Society Of Gynecologic Oncology Research Articles

Re-examining the state of enhanced recovery after surgery recommendations: A repeat survey of gynecologic oncologists across Canada

Objectives: Enhanced Recovery After Surgery (ERAS) programs are associated with clinical outcome improvements across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019) and Society of Gynecologic Oncology of Canada (GOC) education events.

Gynecologic oncologists in surgery for placenta accreta spectrum: a survey for practice, experience, and interest

ObjectiveSurgery for placenta accreta spectrum is associated with significant maternal morbidity and mortality. The role of gynecologic oncologists in the surgical management of placenta accreta spectrum is currently under investigation....

A mixed-method evaluation of cadaver surgery training for gynecologic oncology.

Traditional surgical training techniques with using patients, and new advances with live animals, artificial models, and simulation methods have several shortcomings. There are a few reports on the usefulness of cadaver surgery training (CST) in gynecology. Herein, we used a mixed-method evaluation to qualitatively and quantitatively explore the educational efficacy of CST by conducting CST programs at the Sapporo Medical University, Japan. In 2020, we conducted two CST programs with 45 participants-13 residents, 8 specialists recognized by Japan Society of Obstetrics and Gynecology, 23 certified endoscopists recognized by Japan Society of Gynecology and Obstetrics Endoscopy and Minimally Invasive Therapy, 15 specialists recognized by Japan Society of Gynecologic Oncology, and 14 certified endoscopists cum oncology. Three participants observed the procedure virtually and 42 were physically present. Laparoscopic radical hysterectomy and pelvic exenteration were performed on five Thiel-embalmed cadavers. Participants were asked to complete pre- and post-training surveys that included qualitative questions, concerning the purpose and cost of CST, and quantitative questions, testing anatomical knowledge. We observed that the rate of score improvement to the quantitative questions increased from 58.6% pre-CST to 75.6% post-CST. Furthermore, oncology specialists and those who performed more surgeries and faced more complications during surgeries recorded high percentage of correct answers. Multiple regression analysis statistically confirmed these results. This study confirmed the educational efficacy of CST.

Regional Variation in Access to Oncologic Care and Racial Disparities Among Cervical Cancer Patients.

The goal of this study was to determine whether access to gynecologic oncologists is correlated with disparate outcomes among cervical cancer patients, especially among Black women. An ecological study was performed using the National Cancer Database among stage I-IVA cervical cancer patients from 2004 to 2014. Data from the National Cancer Institute, the Society of Gynecologic Oncology, and the United States Census were compiled to describe access to care by region. Factors associated with receipt of optimal treatment (defined as surgery and/or radiation for stage IA-IB1 and IIA1; radiation and chemotherapy for stage IB2, IIA2, IIB-IVA or node positive disease) were identified using multivariate logistic regressions stratified by region, controlling for confounding factors including the number of gynecologic oncologists per states in each subregion. Cox multivariate survival analyses stratified by region were also performed. Of 42,213 women, 17.0% were Black. On multivariate analysis controlling for confounders, all Southern women were less likely to receive optimal treatment (adjusted odds ratio [aOR]: 0.80, 95% confidence interval [95% CI]: 0.75-0.85, P <0.001) compared with Northeastern women. Black women in the South (aOR: 0.76, 95% CI: 0.70-0.83, P <0.001) and Midwest (aOR: 0.78, 95% CI: 0.68-0.90, P <0.001) were less likely to receive optimal treatment compared with non-Black women in those regions. Black women in the South (adjusted hazard ratio [aHR]: 1.11, 95% CI: 1.04-1.18, P <0.001) and West (aHR: 1.34, 95% CI: 1.11-1.62, P =0.002) had worse mortality compared with non-Black women in those regions, despite controlling for access to gynecologic oncologists. The South, Midwest, and West had proportionally fewer cancer centers and gynecologic oncologists compared with the Northeast. Southern women are at risk of inadequate treatment for cervical cancer, and Black Southern women are at even higher risk of inadequate treatment and worse overall survival despite controlling for access to gynecologic oncologists. Social determinants of health and other barriers besides access to oncologists likely contribute to observed regional and racial disparities among cervical cancer patients.

The Role of Sentinel Lymph Node Mapping in High-grade Endometrial Cancer.

Total hysterectomy with lymph node assessment is the current standard-of-care for surgical staging in apparent early-stage endometrial cancer. Compared to the traditional complete pelvic lymphadenectomy with or without para-aortic lymphadenectomy, sentinel lymph node (SLN) mapping results in fewer surgical complications, decreased operative time, and lower rates of chronic lymphedema. The technique is endorsed by the National Comprehensive Cancer Network and the Society of Gynecologic Oncology guidelines, and over the past two decades the majority of gynecologic oncologists worldwide have adopted SLN mapping into their practice. However, as the results of the initial SLN studies were mostly based on low-grade tumors, adoption of the technique in high-grade tumors has been slower and more controversial. In this review, we discuss the most recent studies evaluating the SLN mapping in high-grade endometrial cancers. The results of these studies suggest that the SLN detection rate is acceptably high and the negative predictive value is sufficiently low to support the use of SLN mapping in high-grade endometrial tumors to replace complete lymphadenectomy. Validity of SLN mapping techniques does, however, require following a standard algorithm, and success depends also on surgeon expertise. Moreover, the impact of SLN mapping on overall survival in high-grade tumors requires future prospective randomized studies. Finally, a transition toward near-universal SLN mapping techniques for endometrial cancers could significantly impact on the adequacy of gynecologic oncology fellows' surgical training and competency in lymphadenectomy.

