Palliative Care Education in Gynecologic Oncology: a Survey of Gynecologic Oncologists and Gynecologic Oncology Fellows in Thailand.

BACKGROUND: The main purpose of this study was to survey the education and training of certified gynecologic oncologists and fellows in Thailand. A secondary objective was to study the problems in fellowship training regarding palliative care for gynecologic cancer patients. MATERIALS AND METHODS: A descriptive study was conducted by sending a questionnaire regarding palliative care education to all certified gynecologic oncologists and gynecologic oncology fellows in Thailand. The contents of the survey included fellowship training experience, caring for the dying, patient preparation, attitudes and respondent characteristics. Statistics were analyzed by percentage, mean and standard deviation and chi-square. RESULTS: One hundred seventy completed questionnaires were returned; the response rate was 66%. Most certified gynecologic oncologists and fellows in gynecologic oncology have a positive attitude towards palliative care education, and agree that "psychological distress can result in severe physical suffering". It was found that the curriculum of gynecologic oncology fellowship training equally emphasizes three aspects, namely managing post-operative complications, managing a patient at the end of life and managing a patient with gynecologic oncology. As for experiential training during the fellowship of gynecologic oncology, education regarding breaking bad news, discussion about goals of care and procedures for symptoms control were mostly on-the-job training without explicit teaching. In addition, only 42.9% of respondents were explicitly taught the coping skill for managing their own stress when caring for palliative patients during fellowship training. Most of respondents rated their clinical competency for palliative care in the "moderately well prepared" level, and the lowest score of the competency was the issue of spiritual care. CONCLUSIONS: Almost all certified gynecologic oncologists and fellows in gynecologic oncology have a positive attitude towards learning and teaching in palliative care. In this study, some issues were identified for improving palliative care education such as proper training under the supervision of a mentor, teaching how to deal with work stress, competency in spiritual care and attitudes on responsibility for bereavement care.

Incidence and Clinical Characteristic of Venous Thromboembolism in Gynecologic Oncology Patients attending King Chulalongkorn Memorial Hospital over a 10 Year Period.

BACKGROUND: Venous thromboembolisms (VTEs) constitute a group of diseases including deep vein thrombosis (DVT) and pulmonary embolism (PE). They regarded as the second leading cause of death in cancer patients and several studies have confirmed that VTEs have a negative impact on survival and recurrent rate in both ovarian and endometrial cancer cases. The incidence of VTEs differs worldwide and depends on several risk factors including race, underlying disease, lifestyle, body weight, BMI and genetic risk factors. There is heterogeneity of DVT rates between Asian and Western countries. This study was conducted in order to evaluate the character and incidence of VTEs in gynecologic oncology patients in King Chulalongkorn Memorial Hospital over a 10 year period. MATERIALS AND METHODS: A retrospective chart review was performed with VTEs defined as objective diagnosis of acute DVT or PE with typical symptoms and signs. Diagnoses were approved byan internist and/ or confirmed with imaging studies. Data from both outpatient and inpatient sessions of the affected cases from January 2004 to December 2013 were extracted. General characteristics of the patients were collected with details of the diseases, types of cancer, stage, date of diagnosis of cancer, operative data, treatment outcome, progression free survival and overall survival. RESULTS: Thirty cases of VTEs were identified in a total 2,316 gynecologic oncology cases. The incidence of symptomatic VTEs in total gynecologic oncology patients in our institution is 1.295%. The incidence of VTEs in ovarian cancer patients in our institution was 5.9%. Duration for VTE detection ranged from 13 months before diagnosis of cancer to 33 months after diagnosis of cancer. Most of the VTE cases were detected in ovarian cancer patients (60%). The most common cell type was adenocarcinoma (moderately to poorly differentiated) which accounted for 26.7% of the cases. The second most common cell type was clear cell carcinoma with 23.3% of the cases. Thirty percent of VTE cases developed before cancer was diagnosed, 20% were diagnosed at the same time as cancer detection and fifty percent developed after cancer was diagnosed. Median disease free survival of the gynecologic oncology patients with VTE was 7.5 months. Median overall survival (OS) was 12 months. Median progession free survivals of DVT and PE groups were 11.5 and 5.5 months, respectively. OS of DVT and PE was 12.0 and 11.5 months respectively. CONCLUSIONS: The incidence of VTE in Asian countries is believed to be lower than in European or Western countries. From our retrospective review, the incidence of VTEs in all types of gynecologic oncology was 1.295%, much lower than reported in the West. The reason for the lower incidence may genetic differences. Another factor is that VTE in this review was symptomatic, which is less than asymptomatic VTE. More than half of VTEs in this study developed in ovarian cancer patients. The results are compatible with earlier reports that among gynecologic malignancies, the incidence of VTE is highest in ovarian cancer.

