically significant increase in documentation following QI initiation (pre-QI: 8/61 [13.1%], post-QI: 38/58 [65.5%]; p < 0.001). Of those who were eligible, 9.5% were offered thromboprophylaxis pre-QI (2/21) and 65% post-QI (13/20) (p < 0.001). Table 1 describes the percentages of eligible patients initiating thromboprophylaxis in accordance with the recommendations. There were no new venous thromboembolic events among eligible patients’ pre-QI and one post-QI. Conclusions: Over one-third of gynecologic cancer patients starting outpatient chemotherapy met eligibility criteria for pharmacologic thromboprophylaxis. Following the implementation of our QI initiative, there was an increase in KS calculation, documentation, and appropriate prescription of thromboprophylaxis among eligible patients. Studies are ongoing to measure patient adherence to pharmacologic thromboprophylaxis and to determine if adherence to thromboprophylaxis guidelines improves outcomes in this population.

Palliative medicine referral and end-of-life interventions among minority patients with advanced or metastatic gynecologic cancer (433)

Palliative medicine referral and end-of-life interventions among minority patients with advanced or metastatic gynecologic cancer (433)

Socioeconomic disparities in distress and coping in gynecologic oncology patients (568)

Socioeconomic disparities in distress and coping in gynecologic oncology patients (568)

Risk factors associated with distress among postoperative patients in an academic gynecologic oncology practice (482)

<b>Objectives:</b> Distress is higher among gynecologic oncology patients than other cancer types and is correlated with poor clinical outcomes and decreased quality of life. The purpose of this study was to determine risk factors associated with elevated National Comprehensive Cancer Network Distress Thermometer (NCCN DT) results among patients in gynecologic oncology practice. <b>Methods:</b> A retrospective chart review of all visits at a single gynecologic oncology practice between September 2016 and December 2020 was performed. Distress was measured using the NCCN DT, administered at the postoperative visit for every patient undergoing surgery in practice. DT were analyzed as discretized values (DT < 3=low distress, DT 4-8 = moderate distress, or DT, ≥9 = high distress), chosen based on clinic thresholds for distress score intervention. Patients with a score > 4 received a referral to social work, with an urgent referral for a score >9. Univariate and multivariate logistic regression analyses were performed to analyze differences in NCCN DT results by multiple personal, demographic and disease-related variables. Risk factors were determined using the Wald test with Bonferroni correction for univariate analyses. The threshold for statistical significance was set at <i>p</i><0.05. <b>Results:</b> A total of 1798 NCCN Distress Thermometers were collected at postoperative visits and included in the analysis (mean age: 58.31± 13.98 years, mean BMI: 31.66± 9.42). Ovarian (36.51%) and endometrial cancer (31.74%) were the most common cancers. More than half (59.07%) of patients reported a partnered relationship status and had private insurance (56.73%). Benign pathology was known prior to completion of the NCCN DT in 13.07% of patients. Most patients (71.64%) endorsed a low level of distress. A moderate level of distress was reported by 26.53% of patients, whereas a minority of patients (1.84%) documented a high distress level. Increasing levels of distress were significantly associated with a history of depression (p=.001), tobacco use (p=.007), and vaginal cancer (p=.008). Knowledge of benign pathology prior to completion of NCCN DT (p=.023) was associated with low levels of distress. <b>Conclusions:</b> More than a quarter of women undergoing surgery in a gynecologic oncology practice reported moderate or high distress at their postoperative visit. Understanding of risk factors provides opportunities to identify patients most at risk for experiencing high distress. Patients with known benign pathology demonstrated decreased distress, indicating that surgical intervention alone does not significantly impact levels of distress. Association between unmodifiable risk factors and distress, such as vaginal cancer, provides an opportunity for targeted intervention early in the treatment course, while the association with modifiable risk factors (tobacco use, depression) provides insight into counseling and prevention strategies.

