"A Mission and Purpose to Make Some Sense out of Everything That Was Happening to Me": A Qualitative Assessment of Mentorship in a Peer-to-Peer Gynecologic Cancer Program.

This study aimed to elucidate the relationship between mentorship, survivorship, and identity construction in people who have had gynecologic cancer and participated as mentors in a peer mentorship program. A qualitative descriptive study was designed, and hour-long semi-structured interviews with peer mentors were conducted. Interviews investigated how serving as a peer mentor influenced understanding of mentors' own cancer experiences. Thematic analysis was then conducted. All authors open-coded a subset of interviews to develop a codebook, which was then used to code the remaining transcripts. This qualitative inductive analysis of over 7 h of data was managed with NVivo 12. Seven peer mentor participants (N = 7) were interviewed. Four main themes emerged: serving in the social role of mentor gave participants (i) a sense of daily direction in their lives, (ii) an opportunity to give back to others in the cancer community, (iii) an explanatory reason for their cancer journey, and (iv) the ability to reify their own status as survivor. Providing support through a peer mentorship program helped our participants make meaning in their own cancer experience.

Evaluation of Homologous Recombination Deficiency in Ovarian Cancer.

OPINION STATEMENT: Homologous recombination deficiency (HRD) is an important biomarker guiding selection of ovarian cancer patients who will derive the most benefit from poly(ADP-ribose) polymerase inhibitors (PARPi). HRD prevents cells from repairing double-stranded DNA damage with high fidelity, PARPis limit single-stranded repair, and together these deficits induce synthetic lethality. Germline or somatic BRCA mutations represent the narrowest definition of HRD, but do not reflect all patients who will have a durable PARPi response. HRD can also be defined by its downstream consequences, which are measured by different metrics depending on the test used. Ideally, all patients will undergo genetic counseling and germline testing shortly after diagnosis and have somatic testing sent once an adequate tumor sample is available. Should barriers to one test be higher, pursuing germline testing with reflex to somatic testing for BRCA wildtype patients or somatic testing first strategies are both evidence-based. Ultimately both tests offer complementary information, germline testing should be pursued for any patient with a history of ovarian cancer, and somatic testing is valuable at recurrence if not performed in the upfront setting. There is a paucity of data to suggest superiority of one germline or somatic assay; therefore, selection should optimize turnaround time, cost to patients, preferred result format, and logistical burden. Each clinic should implement a standard testing strategy for all ovarian cancer patients that ensures HRD status is known at the time of upfront chemotherapy completion to facilitate comprehensive counseling about anticipated maintenance PARPi benefit.

Facilitators and Barriers to Recruiting Surgeons into Hospice and Palliative Medicine Training.

CONTEXT: Few individuals have fellowship training in both hospice and palliative medicine (HPM) and a surgical specialty including general surgery, general obstetrics and gynecology, or affiliated subspecialties. There is a paucity of data to explain why some surgeons choose to pursue HPM fellowship training. OBJECTIVE: Identify facilitators and barriers to palliative medicine fellowship training among physicians from a surgical specialty. METHODS: We conducted individual semistructured interviews with 17 surgeons who were also fellowship-trained in HPM. Interviews were recorded, transcribed, and thematic analysis was conducted to identify themes. RESULTS: Participants reported pivotal experiences-either positive exposure to palliative care or suboptimal surgical care experiences-as a key motivator for pursuing specialty palliative care training. Additionally, participants chose HPM training because they felt that practicing from a HPM perspective aligned with their personal care philosophy, and in some cases, offered professional opportunities to help achieve career goals. Participants reported encountering bias from both HPM and surgical faculty, and also found that some HPM fellowship programs did not accept surgical trainees. Surgeons also reported logistical concerns related to coordinating a one-year fellowship as a barrier to formal HPM training. CONCLUSIONS: Understanding the motivations of surgeons who pursue HPM training and identifying challenges to completing fellowship may inform solutions to expand surgeon representation in palliative care. Both HPM and surgical faculty should be educated on the benefits of specialty HPM training for surgical trainees and practicing surgeons. Further research should explore HPM fellowship best practices for welcoming and training surgeons and other underrepresented specialties.

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care.

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Higher baseline BMI and lower estimated median income is associated with increasing BMI after endometrial cancer diagnosis.