Direct oral anticoagulant (DOACs) prescribing practices of members of the Society of Gynecologic Oncology and American Society of Clinical Oncology (374)

<b>Objectives:</b> The risk of venous thromboembolism (VTE) in patients with gynecologic malignancy is 25-38% and is associated with significant morbidity and mortality. Direct oral anticoagulants (DOACs) have emerged as an alternative to injectable medications for thromboprophylaxis and treatment of VTE. Several recent clinical trials have demonstrated the benefit of DOACs in high-risk patients receiving systemic chemotherapy as well as postoperative prophylaxis after surgery for gynecologic cancer. Major consensus guidelines from multiple organizations support the use of DOACs for these indications, but prescription practices are not well characterized. <b>Methods:</b> A survey was sent concurrently to members of the Society of Gynecologic Oncology (SGO) and the American Society of Clinical Oncology (ASCO) Research Survey Pool between May and June of 2021. The study was designed to assess DOAC prescription practices amongst members of these societies who routinely prescribe chemotherapy. Bivariate analyses comparing responses from ASCO and SGO participants were compared using Chi-square and Fisher's exact tests. <b>Results:</b> A total of 103 physicians were included in the ASCO group and 139 in the SGO group (response rates 15% and 8%, respectively). A majority of participants in both groups reported familiarity with prescribing DOACs (99% of ASCO and 96% of SGO respondents). ASCO respondents were more likely to consider DOACs as first-line therapy for the treatment of cancer-associated VTE than SGO members (82% vs 63%, p < 0.01). In comparison, SGO members were more likely to consider low molecular weight heparin (LMWH) (66% vs 25%, p < 0.01). Most respondents in both groups (75%) felt DOACs were equally safe and effective compared to LMWH but more ASCO members felt DOACs were cost-effective (70% vs 49%, p < 0.01). More SGO respondents reported having prescribed prophylactic anticoagulation during chemotherapy than ASCO members (53% vs 35%, p < 0.01). A majority of participants in both groups reported knowledge of the Khorana score as a risk assessment tool (60% and 61%); however, only 30% of respondents felt this scoring system reliably predicts risk of VTE in ambulatory outpatients initiating chemotherapy and at least 70% of participants in both groups had never used this tool. SGO respondents were more likely to feel that there was insufficient evidence to recommend prophylactic anticoagulation to high-risk outpatients initiating chemotherapy for gynecologic cancer (41% vs 29%, p < 0.01). Among the 150 respondents who performed surgery for gynecologic cancer, 80% felt LMWH is the standard of care for postoperative thromboprophylaxis compared to only 15% who felt DOACs were the standard of care. The most commonly cited barriers to DOAC prescription for prevention of cancer-associated VTE were insurance approval for the medication, out-of-pocket expense to the patient, and lack of data to support efficacy. <b>Conclusions:</b> ASCO respondents were more likely to prescribe DOACs for both treatment and prophylaxis of cancer-associated VTE than SGO members. However, SGO members were more likely to prescribe prophylactic anticoagulation to high-risk patients initiating chemotherapy compared to ASCO members. The use of the Khorana scoring system was low amongst respondents from both societies.

Variability in Operative Experience Among US Gynecologic Oncology Fellows (030)

<b>Objectives:</b> The Accreditation Council for Graduate Medical Education (ACGME) case log system provides a mechanism to assess the breadth and depth of the clinical experience provided by gynecologic oncology fellowships. Logging has been required since 2017; however, the required minimum number of procedures has not yet been determined. We aimed to evaluate the range of operative experience across gynecologic oncology fellowship programs in relation to proposed procedure-specific minimum numbers. <b>Methods:</b> ACGME surgical case logs of graduating gynecologic oncology fellows from 2019 to 2020 were analyzed for case volume trends. <b>Results:</b> Data were collected from 64 graduating gynecologic oncology fellows enrolled in 50 US programs. The median number of intestinal surgeries performed by graduating fellows was 42 (19 performed by those in the 10^th percentile to 89 performed by those in the 90^th percentile); a minimum of 20 has been proposed by the ACGME. By contrast, ACGME requires general surgery residents to complete a minimum of 25 small and 40 large intestinal surgeries during training. Gynecologic oncology fellows who performed more than ten intestinal procedures in training were more likely to feel prepared to perform these surgeries independently, however, only 58% reported feeling prepared to do so within three years of graduation. The median number of urologic procedures performed by graduating fellows was one (0 to 4); a minimum of 2 has been proposed by the ACGME. However, ACGME requires urology residents to complete a minimum of eight urinary diversion procedures during training, with the stipulation that this minimum "does not signify the achievement of competence." The median number of radical hysterectomies performed by graduating fellows was 17 (8 to 32). A minimum of ten has been proposed by the ACGME. A single-institution study of gynecologic oncology fellow productivity reported 17 radical hysterectomies completed per fellow per year since 2005. The median number of exenterations performed by graduating fellows was three (1 to 8); a minimum of two has been proposed by the ACGME. A single-institution study of exenterations over 20 years showed an average of six procedures per surgeon and no association of operative experience with complications or survival. The median number of inguinal dissections performed by graduating fellows was 11 (4 to 18). As this is considered a rare procedure, no minimum has been proposed by the ACGME. A minimum of ten was proposed to overcome the surgeon learning curve for inclusion in GROINSS-V-I. <b>Conclusions:</b> In the US, gynecologic oncology fellows experience significant variability in their surgical training. Based on our extrapolation of ACGME data, approximately half of the fellows fall below the proposed case minimums for urologic procedures. All but those in the bottom 10^th percentile met proposed minimums for radical hysterectomies, exenterations, and intestinal procedures. However, ACGME-proposed case minimums may be inadequate to achieve competence. Understanding the scope and variability of gynecologic oncology surgical training is needed to continue to improve and address gaps in fellow education.