Model for predicting the burden and cost of treatment in cervical cancer and HPV-related diseases in Thailand.

PURPOSE: Cervical cancer is a significant health burden in many countries. Long-term cost of care is still not well understood. We aimed to evaluate the long-term burden of illness and healthcare resource utilization associated with cervical cancer, cervical intraepithelial neoplasia (CIN) and genital warts from the care provider perspective. METHOD: We developed a health state-transition Markov model to portray the algorithm of treatment of stages of cervical cancer, CIN and genital warts by tracking a hypothetical lifetime cohort of 12-year-old girls. Costs in this study were unit cost; capital costs and labor costs were included in the unit cost for inpatients and out-patients. RESULTS: The highest incidence of CIN and genital warts was observed in women aged 20-30 years old. For cervical cancer, the highest incidence was 45-55 years. Death rate was estimated at 2%, 8%, 84% and 94% in cervical cancer Stage IA1, IA2-IIA, IIB-IVA and IVB, respectively. The estimated mean direct cost per patient with cervical cancer Stage IA1, IA2-IIA, IIB-IVA, IVB, CIN1, CIN2/3 and genital warts were 41,117 Thai Baht ($1,277 US), 97,250 Thai Baht ($3,020 US), 402,683 Thai Baht ($12,506 US), 322,619 Thai Baht ($10,019 US), 5,381 Thai Baht ($167 US), 49,933 Thai Baht ($1.551 US) and 3,585 Thai Baht ($111 US), respectively. Cost for survival or death case was indifferent. The overall lifetime costs from the provider perspective were evaluated at 859.1 million Baht ($26.7 million US) per a cohort of 100,000 women which corresponds to approximately 4,244 million Baht ($131.8 million US) for the current number of Thai 12-year-old girls. CONCLUSIONS: HPV-related diseases impose health and cost burdens in Thailand. The national immunization programme to reduce this burden as well as further research to evaluate the impact is keenly expected.

Depot medroxyprogesterone acetate and epithelial ovarian cancer: a multicentre case-control study.

OBJECTIVE: To evaluate the effect of depot medroxyprogesterone acetate (DMPA) in protecting against epithelial ovarian cancer (EOC) and to evaluate factors associated with the risk of EOC. DESIGN: A multicentre, case-control study. SETTING: Twelve hospitals located across Thailand. POPULATION: Three hundred and thirty patients with EOC ('cases') and 982 matched controls were recruited from the 12 hospitals. Cases were newly diagnosed patients with EOC, demonstrated pathologically. Controls were age-matched patients admitted to different wards in the same hospital. METHODS: Cases and controls were interviewed by trained interviewers using a standardised pre-tested questionnaire. The factors associated with EOC were evaluated using univariate and multivariate analyses. MAIN OUTCOME MEASURES: The odds ratio (OR) and 95% confidence interval (95% CI) were calculated to assess the relationship between DMPA and EOC. RESULTS: The use of DMPA was found to be associated with a 39% reduction in the risk of EOC with an OR of 0.61 and a 95% CI of 0.44-0.85 (P = 0.002). A significant risk reduction (83%) was observed when the duration of DMPA use was >3 years (OR 0.17; 95% CI 0.07-0.39; P < 0.001). Other factors associated with a reduced risk of EOC were the use of combined oral contraceptive pills and breastfeeding. A factor associated with an increased risk of EOC was a family history of gynaecological cancer. CONCLUSIONS: The results suggest that DMPA may have a protective effect against EOC. If this effect is real, then it represents an important non-contraceptive benefit of DMPA.