Introduction: Endometrial cancer is often directly related to obesity and interventions for weight loss have mixed results. Risk factors for continued weight gain after diagnosis are not clearly defined in the literature. The objective of this study is to describe risk factors associated with increased body mass index (BMI) trajectory among endometrial cancer patients. Methods: Patients who were surgically treated for endometrial cancer at a single institution between 2010 and 2015 were identified. Demographics including age, race/ethnicity and estimated median income at diagnosis were obtained. BMI at five time points after diagnosis were calculated. BMI trajectories were estimated by latent class growth modeling using the PROC TRAJ procedure in SAS. Chi-squared tests and ANOVA were used to assess differences between trajectory groups. Statistical significance was set to a p-value < 0.05. Results: Of 695 patients included in the study, the average age at diagnosis was 62 years and over 70% of patients were obese at baseline. Patients experienced increasing, stable, or decreasing BMI over 2 years following diagnosis. Patients with younger age and lower estimated median income were most likely to be in the increasing BMI group. Among obese patients, those with Class I obesity (BMI 30 to 34.9 kg/m2) were most likely to experience decreasing BMI and those with Class III obesity (BMI > 40 kg/m2) were most likely to experience increasing BMI, p < 0.0001. Conclusion: A third of endometrial cancer survivors experience increasing BMI. Severity of obesity at diagnosis matters, patients with severe obesity (Class III) were most likely to experience weight gain.

Palliative care in gynecologic oncology: a narrative review of current literature and vision for the future.

BACKGROUND AND OBJECTIVE: Several professional societies have recommended incorporating palliative care into routine oncology care, yet palliative care remains underutilized among women with gynecologic cancers. This narrative review highlights current evidence regarding utilization of palliative care in gynecologic oncology care. Additionally, the authors offer recommendations to increase early integration and utilization of palliative care services, improve education for current and future gynecologic oncology providers, and expand the palliative care workforce. METHODS: The authors reviewed studies of palliative care interventions in oncology settings, with an emphasis on studies that included women with gynecologic malignancies. A panel of author/experts were gathered for a semi-structured interview to discuss the future of palliative care in gynecologic cancer care. The interview was recorded and reviewed to highlight themes. KEY CONTENT AND FINDINGS: Data supports routine integration of palliative care into gynecologic oncology practice. To expand delivery of palliative care, additional research that investigates implementation of palliative care across different healthcare settings is needed. There is a shortage of palliative care providers in the United States. Therefore, it is critical for gynecologic oncologists to receive a robust education in primary palliative care skillsets. Additionally, to expand the specialty palliative care workforce, palliative medicine leaders should recruit more gynecologic oncologists and other surgeons into palliative care fellowship programs. CONCLUSIONS: Expanded utilization of palliative care offers an opportunity to improve quality of care and outcomes for women with gynecologic cancers.

Hospice and Palliative Medicine Fellowship after Surgical Training: A Roadmap to the Future of Surgical Palliative Care.

OBJECTIVE: Surgeons comprise only 2% of Hospice and Palliative Medicine (HPM) board-certified physicians. Little is known about the motivations of individuals who pursue this combined training or the perceived benefits of this pathway. This study aimed to capture the pathways and experiences of HPM fellowship trained surgeons and to establish recommendations for surgical trainees who may benefit from HPM fellowship training. DESIGN: A qualitative study was designed using semi-structured zoom interviews that elicited experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. SETTING: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. PARTICIPANTS: Eligibility included completion of a 1-year HPM fellowship and training in general surgery, general obstetrics and gynecology, or affiliated subspecialties. RESULTS: Seventeen interviews were conducted. All participants expressed satisfaction with their HPM fellowship training. Four themes emerged as recommendations for surgeons to pursue HPM fellowship training: 1) a commitment to joining the HPM workforce, 2) becoming ambassadors for HPM and surgical culture change, 3) desire for advanced communication and symptom management skills at the specialist level, and 4) specialist level HPM skills may enhance surgical career. CONCLUSIONS: HPM fellowship training is achievable through multiple pathways for surgeons from a variety of training backgrounds.

Higher baseline BMI and lower estimated median income associated with increasing BMI after endometrial cancer diagnosis.

Introduction: Endometrial cancer is often directly related to obesity and interventions for weight loss have mixed results. Risk factors for continued weight gain after diagnosis are not clearly defined in the literature. The objective of this study is to describe risk factors associated with increased body mass index (BMI) trajectory among endometrial cancer patients. Methods: Patients who were surgically treated for endometrial cancer at a single institution between 2010 and 2015 were identified. Demographics including age, race/ethnicity and estimated median income at diagnosis were obtained. BMI at five time points after diagnosis were calculated. BMI trajectories were estimated by latent class growth modeling using the PROC TRAJ procedure in SAS. Chi-squared tests and ANOVA were used to assess differences between trajectory groups. Statistical significance was set to a p-value < 0.05. Results: Of 695 patients included in the study, the average age at diagnosis was 62 years and over 70% of patients were obese at baseline. Patients experienced increasing, stable, or decreasing BMI over 2 years following diagnosis. Patients with younger age and lower estimated median income were most likely to be in the increasing BMI group. Among obese patients, those with Class I obesity (BMI 30 to 34.9 kg/m2) were most likely to experience decreasing BMI and those with Class III obesity (BMI > 40 kg/m2) were most likely to experience increasing BMI, p < 0.0001. Conclusion: A third of endometrial cancer survivors experience increasing BMI. Severity of obesity at diagnosis matters, patients with severe obesity (Class III) were most likely to experience weight gain.