Patient and provider perspectives on telemedicine utilization for Gynecologic Oncologic care among underserved women at an urban teaching hospital in the era of COVID-19 (279)

Objectives: The use of telemedicine has dramatically increased during the COVID-19 pandemic, requiring patients and providers to quickly adapt to this new mode of healthcare delivery. Our study objective was to describe patient and provider experiences using telemedicine for gynecologic oncology (GO) care among medically underserved women in an urban academic teaching hospital.Methods: We conducted a prospective study evaluating patient and provider acceptability and feasibility with telemedicine among medically underserved women seeking GO care from January to August 2021. Eligible patients for this sub-analysis included those using telemedicine for GO visits and preoperative or postoperative gynecologic care at a government-funded clinic in New York City. Providers included residents, GO fellows, and nurse practitioners (NPs). A newly developed telemedicine survey and a modified version of the validated Telemedicine Usability Questionnaire (TUQ) were administered to providers and patients, respectively, for each visit. The TUQ has six subscales to assess telemedicine usability, including usefulness, ease of use, interface quality, interaction quality, reliability, and satisfaction with mean Likert scale scores calculated for all questions. All statistical analyses were completed using the Wilcoxon signed-rank test. Results: A total of 166 surveys were completed with 28 provider and 27 patient surveys eligible for inclusion in this sub-analysis. 81% (22) visits were completed by video, 19% (5) by phone. Median patient age was 43 (24-67), 52% (14) had at least a college degree, 30% (8) self-identified as Asian, 19% (5) as Black, and 15% (4) as Hispanic. The overall TUQ mean score was 4.26. Subscale mean scores were calculated for usefulness (4.60), ease of use (4.48), interface quality (4.44), interaction quality (4.75), reliability (3.74), and satisfaction/future use (4.59). The reliability mean score, which measures whether patients think telemedicine visits are as good as in-person visits, was significantly lower compared to the other subscales (Table 1). Of the 28 providers, 68% (19) were residents and 32% (9) were GO fellows or NPs. Resident providers’ mean scores for self-perceived ability to adequately counsel patients using telemedicine was significantly lower than that of GO fellows and NPs (p=0.01). Of the 25 paired patient-provider surveys within this cohort, there was high concordance between providers’ self-perceived ability to counsel patients via telemedicine and patients’ satisfaction with the telemedicine services (p=1.00).Conclusions: Women presenting for GO and perioperative visits reported positive experiences using telemedicine. While telemedicine may increase access to healthcare services, patient’s perceptions regarding equivalence to in-person visits is of particular interest in marginalized populations. Teaching hospitals must also evaluate whether providers feel adequately trained to deliver telemedicine visits, with a particular emphasis on trainees.

Publication Rates of Podium Presentations at Society of Gynecologic Oncology (SGO) 2017 and 2018 Annual Meeting (LBA 1)

<b>Objectives:</b> The Society of Gynecologic Oncology (SGO) Annual Meeting allows for researchers to share novel projects and demonstrate their importance and validity to conference participants. Podium, or oral, presentations are deemed to be of most significant value during these meetings with results potentially leading to practice changes. The purpose of this study was to determine the publication rate of podium presentations from the 2017 and 2018 SGO Annual Meetings that resulted in published manuscripts in peer-reviewed journals. <b>Methods:</b> All podium presentations were reviewed at the 2017 and 2018 SGO Annual Meetings using the online program. Abstracts were evaluated for publication from Jan 1, 2017 to March 30, 2020 and Jan 1, 2018 to June 30, 2021, respectively, to allow for a 3-year period for publication and include abstracts that were published prior to the conference from the 2017 and 2018 Annual Meeting, respectively. Titles and abstract authors were searched via Google, Google Scholar, and PubMed. Articles were considered published if at least one abstract author, more than 50% of the exact title was listed, and if the objective corresponded with the abstract. Publication rate, time to publication from the date of the Annual Meeting, and journal impact factor of the respective published year were collected. Descriptive data analysis was performed. <b>Results:</b> In 2017 and 2018, a total of 60 and 83 oral presentations were reviewed with 37/60 (61.7%) and 47/83 (56.6%) podium presentations published within 3 years from the time of presentation, respectively. The average time to publication was 12.3 months (2017) and 13.6 months (2018). The average Impact Factor across all journals was 7.08 (2017) and 11.76 (2018). 2017 and 2018 presentations with publication in the journal with the highest impact factor was 41.32 (Lancet Oncology) and 70.67 (New England Journal of Medicine), respectively. Of the presentations published, 54.1% (2017) and 38.3% (2018) appeared in Gynecologic Oncology. Of all oncology subtypes, ovarian cancer manuscripts were the most frequently published, followed by endometrial, cervical, then vulvar (Figure 1) from both 2017 and 2018 podium presentations. <b>Conclusions:</b> At the 2017 and 2018 SGO Annual Meeting, approximately 60% of podium presentations were published in a peer-reviewed journal within 3 years. Although slightly more than half of presentations were published, a large majority remained unpublished. Caution must be taken when invoking new practice changes solely based on these podium presentations and additional time for publication must be considered for larger, more advanced clinical trials.Fig. 1

Thromboembolic events in gynecologic cancer patients treated with chemotherapy (380)

