Reduced healthcare access contributes to delay of care in endometrial cancer.

OBJECTIVE: We aimed to characterize delays to care in patients with endometrioid endometrial cancer and the role healthcare access plays in these delays. METHODS: A chart review was performed of patients with endometrioid endometrial cancer who presented with postmenopausal bleeding at a diverse, urban medical center between 2006 and 2018. The time from symptom onset to treatment was abstracted from the medical record. This interval was subdivided to assess for delay to presentation, delay to diagnosis, and delay to treatment. RESULTS: We identified 484 patients who met the inclusion criteria. The median time from symptom onset to treatment was 4 months with an interquartile range of 2 to 8 months. Most patients had stage I disease at diagnosis (88.6%). There was no significant difference in race/ethnicity or disease stage at time of diagnosis between different groups. Patients who had not seen a primary care physician or general obstetrician-gynecologist in the year before symptom onset were more likely to have significantly delayed care (27.7% vs 14.3%, p = 0.02) and extrauterine disease (20.2% vs 4.9%, p < 0.01) compared to those with established care. Black and Hispanic patients were more likely to experience significant delays from initial biopsy to diagnosis. CONCLUSIONS: Delays exist in the evaluation of endometrial cancer. This delay is most pronounced in patients without an established outpatient primary care provider or obstetrician-gynecologist.

Necessity of routine cardiac evaluation in patients receiving pegylated liposomal doxorubicin for gynecologic cancer.

OBJECTIVE: Pegylated liposomal doxorubicin (PLD) has similar reported clinical efficacy compared with conventional doxorubicin with less cardiotoxicity. The manufacturer of PLD advises that cardiac function should be evaluated with endomyocardial biopsy, echocardiography or multigated radionucleotide scan (MUGA) pre-treatment and during therapy. This study was designed to assess the necessity of pre-treatment cardiac evaluation in patients receiving PLD. METHODS: After IRB approval, a retrospective study of all women with gynecologic cancer who received PLD from 2006 to 2018 was performed. Demographic information, treatment records, cardiac risk factors, and cardiac surveillance testing were examined. Wilcoxon signed rank sum test and logistic regression were used to evaluate the association of cumulative PLD exposure with cardiotoxicity. RESULTS: A total of 235 patients received PLD for gynecologic cancer. Patients received a median of 3 cycles of PLD with a cumulative dosage of 237 mg over a median follow-up time of 24 months. Sixteen patients in the cohort (7%) had no cardiac surveillance at all. Of the remaining patients who underwent cardiac testing, 183 (84%) received MUGA scans and 36 (16%) had echocardiography. Of the 56 patients who had both pre- and post-treatment cardiac testing, there was no significant difference in median ejection fraction (p = 0.17). Three patients developed PLD-associated cardiac toxicity but only one patient had severe manifestations requiring discontinuation of PLD therapy. CONCLUSIONS: Routine cardiac testing before, during or after treatment with PLD may be unnecessary. Cardiac testing may be more appropriate for individual patients for whom the clinical suspicion of PLD-related cardiac toxicity is high.

Readability assessment of online gynecologic oncology patient education materials from major governmental, non-profit and pharmaceutical organizations.

OBJECTIVE: Patients are increasingly using online materials to learn about gynecologic cancer. Providers can refer patients to online educational materials produced by a number of different major medical organizations and pharmacology companies. The National Institutes of Health (NIH) and the American Medical Association (AMA) recommend that patient educational materials (PEMs) are written between a sixth and eighth grade reading level. In this study, we assess the readability of online PEMs published by major medical organizations and industry partners. METHODS: Websites from twelve websites providing educational materials for gynecologic oncology patients were surveyed. Online PEMs were identified and analyzed using seven validated readability indices. One-way ANOVA and Tukey's Honestly Significant Difference (HSD) post-hoc analysis were performed to detect differences in readability between publishers. RESULTS: Two-hundred and sixty PEMs were included in this analysis. Overall, PEMs were written at a mean 11th±0.6 grade reading level. Only 6.5% of articles were written at the AMA/NIH recommended reading grade level of 6th to 8th grade or below. ANOVA demonstrated a significant difference in readability between publishing associations (p<0.01). PEMs from the Centers for Disease Control had a mean 9th±1.2 grade reading level and were significantly lower than all other organizations. PEMs from The Foundation for Women's Cancer had a mean 13th±1.8 grade reading level and were significantly higher than most other organizations. PEMs from pharmaceutical companies (mean readability=10.1±1.1, N=30) required the lowest reading grade level and were significantly more readable than those from governmental organizations (11.1±1.7, p<0.05) and nonprofit medical associations (12.4±1.7, p<0.01) in ANOVA and Tukey-Kramer post hoc analysis. CONCLUSIONS: Gynecologic oncology PEMs available from twelve major organization websites are written well above the recommended sixth to eighth grade reading difficulty level.