"There's somebody like me": perspectives of a peer-to-peer gynecologic cancer mentorship program.

PURPOSE: The Ovarian Cancer Research Alliance's Woman to Woman (W2W) program is a peer mentorship program for women with gynecological cancer that was founded in 2004 and has expanded to 43 sites nationwide. An initial program survey was conducted in 2013, but no qualitative studies have investigated patient experiences with peer support programs for gynecologic cancer in the USA. This study examines the match experience at one program site. The aim of this qualitative study was to capture mentor and mentee experiences giving and receiving peer support, including how relationships were initiated and developed. METHODS: Hour-long, semi-structured interviews were conducted with both mentors and mentees. Interviews focused on the dynamics of the mentor-mentee relationship. Interviews were recorded, transcribed verbatim, and open-coded. A qualitative descriptive approach was used to organize findings into themes. RESULTS: Sixteen participants (N = 16) were interviewed (seven mentors and nine mentees.) Three broad themes emerged: (i) pathways to the program; (ii) how connection occurred; and (iii) themes of compatibility. While program participants universally valued their match experience, frequency and mode of communication, as well as expectations of the match relationship were widely divergent among the program participants. CONCLUSION: The W2W peer mentorship program is a valuable resource for patients with gynecologic cancer. Refining the wants and needs of mentees including mode of communication, frequency of communication, type of support desired, identifying topics of mutual interest, and introducing the concept of recurrence may improve the connectivity experienced by mentor-mentee dyads.

Palliative Chemotherapy and the Surgical Oncologist.

Outcomes are improving for patients with advanced cancer, in part because of increasing diversity and efficacy of systemic therapy, often described as "palliative chemotherapy." Patients with advanced cancer receiving systemic treatment sometimes require surgical interventions, and their cancer care teams must collaborate to optimally manage medical and surgical challenges while also considering patients' goals and values. Structured communication can overcome the inherent ambiguity of the term "palliative chemotherapy" and facilitate optimal quality of care and quality of life for patients with advanced cancer who require surgical interventions.

Case Report: Uterine Didelphys and Cervical Agenesis in an 18 Year-Old Woman Presenting with a Pelvic Mass.

BACKGROUND: Although Müllerian anomalies are relatively common they can be easily misdiagnosed as other gynecologic conditions leading to inappropriate treatment. CASE: An 18-year-old woman presented to the hospital with abdominal pain and was found to have a 17-cm pelvic mass and absence of the cervix. Because of concern for recurrent endometrioma formation in the setting of a Müllerian anomaly, she underwent a hysterectomy. During surgery, she was noted to have complete uterine didelphys with cervical agenesis and a normal vagina. SUMMARY AND CONCLUSION: This extremely rare Müllerian anomaly represents one of the only descriptions to date of uterine didelphys with cervical agenesis and normal vaginal development. Appropriate identification and management of Müllerian anomalies is essential for guiding the care of these young, complex patients.

Disparities in ovarian cancer survival at the only NCI-designated cancer center in Kansas.

BACKGROUND: This study examined the impact of geographic distance on survival outcomes for patients receiving treatment for ovarian cancer at the only NCI-designated cancer center (NCI-CC) in Kansas. METHODS: We identified ovarian cancer patients treated at the University of Kansas Cancer Center between 2010 and 2015. Demographic factors and clinical characteristics were abstracted. The main outcome measure was overall survival according to geographic distance from the institution. Kaplan Meier survival curves and Cox proportional hazard models were generated using SAS v9.4. RESULTS: 220 patients were identified. Survival analysis based on distance from the institution demonstrated that patients who lived ≤10 miles from the institution had worse overall survival (p = 0.0207) and were more likely to have suboptimal cytoreductive surgery (p = 0.0276). Lower estimated median income was also associated with a 1.54 increased risk of death, 95% CI (1.031-2.292), p = 0.0347. CONCLUSIONS: We determined that ovarian cancer survival disparities exist in our patient population. Lower rates of optimal cytoreductive surgery has been identified as a possible driver of poor prognosis for patients who lived in proximity to our institution.

Undergoing active treatment for gynecologic cancer during COVID-19: A qualitative study of the impact on healthcare and social support.