Objectives: The rate of venous thromboembolism (VTE) in gynecologic cancer patients undergoing cancer-directed therapy is not well described. The objective of this study was to evaluate the incidence and risk factors for VTE among patients with newly diagnosed and recurrent gynecologic cancer who receive systemic chemotherapy. Methods: This is a single institution longitudinal retrospective cohort study. The primary endpoint of this study was to determine the cumulative incidence of VTE from the time of cancer diagnosis to receipt of outpatient chemotherapy between January 1, 2020, and January 1, 2021. Secondary outcomes included identifying risk factors associated with VTE. Clinical and demographic data were collected, and descriptive statistics were performed. Pearson Chi-square or Fisher’s exact tests were used for categorical variables. Student’s t-tests or the Wilcoxon Rank-Sum tests were used for continuous variables. All statistical tests considered were two-sided, and a p-value of <0.05 was considered significant. Data analyses were performed in R (V 4.0.5 or later). Results: Of the 215 ambulatory gynecologic cancer patients who underwent chemotherapy, 45 (21%) experienced venous thromboembolism at some point during their cancer course. Our cohort included 117 (54%) ovarian, 66 (31%) uterine, 24 (11%) cervical, and eight (4%) vulvovaginal cancers. The timeline for VTE diagnoses was as follows: nine (20%) were diagnosed at the time of cancer diagnosis, 21 (46.7%) while actively getting chemotherapy, seven (15.6%) in the postoperative period, and eight (17.8%) during surveillance. The incidence of VTE during chemotherapy was 9.6% in patients with a new diagnosis and 12.5% in those with recurrence. Prechemotherapy anemia with hemoglobin <10g/dL (p=0.01), thrombocytosis with platelet ≥350,000/μL (p=0.01), albumin level (p=0.042), and more than three prior chemotherapy lines (p=0.003) were significantly associated with risk of embolism. There was a significant association of Khorana score with VTE risk (p=0.039), with higher scores in the VTE group (median: 2) than in the group without VTE (median: 1). Conclusions: In our cohort of gynecologic cancer patients, we found a high overall incidence of VTE, particularly during receipt of chemotherapy. This was true for patients with newly diagnosed and recurrent cancer. As recently recommended by the Society of Gynecologic Oncology, the use of pharmacologic thromboprophylaxis in highrisk cancer patients undergoing chemotherapy should be strongly considered. Objectives: The rate of venous thromboembolism (VTE) in gynecologic cancer patients undergoing cancer-directed therapy is not well described. The objective of this study was to evaluate the incidence and risk factors for VTE among patients with newly diagnosed and recurrent gynecologic cancer who receive systemic chemotherapy. Methods: This is a single institution longitudinal retrospective cohort study. The primary endpoint of this study was to determine the cumulative incidence of VTE from the time of cancer diagnosis to receipt of outpatient chemotherapy between January 1, 2020, and January 1, 2021. Secondary outcomes included identifying risk factors associated with VTE. Clinical and demographic data were collected, and descriptive statistics were performed. Pearson Chi-square or Fisher’s exact tests were used for categorical variables. Student’s t-tests or the Wilcoxon Rank-Sum tests were used for continuous variables. All statistical tests considered were two-sided, and a p-value of <0.05 was considered significant. Data analyses were performed in R (V 4.0.5 or later). Results: Of the 215 ambulatory gynecologic cancer patients who underwent chemotherapy, 45 (21%) experienced venous thromboembolism at some point during their cancer course. Our cohort included 117 (54%) ovarian, 66 (31%) uterine, 24 (11%) cervical, and eight (4%) vulvovaginal cancers. The timeline for VTE diagnoses was as follows: nine (20%) were diagnosed at the time of cancer diagnosis, 21 (46.7%) while actively getting chemotherapy, seven (15.6%) in the postoperative period, and eight (17.8%) during surveillance. The incidence of VTE during chemotherapy was 9.6% in patients with a new diagnosis and 12.5% in those with recurrence. Prechemotherapy anemia with hemoglobin <10g/dL (p=0.01), thrombocytosis with platelet ≥350,000/μL (p=0.01), albumin level (p=0.042), and more than three prior chemotherapy lines (p=0.003) were significantly associated with risk of embolism. There was a significant association of Khorana score with VTE risk (p=0.039), with higher scores in the VTE group (median: 2) than in the group without VTE (median: 1). Conclusions: In our cohort of gynecologic cancer patients, we found a high overall incidence of VTE, particularly during receipt of chemotherapy. This was true for patients with newly diagnosed and recurrent cancer. As recently recommended by the Society of Gynecologic Oncology, the use of pharmacologic thromboprophylaxis in highrisk cancer patients undergoing chemotherapy should be strongly considered.

Adaptive and maladaptive humor styles are closely associated with burnout and professional fulfillment in members of the Society of Gynecologic Oncology (356)

