ABSTRACTOvarian cancer is the third most common gynecologic malignancy worldwide but accounts for the highest mortality rate among these cancers. A stepwise approach to assessment, diagnosis, and ...treatment is vital to appropriate management of this disease process. An integrated approach with gynecologic oncologists as well as medical oncologists, pathologists, and radiologists is of paramount importance to improving outcomes. Surgical cytoreduction to R0 is the mainstay of treatment, followed by adjuvant chemotherapy. Genetic testing for gene mutations that affect treatment is the standard of care for all women with epithelial ovarian cancer. Nearly all women will have a recurrence, and the treatment of recurrent ovarian cancer continues to be nuanced and requires extensive review of up to date modalities that balance efficacy with the patient’s quality of life. Maintenance therapy with poly ADP-ribose polymerase inhibitors, bevacizumab, and/or drugs targeting homologous recombination deficiency is becoming more widely used in the treatment of ovarian cancer, and the advancement of immunotherapy is further revolutionizing treatment targets.
This month we will review the latest data on prevention of incidence of venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, in patients undergoing ...gynecologic surgery. Dr. Guntupalli discusses four recent publications, which are concluded with a “bottom-line” that is the take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.
AbstractVenous thromboembolism (VTE) is a major cause of both morbidity and mortality in patients with cancer. Venous thromboembolism, which includes both deep vein thrombosis and pulmonary embolism, ...affects a sizable portion of patients with malignancy and can have potentially life threatening complications. Accurate assessment of risk as well as diagnosis and treatment of this process is paramount to preventing death in this high risk population. Various risk models predictive of venous thromboembolism in patients with cancer have been developed, and knowledge of these rubrics is essential for the treating oncologist. Subgroups of particular interest are inpatients receiving chemotherapy, postoperative patients after surgical debulking, and patients undergoing radiotherapy. Numerous newer drugs have become available for the prevention of venous thromboembolism in patients with cancer who are at high risk of developing the disease. These include the class of drugs called direct oral anticoagulants, (DOACs) which do not require the same monitoring that other modalities have previously required and are taken by mouth, preventing the discomfort associated with subcutaneous strategies. The appropriate risk stratification and intervention to prevent venous thromboembolism are vital to the treatment of patients with cancer.
Female sexual dysfunction is associated with personal distress and includes female sexual interest and arousal disorder (including former hypoactive sexual desire disorder), female orgasmic disorder, ...genitopelvic pain and penetration disorder, and substance- or medication-induced sexual dysfunction. These disorders are remarkably common among women, with an estimated prevalence of 20–40%. It is our responsibility as obstetrician–gynecologists to identify risk factors and screen for female sexual dysfunction. Appropriate screening allows for further exploration into sexual function and dysfunction and, ultimately, determination of associated distress. Treatment often involves addressing the underlying issue through therapy or medical management. For female sexual interest and arousal disorder, treatment generally includes cognitive behavioral therapy, often with a mindfulness focus, and consideration of pharmaceutical management. Female orgasmic disorder is treated with education and awareness, as well as therapy. Evaluation for underlying etiology is particularly critical for genitopelvic pain and penetration disorder to allow treatment of an underlying condition. Finally, substance- or medication-induced sexual dysfunction is best managed by cessation of the implicated substance and consideration of adjunctive therapy if dysfunction is related to antidepressants. Female sexual dysfunction is often overlooked in clinical practice; however, there are effective medical and psychological options for management.
The cost-effectiveness of apixaban was compared with enoxaparin for prevention of postoperative venothromboembolic events (VTE) in gynecologic oncology patients. Current guidelines recommend ...thromboprophylaxis with low molecular weight heparin for 28 days following gynecologic cancer surgery, but recent trials suggest that oral apixaban may be a safe, patient-preferred alternative. Apixaban was superior to enoxaparin in a Canadian cost-effectiveness analysis using orthopedics trial data.
Medication costs, adherence rates, event rates, event costs, and utility decrements were estimated using prior clinical trial data and literature review for input into a short-term decision model to simulate outcomes in a hypothetical cohort of 1000 patients. Incremental cost-effectiveness ratios (ICERs) were calculated as net cost difference per quality-adjusted life year (QALY) gained. Input values at which net costs and QALYs were equivalent and ICERs at upper and lower bounds were evaluated.