The COVID-19 pandemic poses unique challenges for oncology patients and clinicians. While guidelines for oncology care delivery during the pandemic have been established, there is a paucity of data examining patient experiences of cancer care during the COVID pandemic. This qualitative study captured the perspectives of women undergoing active treatment for gynecologic malignancy at an academic medical center. Hour-long semi-structured interviews were conducted via video-conference and transcribed verbatim. Focused coding was conducted to identify all data related to COVID-19. These data were then categorized into themes that emerged inductively. Seven women (N = 7) were interviewed. Several themes arose under two main categories: 1) Impact of COVID-19 on cancer care delivery and interactions and 2) Intersection of cancer and COVID-19 outside of the healthcare setting. Under category 1, themes included: going to treatment alone; variable access to care and information. Under category 2, themes included: unavailability of cancer-specific social support; mask wearing; COVID-19 & life outlook; adapting coping strategies. Participants' perceptions of having cancer during the COVID-19 pandemic varied and were not always negative. Healthcare systems can draw on our findings to inform interventions to ensure optimal patient care. Additionally, given our finding that noncompliance with mask wearing and physical distancing can be uniquely distressing to cancer patients, healthcare systems should prioritize clear messaging around COVID-19 precautions and ensure compliance of staff and patrons. Due to the rapidly changing nature of the pandemic, outcomes for these patients should be monitored and care guidelines should incorporate first-hand patient narratives.

The impact of skeletal muscle abnormalities on tolerance to adjuvant chemotherapy and radiation and outcome in patients with endometrial cancer.

INTRODUCTION: Skeletal muscle abnormalities, such as low skeletal muscle mass, measured by skeletal muscle index (SMI), and low skeletal muscle quality, measured by skeletal muscle density (SMD), are associated with poor prognosis in cancer. There has been little investigation of their impact on tolerance to radiation therapy and overall outcome in gynaecologic cancers. We examined the effect of low SMI and SMD on treatment tolerance and survival outcomes in patients with endometrial cancer receiving pelvic radiation. METHODS: Stage IB-IVA patients with endometrial cancer treated at one institution between 2007 and 2017 were reviewed. All patients received hysterectomy and pelvic radiation. SMI was based on the cross-sectional area of skeletal muscle at the L3 vertebral body. SMD was expressed as the mean radiation attenuation in Hounsfield units (HUs) at the same vertebral level. RESULTS: Sixty-four patients met criteria for analysis. Forty-four per cent had low SMI (<41 cm2 /m2 ), 80% had low SMD (mean < 33 HU if BMI> 25 and mean < 41 HU if BMI < 25), and 33% had both. Patients with both features were less likely to complete planned chemotherapy (p = 0.01); this was consistent on multivariate analysis. Radiation treatments were well-tolerated regardless of SMI or SMD. On survival analysis, having both low SMI and low SMD was associated with poorer outcomes compared with having either individual factor (p = 0.04). CONCLUSION: Large percentages of patients with endometrial cancer have low skeletal muscle mass and density. Low skeletal muscle measures predict for poor tolerance to chemotherapy in this patient population. Compliance with adjuvant radiation is high, regardless of SMI and SMD.

Association Between Statin Use and Endometrial Cancer Survival.

OBJECTIVE: To evaluate the association of 3 hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor (statin) use and concordant polypharmacy with disease-specific survival from endometrial cancer. METHODS: A retrospective cohort study was conducted of 985 endometrial cancer cases treated from January 1999 through December 2009 at a single institution. Disease-specific survival was estimated by Kaplan-Meier analyses. A Cox proportional hazards model was used to study factors associated with survival. All statistical tests were two-sided and performed using Stata. RESULTS: At the time of analysis, 230 patients (22% of evaluable patients) died of disease and median follow-up was 3.28 years. Disease-specific survival was greater (179/220 [81%]) for women with endometrial cancer taking statin therapy at the time of diagnosis and staging compared with women not using statins (423/570 [74%]) (log rank test, P=.03). This association persisted for the subgroup of patients with nonendometrioid endometrial tumors who were statin users (59/87 [68%]) compared with nonusers (93/193 [43%]) (log rank test, P=.02). The relationship remained significant (hazard ratio 0.63, 95% confidence interval [CI] 0.40-0.99) after adjusting for age, clinical stage, radiation, and other factors. Further evaluation of polypharmacy showed an association between concurrent statin and aspirin use with an especially low disease-specific mortality (hazard ratio 0.25, 95% CI 0.09-0.70) relative to those who used neither. CONCLUSION: Statin and aspirin use was associated with improved survival from nonendometrioid endometrial cancer.