<b>Objectives:</b> Individual differences in humor styles (adaptive: affiliative, self-enhancing; maladaptive: aggressive, self-defeating) are associated with numerous mental health measures. Burnout (BO) and professional fulfillment (PF) are two distinct measures that affect personal and professional well-being. This study examined the relationship of humor styles with PF and BO among Society of Gynecologic Oncology (SGO) members. <b>Methods:</b> SGO members were surveyed in November 2020. The survey included 64 questions (32-item Humor Styles Questionnaire, 16-item Stanford Professional Fulfillment Index, and 16-item demographic and practice characteristics). Differences among faculty physicians (FAC), physician trainees (Res/Fel), and advanced practice providers (APP) were compared using two-tailed t-tests for continuous variables and Chi-square tests for categorical variables. Multivariable linear regression adjusted the association of humor styles with BO and PF for possible confounders. <b>Results:</b> Of 1982 SGO members invited to participate, 321 (16.2%) returned surveys, including 222 (69.4%) FAC, 75 (23.4%) Res/Fel, and 23 (7.2%) APP. All categories of respondents scored highest for affiliative humor and lowest for aggressive humor. There were no significant differences between provider types in the use of adaptive humor styles. For maladaptive styles, Res/Fel were significantly more likely to employ both aggressive (FAC vs Res/Fel, p=0.017; Res/Fel vs APP, p=0.011) and self-defeating (FAC vs Res/Fel, p=0.011; Res/Fel vs APP, p=0.004) styles than FAC and APP. Ninety-five (29.7%) respondents met the criteria for BO, and 163 (50.9%) had professional fulfillment. There were no differences in BO among provider types. FAC was significantly more fulfilled than Res/Fel (2.83±0.88 vs 2.59±0.83, p=0.038). For adjusted BO analyses, BO was negatively associated with self-enhancing humor and positively associated with self-defeating humor (Table 1). Further, being a trainee (p=0.010) and being >55 years old (p=0.008) were protective for BO, whereas working >60 hours per week was led to higher BO (p=0.008). In adjusted analyses, PF was positively associated with self-enhancing humor and negatively associated with self-defeating humor (Table 1). Spending over 10% of work hours on non-patient care activities was negatively associated with PF (p=0.008). Table 1 <b>Conclusions:</b> Among SGO respondents, 29.7% were burned out, and 50.9% were fulfilled. Beyond advocating for less working hours and less administrative duties, humor-based interventions focused on increasing the use of self-enhancing and reducing the use of selfdefeating humor may lead to less BO and greater PF in SGO members, especially among trainees.

Will ovarian transposition become the forceps of gynecologic oncology? A survey of the Society of Gynecologic Oncology members (506)

Objectives: To determine practice patterns of ovarian transposition (OT) and understand providers’ perceptions of the risks and benefits of the procedure. Methods: Survey links were emailed to all members of the Society of Gynecologic Oncology (SGO). REDcap was used to collect anonymous responses, including demographics, practice patterns, and beliefs regarding OT. Completed survey data were summarized using descriptive statistics; demographics of respondents who did or did not perform OT were compared. Results: The survey was sent to all 1400 physician members of SGO. We received 323 (23%) responses, of which 246 (76%) were completed. Eighty-three (34%) respondents did not perform OT. Of those who performed OT (n=163), 107 (66%) performed 1-2 procedures per year. Respondents who performed OT were statistically older and more likely to be male, married, and had children (p <0.01 for all) (Table 1). Participants who had fewer years in practice or who practiced in an academic setting were less likely to perform OT, whereas respondents in private practice were more likely to perform OT (p <0.03). Practice in New England or the Mid-Atlantic was associated with less OT (p=0.03). Respondent’s ethnicity, patient population, or affiliation with a fertility clinic were not associated with OT practice. For respondents who performed OT, the median, upper age limit for patients undergoing OT was 45 years (range: 35-60 years). Respondents who performed OT used the anterior superior iliac spine (38%), followed by L4-L5 (29%) as a landmark for transposed ovaries. They indicated ovarian failure followed by pain, and cyst formation, as the most common complications. When ranked, the most common indication for OT was the retention of hormonal function, followed by fertility preservation and patient preference. Of all respondents, 36% of patients were rarely or never able to achieve their fertility goals after OT, and 25% felt that OT had, at best, a low likelihood of maintaining hormonal function. Conclusions: Practice patterns of OT vary by demographic factors. There is a need for more conclusive evidence regarding the benefits and risks of the procedure in order to standardize recommendations and determine best practices. Objectives: To determine practice patterns of ovarian transposition (OT) and understand providers’ perceptions of the risks and benefits of the procedure. Methods: Survey links were emailed to all members of the Society of Gynecologic Oncology (SGO). REDcap was used to collect anonymous responses, including demographics, practice patterns, and beliefs regarding OT. Completed survey data were summarized using descriptive statistics; demographics of respondents who did or did not perform OT were compared. Results: The survey was sent to all 1400 physician members of SGO. We received 323 (23%) responses, of which 246 (76%) were completed. Eighty-three (34%) respondents did not perform OT. Of those who performed OT (n=163), 107 (66%) performed 1-2 procedures per year. Respondents who performed OT were statistically older and more likely to be male, married, and had children (p <0.01 for all) (Table 1). Participants who had fewer years in practice or who practiced in an academic setting were less likely to perform OT, whereas respondents in private practice were more likely to perform OT (p <0.03). Practice in New England or the Mid-Atlantic was associated with less OT (p=0.03). Respondent’s ethnicity, patient population, or affiliation with a fertility clinic were not associated with OT practice. For respondents who performed OT, the median, upper age limit for patients undergoing OT was 45 years (range: 35-60 years). Respondents who performed OT used the anterior superior iliac spine (38%), followed by L4-L5 (29%) as a landmark for transposed ovaries. They indicated ovarian failure followed by pain, and cyst formation, as the most common complications. When ranked, the most common indication for OT was the retention of hormonal function, followed by fertility preservation and patient preference. Of all respondents, 36% of patients were rarely or never able to achieve their fertility goals after OT, and 25% felt that OT had, at best, a low likelihood of maintaining hormonal function. Conclusions: Practice patterns of OT vary by demographic factors. There is a need for more conclusive evidence regarding the benefits and risks of the procedure in order to standardize recommendations and determine best practices.