The use of QuikClot combat gauze in cervical and vaginal hemorrhage.

QuikClot combat gauze is a synthetic hemostatic dressing used for hemorrhage control. There is a paucity of data describing the clinical use and hemostatic results of combat gauze in the obstetric and gynecologic setting. This case series demonstrates the use of combat gauze as an effective hemostatic agent when used as vaginal packing in cervical and vaginal hemorrhage. Hemostasis was achieved rapidly in all cases and further interventions were avoided. The combat gauze remained in place for a mean time of 15 h with no adverse side effects observed. The use of combat gauze as vaginal packing may provide an alternative option in the treatment of cervical and vaginal hemorrhage when other traditional conservative and surgical interventions fail or are unavailable.

Pregnancy context and women's health-related quality of life.

OBJECTIVE: The objective was to quantify the association of pregnancy context and health-related quality of life (HRQoL). STUDY DESIGN: English- or Spanish-speaking women, aged 16-44, with pregnancies <24 weeks' gestation were enrolled in this cross-sectional study between June 2014 and June 2015. Participants completed self-assessments of pregnancy "context," including timing, intention, wantedness, desirability, happiness, and planning (measured with the London Measure of Unplanned Pregnancy). HRQoL was measured using the Patient Reported Outcomes Measurement Information System Global Short Form. Associations between measures of pregnancy context and HRQoL scores in the lowest tertile were examined using multivariable logistic regression to adjust for potential confounding variables. RESULTS: We enrolled 161 participants (mean age=27.2±6.6 years). Only 14% self-identified as White, non-Hispanic; 42% Hispanic; 37% Black, non-Hispanic; and 7% multiracial. Most (79%) participants were unmarried, and 75% were parenting. Mean gestational age was 9±4.6 weeks. In unadjusted models, women reporting mixed feelings about wanting to have a baby, an undesired pregnancy or feeling unhappy about learning of their pregnancy more frequently had low mental and physical HRQoL compared to women reporting wanted, desired, happy pregnancies. Women with an unplanned pregnancy or pregnancy occurring at the wrong time also had lower physical HRQoL than women reporting pregnancies that were planned or happened at the right time. However, after multivariate adjustment, including history of depression, pregnancy contexts were not associated with low mental or physical HRQoL. CONCLUSIONS: After adjusting for multiple confounders, pregnancy context is not significantly associated with HRQoL. IMPLICATIONS: The focus on pregnancy intention in public health programs may not sufficiently assess multidimensional aspects of pregnancy context and may not align with patient-centered outcomes such as HRQoL.

Correction of coagulopathy associated with non-bacterial thrombotic endocarditis (NBTE) by surgical debulking in a case of ovarian clear cell carcinoma.

•Ovarian cancer, particularly clear cell carcinoma, creates a hypercoagulable state.•This state can predispose to non-bacterial thrombotic endocarditis (NBTE).•NBTE can embolize and cause widespread arterial infarction.•NBTE is sometimes associated with a treatment refractory disseminated coagulopathy.•Surgical removal of the primary mass can sometimes reverse the coagulopathy.

Incidental injury and repair of obturator nerve during laparoscopic pelvic lymphadenectomy.

OBJECTIVE: To demonstrate a surgical video wherein left obturator nerve was iatrogenically injured during pelvic lymphadenectomy and repaired immediately with laparoscopic epineural end-to-end tension free anastomosis. METHODS: This is a step-by-step demonstration of an incidental injury and laparoscopic repair of left obturator nerve during pelvic lymphadenectomy. The patient was a 59year-old Hispanic female who was found to have endometrial adenocarcinoma. She was referred to our division for laparoscopic staging during which left obturator nerve was iatrogenically injured. After completion of left pelvic lymphadenectomy, proximal and distal cut ends of the obturator nerve were identified. Careful inspection revealed that the nerve was transected cleanly without any fraying of the edges. Tension-free reattachment of the edges seemed possible without further mobilization of the nerve since the resected part was approximately 5mm. The obturator nerve edges were oriented and stay sutures were placed in order to perform tension-free anastomosis. Epineural end-to-end coaptation was completed with 5-0 polypropylene sutures [1,2]. RESULTS: Postoperatively, the patient did not exhibit any clinically apparent loss of adductor function or any other neurologic deficiency and was discharged home on postoperative day one. Over 6months of follow-up, the patient experienced no residual neuropathy or deficit in the left thigh. CONCLUSION: Laparoscopic repair of a transected obturator nerve during gynecologic surgery is feasible. In this case, immediate repair of the damaged nerve by an experienced laparoscopic gynecologic surgeon did not result in any neurologic deficit postoperatively.