Avoidable admissions in gynecology oncology patients undergoing minimally invasive hysterectomy (520)

Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution’s prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge; reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges. Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution’s prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge; reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges.

Just text me: A feasibility study of postoperative texting evaluations for gynecologic oncology patients (291)

<b>Objectives:</b> Postoperative recovery is a stressful time for patients. As part of the standard of care, postoperative gynecologic oncology patients at the University of Pennsylvania Health System receive post-discharge phone calls by gynecologic oncology nurses to evaluate and recommend intervention as needed during patients' postoperative recovery. Given the high clinical volume, we aimed to determine if an automated text messaging program and healthcare innovation strategies, in lieu of routine telephonic nursing evaluations, could provide postoperative patient assessments that were comprehensive, were satisfactory to patients, and decreased provider clinical workload. <b>Methods:</b> English speaking patients undergoing surgery with four providers in the Division of Gynecologic Oncology at the University of Pennsylvania Health System from February 2021 to June 2021 were eligible for enrollment. Patients were offered routine telephonic evaluations by the gynecologic oncology nurses versus text message-based evaluations. Enrolled patients were texted 48 hours following discharge using an algorithm based on the Division's routine telephonic script. A "fake back end", i.e. a care team member who sent and responded to patient text messages, was utilized given the pilot nature of this study. Patients who did not respond were called by the nursing team to complete the remaining questions for evaluation. Patients with responses requiring further assessment were called by the nursing team for triage. Over the course of the pilot study, the algorithm was edited in response to patient and provider feedback. This program was approved by the Penn Medicine Institutional Review Board Quality Initiative and supported by the Center for Health Care Innovation. <b>Results:</b> Sixty-nine patients were approached for the program with 56 patients enrolling. Median age of enrollees was 54 years (IQR= 45.1-62.5). Basic demographics are provided in Table 1. The most common reason for declining the program was patient preference of telephone call. Of enrollees, 41 (73%) initiated the program. Of the 41 active enrollees, 18 (44%) completed the entire algorithm. Median time to completion of the algorithm was 34 (IQR 20-81) minutes. The 18 completed algorithms saved an estimated 4.5 hours of provider time. Reasons for non-completion were: 5 (22%) response indicated need for provider assessment, 3 (13%) algorithm error, and 15 (65%) patient non-response. Of the 17 enrollees who answered "On a scale of 0-10, how likely are you to recommend this texting program to a friend if they were getting the same procedure as you?" there were 13 promoters (9-10), 1 neutral participant (7-8), and 3 detractors (6 or less). Twelve participants responded with a score of 10/10. The lowest score was a 5 from a single patient. <b>Conclusions:</b> Text messaging programs for gynecologic oncology patients are feasible in providing efficient postoperative care and are satisfactory to patients. Further study is needed to determine the safety and scalability of automated patient evaluation text messaging platforms.

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

The past and future use of perioperative opioids in gynecologic oncology patients after open surgery (535)