Telehealth utilization in gynecologic oncology clinical trials (295)

<b>Objectives:</b> In light of the COVID-19 pandemic, the Society of Gynecologic Oncology (SGO), National Cancer Institute, and Food and Drug Administration published clinical practice statements encouraging the use of telemedicine in clinical trials, which had previously been prohibited. Our study aimed to assess the feasibility and safety of telehealth utilization in clinical trials for gynecologic malignancies. <b>Methods:</b> A retrospective cohort study was performed. Patients who were enrolled in a gynecologic oncology clinical trial at the University of Pennsylvania Health System from March 16, 2020, to August 30, 2020, were included. Receipt of care during the telehealth period (March 16, 2020, to August 30, 2020) was compared to the pre-telehealth period (September 30, 2019, to March 15, 2020). Pairwise comparisons of clinical trial outcomes were performed between the two time periods, using paired t-test, Wilcoxon signed-rank test, simple linear regression, Chi-square, and ANOVA. <b>Results:</b> Thirty-one patients met the inclusion criteria. The mean age was 63.7 years (SD 10.3); 84% were non-Hispanic White. The median distance from home zip code to study center was 25.2 miles (IQR: 16-46, range: 1.9-170). Most patients had high-grade serous ovarian carcinoma (84%) and had the disease at an advanced stage (Stage III 48%, Stage IV 38.7%). Trial drugs included 22.6% (<i>n</i>=7) intravenous only, 29% (<i>n</i>=9) oral only, and 48.4% (<i>n</i>=15) combination oral/intravenous therapies. The median duration of enrollment was similar between pre-telehealth (5.2 months, IQR: 3.2-5.6) and telehealth periods (5.6 months, IQR: 3.8-5.6), (p=0.682). During the TELEHEALTH period, significantly more virtual provider visits (p <0.001) and remote laboratory testing (p=0.015) occurred, with similar rates of remote imaging (p=0.551). Delayed provider visits (p = 0.965), laboratory testing (p = 0.989) and imaging (p = 0.999) occurred infrequently in both timeframes. The number of patient touchpoints (portal messages and phone calls) per month did not increase (p = 0.147). Patients who lived farther from the study center were more likely to use remote imaging (p = 0.013); however, the distance was not associated with the use of virtual provider visits (p = 0.309) or remote laboratory testing (p = 0.821). Number of dose reductions (p = 0.112) and toxicity-related treatment delays (p = 0.888) were similar. Increased need for extra imaging was noted in the telehealth period (p=0.007) and was not associated with disease progression (p=0.614). Extra provider visits, emergency department visits, and hospital admissions were infrequent and similar in both timeframes (Table 1). The total number of deviations was increased (p=0.010); however, when adjusted for minor deviations documenting telehealth use or deferment of research-related laboratory testing given the pandemic precautions, there was no difference between timeframes (p = 0.468). The total number of adverse events and severe adverse events did not increase in the telehealth period (p=0.494 and p=0.601, respectively). <b>Conclusions:</b> Utilizing telehealth in clinical trials for gynecologic oncology patients did not increase clinical workload or adverse patient outcomes. Documentation of telehealth use and pause of research-related laboratory collections resulted in a higher number of protocol deviations during the telehealth period. Telehealth should be incorporated into future clinical trials as it appears safe and feasible and may facilitate access for remote, rural, and under-served populations.

Fulfilled but worn out: Evaluating compassion satisfaction and compassion fatigue among Gynecologic Oncologists (093)

<b>Objectives:</b> Professional quality of life is composed of positive (compassion satisfaction) and negative (compassion fatigue) components. Compassion fatigue is composed of two attributes: burnout and secondary traumatic stress (work-related trauma resulting from secondary exposure to people who have experienced extremely or traumatically stressful events). The objective of this study was to evaluate the professional quality of life of Gynecologic Oncologists. <b>Methods:</b> Society of Gynecologic Oncology (SGO) members, classified as full member Gynecologic Oncologists, were surveyed via an anonymous RedCAP online survey regarding their professional quality of life. The survey was composed of a brief questionnaire assessing basic demographics followed by the ProQOL survey, a validated scale assessing the professional quality of life. This scale measured compassion satisfaction, burnout, and secondary trauma. Descriptive statistics were calculated. Associations between sociodemographic variables and professional quality of life components were analyzed using linear and logistic regression. <b>Results:</b> Of the 1,241 invited members, 151 (12%) completed the survey. The median age was 46 years old. Most respondents were female (60%), White (78%), and practiced in an academic institution (55%). ProQOL revealed that most respondents had moderate (57%) or high compassion satisfaction (41%) while few had low compassion satisfaction (1%). However, the majority also had moderate (63%) to high (2%) levels of burnout. Approximately half of the respondents reported a moderate (48%) or severe (2%) level of secondary trauma. Linear regression found that an increase in age was associated with increased compassion satisfaction (B=0.192, p=0.04) and lower rates of burnout (B=-0.217, p=0.02). Male respondents had lower burnout scores and lower secondary trauma scores when compared to those who did not identify as male (B=-0.181, p=0.05, and B=-0.179, p=0.06, respectively). Logistic regression found that those in a strictly academic practice environment were 2.12 times more likely to experience moderate or high levels of burnout than those in mixed or private practice (OR: 2.12, p=0.04). Female participants were 2.6 times more likely to report moderate or high secondary trauma than those who did not identify as female (p=0.02). <b>Conclusions:</b> Gynecologic Oncologists experience high levels of compassion satisfaction related to their work. However, they also experience a significant amount of compassion fatigue, as demonstrated by the moderate to high level of burnout and secondary trauma endorsed by many respondents. Sociodemographic factors, such as age, gender, and type of practice, may place some individuals at higher risk for compassion fatigue. This data may be used as a foundation for identifying and developing interventions to assist a significant number of Gynecologic Oncologists experiencing compassion fatigue.