Using aggregated costs, apixaban was less expensive and more effective than enoxaparin, and remained so or had high value in all scenarios on sensitivity analysis. Examining disaggregated ICERs, apixaban was cost-effective for deep venous thrombosis (DVT); of high value for clinically-relevant non-major bleeding (CRNMB) ($411); low value for major bleeding ($183,465), VTE-related death ($2,711,229), and all-cause mortality ($297,522); and not cost-effective for pulmonary embolism prevention.
Apixaban is more cost-effective than enoxaparin for the prevention of postoperative VTE in patients with gynecologic cancer. This appears to be driven largely by DVT and CRNMB prevention.
•Apixaban was less expensive and more effective than enoxaparin overall•Apixaban remained cost-effective or of high value on sensitivity analysis•Apixaban was cost-effective in deep venous thrombosis and of high value in clinically relevant non-major bleeding prevention•Apixaban was not cost effective in prevention of pulmonary embolism
Background
Venous thromboembolism is a preventable complication of gynecologic cancer surgery that leads to postoperative morbidity and mortality. This study compared apixaban with enoxaparin to ...identify whether apixaban had the same safety and efficacy for patients undergoing gynecologic cancer surgery.
Methods
The study identified patients with a gynecologic malignancy who underwent surgery and were prescribed apixaban at discharge between June 2020 and April 2023. International Classification of Diseases 10 codes were used to identify patients who had a thromboembolism within 90 days or a bleeding event within 60 days after surgery. The rates of events for patients prescribed apixaban were compared with those for a historical cohort of patients who received enoxaparin. Fisher’s exact tests were used to compare categorical variables, and
t
tests were used to compare continuous variables. A logistic regression was performed to compare the odds of thromboembolism between the two groups.
Results
Baseline patient characteristics differed in terms of body mass index (BMI), race, route of surgery, and type of cancer. Of the 490 patients in the apixaban cohort, 12 (2.4%) had a thromboembolism compared with 3 (2.1%) of the 138 patients in the enoxaparin group (adjusted odds ratio aOR, 1.02; 95% confidence interval CI 0.30–4.70;
p
> 0.999). The odds ratio was adjusted for BMI, age, and route of surgery. A bleeding event occurred for 1 (0.2%) of the 490 patients in the apixaban group and for 1 (0.7%) of the 138 patients in the enoxaparin group.
Conclusions
This validation study showed that apixaban is a safe and effective method of postoperative venous thromboembolism prophylaxis. The data provide support to previous data and guideline updates recommending the use of apixaban for postoperative prophylaxis.
•Cardiac metastasis is a rare complication of squamous cell carcinoma of the cervix.•Biologic agents may be a useful treatment modality for cardiac metastasis of squamous cell carcinoma of the ...cervix.•Multidisciplinary approach is required to treat cardiac metastasis of squamous cell carcinoma of the cervix.
OBJECTIVE:To explore the relationship between intrauterine device (IUD) use and risk of ovarian cancer through systematic review of the literature and meta-analysis.
DATA SOURCES:We searched MEDLINE, ...EMBASE, Cochrane Library, Web of Science Core Collection from inception to June 2018. For the MEDLINE search, we included the MeSH terms “intrauterine devices” AND “ovarian neoplasms,” however also searching “intrauter*,” “ovar*” and “fallopian tube,” as well as “cancer” and “carcinoma” as keywords to include all possible variations. Similar search terms were used in the other databases. We also searched ClinicalTrials.gov.
METHODS OF STUDY SELECTION:Case–control and cohort studies that collected individual level data on IUD use and ovarian cancer diagnosis were critically reviewed and data extracted. Review of abstracts from 399 articles through systematic database review and an additional 200 articles through Google Scholar identified a total of 15 studies with individual level data regarding IUD use and incident ovarian cancer. On critical review, 11 of these studies were used for meta-analysis. All case reports and reviews were excluded.
TABULATION, INTEGRATION, AND RESULTS:The data were harmonized and weighted and summary odds ratios (ORs) were calculated. Covariates were identified evaluated separately. A random-effects meta-analysis was performed to confirm minimal bias. Harmonization and weighting of the data revealed an OR association between ever use of an IUD and incident ovarian cancer to be 0.68 (95% CI 0.62–0.75). There were no significant differences found between covariates. Heterogeneity among all studies was found to be I=68%.
CONCLUSION:Intrauterine device use is associated with a reduced incidence of ovarian cancer based on a review of existing retrospective data. Unfortunately, prospective investigation into the role of IUDs in ovarian cancer prevention is limited.
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