<b>Objectives:</b> As surgeons, it is our ethical imperative to minimize the harmful impact on patients and their communities through the prescription of perioperative opioid medication. This study reviews the perioperative opioid use in our gynecologic oncology surgical practice over the last decade. <b>Methods:</b> We undertook a chart review of adult gynecologic oncology patients who underwent open surgery from July 1, 2012, to August 26, 2021. Perioperative and patient characteristics were abstracted. Prospective phone surveys were completed from April through September 2021 in this patient population two to four weeks after surgery to assess self-reported opioid use post-hospital discharge. Quantities of oral and intravenous opioid medications are reported as oral morphine equivalents (OME). Data are presented as proportions or median results by year and compared using Chi-square tests or Wilcoxon rank-sum tests, respectively. <b>Results:</b> There were 1210 patients included in the chart review, and we completed 75 prospective surveys. From 2012 to 2021, the rate of non-steroidal anti-inflammatory drug use increased from 40.7% to 80% (p<0.01), and the use of epidurals and transversus abdominis plane (TAP) blocks increased from 46.5% to 93.9% (p<0.01, Figure 1a). The median length of hospital stay was decreased by 20% (5 to 4 days, p<0.01). The total amount of OME used per patient in the hospital decreased by 62.6% from 2012 to 2021 (412 OME in 2012 vs 154.3 OME in 2021, p<0.01). When divided by length of stay, the median OME used per day also decreased (84.7 OME in 2012 vs 42 OME in 2021, p<0.01). Opioid prescription sizes at the time of hospital discharge significantly decreased as well from 675 OME per patient in 2012 (equivalent to 90 doses of 5mg oxycodone tablets) to 150 OME per patient in 2021 (equivalent to 20 doses of 5mg oxycodone tablets, p<0.01, Figure 1b). From our prospective survey data, the actual amount of OME used by patients in 2021 after hospital discharge was a median of 22.5 OME (equivalent to 3 doses of 5mg oxycodone tablets per patient). There was a decrease in preoperative opioid use from 2012 to 2021 (41.9% in 2012 vs 28.7% in 2021, p=0.05). The refill rate for postoperative opioids did not significantly differ during this time period (18% in 2012 vs 10.4% in 2021, p=0.10). <b>Conclusions:</b> Patients in this study used fewer opioids in the perioperative period between 2012 and 2021, likely due to utilization of enhanced recovery after surgery pathways and increased awareness of the risks of opioid misuse. While our division reduced the median postoperative opioid prescription size from 2012 to 2021 by 77.7%, our findings suggest we could further reduce prescription sizes by an additional 85% and still adequately treat our patients' postoperative pain. Ongoing assessment of surgical patients' opioid medication needs and patterns of prescribing is essential for addressing our contributions to the opioid epidemic.

Assessment of distress and impact on shared decision-making in new gynecologic oncology patients (478)

<b>Objectives:</b> This study aimed to characterize the severity and sources of patient distress at first presentation to a gynecologic oncologist and assess the relationship between distress throughout the visit and patient perceptions of shared decision-making (SDM). <b>Methods:</b> Patients were offered participation in a quality improvement project at the start of their first visit to the gynecologic oncologist. Participants (<i>n</i>=58) had a new diagnosis of cancer, a clinical suspicion of cancer, or another high-risk condition requiring care from a gynecologic oncologist. Upon arrival, participants selfreported demographics, the reason for visit, and distress using the NCCN Distress Thermometer (DT) and Problem List. At the conclusion of the visit, patients repeated the Distress Thermometer and completed the collaboRATE questionnaire, a 3-item patient-reported experience measure of shared decision-making. The collabo-RATE score was calculated as a mean of scores on the three items. Descriptive statistics and Chi-square tests were used to characterize distress. Paired sample t-test was used to measure the change in distress during the visit. Pearson's correlations were used to assess the relationship between distress and SDM. <b>Results:</b> At the start of the visit, the mean distress score (DT) was 5.12 out of 10, and 67% of participants endorsed severe distress (DT >4). Main sources of distress were worry (<i>n</i>=39), nervousness (<i>n</i>=35), sleep disturbances (<i>n</i>=25), sadness (<i>n</i>=24), and fatigue (<i>n</i>=23). At the end of the visit, mean distress had decreased significantly to 4.16 (p=0.02), but the decrease in the percentage of patients with severe distress did not reach significance (p=0.07). There was no relationship between pre- or post-visit distress and shared decision-making (p=0.53 and p=0.70, respectively). Patients at all distress levels reported high levels of shared decision-making, with a mean collaboRATE score of 8.6 out of 9. <b>Conclusions:</b> Initial distress at presentation to a gynecologic oncologist is high, even among patients without a cancer diagnosis. Distress decreased after meeting with the gynecologic oncologist, and patients at all levels of distress perceived high levels of shared decision-making. These findings support the need for psychosocial support among patients facing a possible or confirmed gynecologic malignancy. Gynecologic oncologists should prioritize shared decision-making even when caring for severely distressed patients.