Juggling act: COVID-19’s impact on the quality of life of Gynecologic Oncologists (053)

Objectives: To assess the impact of the COVID-19 pandemic on Gynecologic Oncologists’ professional quality of life.Methods: Society of Gynecologic Oncology (SGO) members classified as full member Gynecologic Oncologists were surveyed via an anonymous RedCAP online survey regarding their professional quality of life. The survey was composed of a brief questionnaire to assess basic demographics and the impact the COVID-19 pandemic has had on their personal and professional lives. This was followed by the ProQOL survey, a validated scale to assess the professional quality of life. Descriptive statistics were calculated. Associations between sociodemographic variables and professional quality of life were analyzed utilizing logistic regression.Results: Of the 1,241 invited members, 151 (12%) completed the survey. The median age was 46 years old. Most participants were female (60%), White (78%), and were in academic practice (56%). Few (3%) reported being cross deployed to care for COVID-19 patients. Most (64%) reported a stable patient volume during the COVID-19 pandemic. Some experienced either a decrease (19%) or an increase (17%) in patient volume. The majority (60%) reported having children under the age of 18 or having children older than 18 that required care/supervision. Half (51%) of that group reported being the primary care organizer for their children. A third (34%) of those with children reported changing childcare plans due to COVID-19. The respondents who had their childcare altered by COVID-19 were 5.3 times as likely to have moderate or high burnout scores compared to those who did not have childcare impacted by the pandemic (OR: 5.3, p=0.003). Logistic regression demonstrated that among respondents with children who required childcare, females were 3.4 times as likely to have moderate or high burnout compared to their counterparts (p=0.05).Conclusions: The majority of Gynecologic Oncologists did not experience significant changes to their work type or workload as a result of the COVID-19 pandemic. However, there was a significant impact on the personal lives of those with children. Gynecologic Oncologists who had their childcare plans altered due to COVID-19 experienced significant levels of moderate to high burnout compared to those who did not have these personal stressors at home.

Adherence to guideline-based preoperative and intraoperative care during risk-reducing bilateral salpingo-oophorectomy among gynecologist-oncologists compared to general gynecologists (335)

<b>Objectives:</b> Risk-reducing Bilateral Salpingoopherectomy (rrBSO) is the only intervention proven to reduce mortality from epithelial ovarian cancer in patients with hereditary breast and ovarian cancer (HBOC)-associated gene mutations. Optimal surgical technique for rrBSO includes five steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetrics and Gynecology. These five steps include: <i>1)</i> Abdominal survey; <i>2)</i> Peritoneal washings; <i>3)</i> Entering retroperitoneal space and creating pedicle 2cm from the ovary; <i>4)</i> Dividing pedicle at the uterus; and <i>5)</i> Removal in an endoscopic bag. rrBSO can be performed by both general gynecologists (GYN) and gynecologist oncologists (GO). We aimed to evaluate adherence to surgical guidelines for rrBSO when performed by GO compared to GYN and assess the utility of preoperative (preop) CA-125 and pelvic ultrasound as predictors of malignancy identified at the time of rrBSO. <b>Methods:</b> A retrospective review of patients who underwent rrBSO from October 1, 2015, to December 31, 2020, by faculty and privately employed physicians at three high volume academic sites within a healthcare system was performed. The primary outcome was compliance with all five steps of rrBSO as dictated by a surgeon. Secondary outcomes included the presence of a pre-malignant or malignant lesion at the time of rrBSO and association with preoperative imaging or CA-125. Patient demographics and clinical characteristics were collected. Descriptive statistics for continuous variables were calculated. Univariable logistic regression was used to screen variables with a p-value criterion of p < 0.05 for entry into the model selection procedure. Multivariate regression was used to identify differences in practice patterns. <b>Results:</b> A total of 236 patients were included. Among them, 122 (52%) cases were performed by a GO. Among the cases documented by GO, 27 (22%) performed all five steps of the procedure, 65 (53%) performed four steps, 26 (21%) performed three steps, four (3%) performed two steps, and none performed only one step. Among the 114 cases by GYN, four (4%) performed all five steps, 17 (15%) performed four steps, 50 (44%) performed three steps, 40 (35%) performed two steps, and three (3%) performed only one step. Univariable analysis demonstrated no association between demographic variables and procedure compliance. GO were significantly more likely to adhere to all five recommended surgical steps, (OR: 7.816, 95% CI: 2.640-23.138, p=0.0002). In total, five patients (2.12%) had pre-malignant or malignant lesions diagnosed at the time of rrBSO. None of the five patients had documented preop CA-125 or preop imaging, and all five cases occurred in patients undergoing surgery with GYN. <b>Conclusions:</b> Our results show a statistically significant difference in compliance to procedural steps of rrBSO between GYN and GO. This demonstrates a need for institution-wide education and implementation of procedural standards and standardized nomenclature for dictations to ensure provider adherence to rrBSO guidelines. Fig. 1

Change in practice of RRSO consults and procedures during the COVID-19 pandemic (563)

Objectives: To investigate the impact of the Covid-19 pandemic on risk-reducing salpingo-oophorectomies (RRSO).Methods: An electronic survey was sent out to 1,127 full members of the Society of Gynecologic Oncology in August 2021. Survey data included physician characteristics, practice location, and self-reported subjective and objective data about their RRSOs and consults.Results: We received 69 responses from US gynecologic oncologists. Two-thirds of respondents were female; the mean age of respondents was 46 years (range: 35-65). Most respondents performed 10-20 RRSOs per year (median: 15, range: 2-75). During the pandemic, 76% of providers delayed RRSOs, and currently, 11% are delaying these surgeries. From March 2020, to February 2021, most providers (86%) transitioned some RRSO consults to telehealth. There was no correlation between uptake of telemedicine by age (R2=0.09) or gender (p=0.80). Those in the West Coast region reported significantly more use of telemedicine than in the Southwest (p<0.01) and Southeast (p<0.01). Providers using telemedicine spent more time with patients in-person than compared to virtually (37 min vs 33 min, p=.005). Sexual function was discussed almost 100% of the time during inperson (median: 100%, range: 10-100) and telehealth (median: 100%, range: 10-100) visits. We found female providers reduced their time discussing sexual function from in-person to telehealth visits from 7.5 to 5.7 minutes (p<0.01), but male providers reported equal time with both modalities (6.0 min). No difference between females and males was noted during in-person (p=0.74) or telehealth visits (p=0.10). Physicians ranked discussing sexual function 7/10 on a priority scale. Topics included (by decreasing frequency) menopausal symptoms, vaginal dryness, decreased libido, and dyspareunia. Barriers to virtual discussions were not being queued by the pelvic exam (30%) and confirming patient privacy (26%). Notably, providers reported that patients felt comfortable and safe via telehealth. Providers reported they perform the majority of RRSOs with multiport laparoscopy (mean 78% of cases), though single port and robotics were common. A wide range of practice regarding the performance of hysterectomy with RRSO was noted: 2% of respondents performed hysterectomies with every RRSO, while 9% rarely performed them.Conclusions: Overall, telemedicine is now commonly used for RRSO consults. While many of these cases were delayed early in the pandemic, few providers are still delaying RRSO. A wide variety of practice was noted regarding surgical modality for RRSO and performance of hysterectomy. The use of telemedicine does not seem to inhibit discussions of sexual function, and most providers discuss sexual health in every RRSO consult. Importantly, the loss of the pelvic exam or private setting did not affect the time providers spent discussing sexual health.

The utilization of indocyanine green fluorescence angiography for anastomotic perfusion assessment following bowel resection for gynecologic malignancies: A pan-Canadian survey (545)

Objectives: Bowel resection is an important component of surgical management of women with advanced gynecologic malignancies. Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that has been shown to effectively evaluate perfusion of large and small bowel anastomoses. The objective of this study was to capture national practice patterns, characterize facilitators and barriers to ICG-FA utilization for bowel perfusion assessment, and identify opportunities for further education across Canada. Methods: A needs assessment survey was developed with a focus group of key stakeholders in the field, as well as a methodologist, and piloted in advance to distribution. The survey captured basic sociodemographics, work history, facilitators and barriers to use of ICG-FA for bowel perfusion assessment, and modalities for further education (e.g., peer-reviewed article, surgical video, national/ international conference, local grand rounds, and invited experts for practical training). On July 1, 2021, the survey was distributed to 115 gynecologic oncologists registered through the Society of Gynecologic Oncology of Canada. Responses were collected until September 1, 2021. Results: The response rate was 31% (n=37), with respondents from all Canadian provinces. Approximately three-quarters (78%) of respondents identified as women, and the majority (60%) have been practicing gynecologic oncology for less than ten years. Of the respondents, 81% (n=30) performed bowel resection, and 67% (n=20) used ICG-FA for anastomotic perfusion assessment after bowel surgery. The three most reported barriers to integrating ICG-FA into routine clinical practice were the lack of training (30%), knowledge (27%), and equipment (27%). Surgical videos were the highest-ranked educational modality, followed by national/international conferences and peer- reviewed articles. Conclusions: ICG-FA for bowel perfusion assessment is a valuable tool that can be used with other risk-assessment strategies to guide operative decision-making in gynecologic oncology. However, further training across multiple educational modalities is needed to build knowledge among the Canadian gynecologic oncologic community, with surgical videos serving as the preferred educational modality. Additionally, more funding for necessary equipment will facilitate the uptake of this tool. This represents a national practice improvement opportunity. Objectives: Bowel resection is an important component of surgical management of women with advanced gynecologic malignancies. Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that has been shown to effectively evaluate perfusion of large and small bowel anastomoses. The objective of this study was to capture national practice patterns, characterize facilitators and barriers to ICG-FA utilization for bowel perfusion assessment, and identify opportunities for further education across Canada. Methods: A needs assessment survey was developed with a focus group of key stakeholders in the field, as well as a methodologist, and piloted in advance to distribution. The survey captured basic sociodemographics, work history, facilitators and barriers to use of ICG-FA for bowel perfusion assessment, and modalities for further education (e.g., peer-reviewed article, surgical video, national/ international conference, local grand rounds, and invited experts for practical training). On July 1, 2021, the survey was distributed to 115 gynecologic oncologists registered through the Society of Gynecologic Oncology of Canada. Responses were collected until September 1, 2021. Results: The response rate was 31% (n=37), with respondents from all Canadian provinces. Approximately three-quarters (78%) of respondents identified as women, and the majority (60%) have been practicing gynecologic oncology for less than ten years. Of the respondents, 81% (n=30) performed bowel resection, and 67% (n=20) used ICG-FA for anastomotic perfusion assessment after bowel surgery. The three most reported barriers to integrating ICG-FA into routine clinical practice were the lack of training (30%), knowledge (27%), and equipment (27%). Surgical videos were the highest-ranked educational modality, followed by national/international conferences and peer- reviewed articles. Conclusions: ICG-FA for bowel perfusion assessment is a valuable tool that can be used with other risk-assessment strategies to guide operative decision-making in gynecologic oncology. However, further training across multiple educational modalities is needed to build knowledge among the Canadian gynecologic oncologic community, with surgical videos serving as the preferred educational modality. Additionally, more funding for necessary equipment will facilitate the uptake of this tool. This represents a national practice improvement opportunity.

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.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women.

Menopausal status, ultrasound and biomarker tests in combination for the diagnosis of ovarian cancer in symptomatic women.