Purpose of Review
This review serves to provide clarity on the nature, scope, and benefits of early palliative care integration into the management of patients with gynecologic malignancies.
Recent ...Findings
There is increased recognition that timely referral to palliative care improves quality of life for patients and their families by providing goal-concordant care that reduces physical and emotional suffering and limits futile and aggressive measures at the end of life. Palliative care services rendered throughout the continuum of illness ultimately increase engagement with hospice services and drive down health expenditures. Despite these myriad benefits, misconceptions remain, and barriers to and disparities in access to these services persist and warrant continued attention.
Summary
Palliative care should be offered to all patients with advanced gynecologic cancers early in the course of their disease to maximize benefit to patients and their families.
•Despite attempts to improve diversity in healthcare, many populations continue to be underrepresented in medicine (URM)•Blinded interviews, which de-emphasize the written application, may reduce ...bias in application review.•We found that blinded interviewers were more likely to rank URM applicants more highly.•Other techniques to limit bias, such as standardized questions and implicit bias training, should be considered.
Biases in application review may limit access of applicants who are underrepresented in medicine (URM) to graduate medical training opportunities. We aimed to evaluate the association between blinding interviewers to written applications and final ranking of all applicants and URM applicants for Gynecologic Oncology fellowship. During 2020 virtual Gynecologic Oncology fellowship interviews, we blinded one group of interviewers to written applications, including self-reported URM status. Interviewers visually interacted with the applicants but did not review their application.Interviewers submitted independent rank lists. We compared pooled rankings of blinded and non-blinded interviewers for all applicants and for URM applicants using appropriate bivariate statistics.
We received 94 applications for two positions through the National Resident Matching Program, of which 18 (19%) self-identified as URM.We invited 40 applicants to interview and interviewed 30 applicants over six sessions. Ten interviewees (33%) self-identified as URM.Of 12 or 13 faculty interviewers during each interview session, 3 or 4 were blinded to the written application. There was no statistically significant difference in rank order when comparing blinded to non-blinded interviewers overall. However, blinded interviewers ranked URM applicants higher than non-blinded interviewers (p = 0.04). Blinding of written application metrics may allow for higher ranking of URM individuals.
•Referral to palliative care within eight weeks of advanced cancer diagnosis is recommended.•Rates of palliative care referral in ovarian cancer patients are high compared with prior ...literature.•Timing of referral suggests a reaction to clinical decline, rather than proactive approach.•Diagnosis of platinum resistance should serve as a stimulus for palliative care referral.
To evaluate patterns of palliative care (PC) integration in patients with platinum resistant ovarian cancer.
Single institution retrospective study of patients with ovarian, tubal, or peritoneal high-grade carcinoma treated 2011–2020. Platinum resistance was identified by chemotherapy regimen or provider definition. Data was extracted evaluating treatment regimens, time to progression, PC and hospice referrals, and survival. Descriptive statistics and survival analyses were performed.
We identified 258 patients with platinum resistant ovarian cancer. Median survival from diagnosis of platinum resistance was 15 months (range 0–161). Most (71 %) patients were referred to PC, with 43 % of referrals within 3 months of death. Fourteen percent of patients were referred directly to hospice without PC involvement. Of 46 patients living with platinum resistant disease, 93 % meet criteria for early PC referral, but less than half have seen PC. Median time from platinum resistance to PC referral was 9 months (range 0–157) and from PC referral to death was 3 months (range 0–110). Median time from platinum resistance to hospice referral was 7 months (range 1–57) and from hospice referral to death was < 1 month (range 0–12).
While rates of PC referral in our cohort are high compared with other single institution cohorts, timing of PC referral suggests referral patterns that are reactive to clinical decline rather than proactive as per national recommendations. A significant percentage of patients are directly referred to hospice for end-of-life care, reflecting missed opportunity for concurrent PC and oncology care earlier in the disease course. Diagnosis of platinum resistance should serve as a stimulus for PC involvement.
The objective of this study is to characterize patterns of utilization of adjuvant chemotherapy (CT) and radiotherapy (RT) in the posthysterectomy management of uterine carcinosarcoma (UCS) in the ...United States.
We queried the National Cancer Database for women diagnosed with UCS between 2004 and 2012 and undergoing hysterectomy. Logistic regression was performed to identify sociodemographic, facility-specific, and treatment-related predictors of receiving multiagent chemotherapy, external beam radiotherapy (EBRT), or brachytherapy (BT).
In total 4272 patients were included, with 2 in 5 (40.5%) receiving no adjuvant therapy. Regarding RT, 2357 (55.1%) received neither EBRT nor BT, 929 (21.7%) received EBRT alone, 518 (12.1%) received BT alone, and 468 (11.0%) received EBRT+BT. Most women (70.8%) received no CT, a minority (1.5%) received single-agent CT, and the rest (27.8%) received multiagent chemotherapy. Logistic regression demonstrated disparities in receipt of adjuvant therapies by age, diagnosis year, insurance, facility volume, facility type, stage, and margin status, with patients with positive surgical margins less likely to receive BT.
Following hysterectomy for UCS, a large proportion of women receives no CT and no RT in the United States. Multispecialty evaluation is critical for individualization of therapy and may address disparities in this aggressive disease.
•MAID (Medical Aid in Dying) is the practice of providing a prescription for a life ending medication to a patient.•MAID is an important topic for gynecologic oncologists and their patients.•SGO ...members desire additional education and guidance regarding MAID.
To assess SGO members’ knowledge, attitudes, and practice patterns regarding Medical Aid In Dying (MAID).
SGO members were surveyed via online survey. The survey included questions regarding demographics, knowledge, attitudes, and practice patterns relating to MAID. Descriptive statistics were calculated. Associations between sociodemographic factors and attitudes related to MAID were analyzed utilizing logistic regression.
Of 1,337 invited members, 225 (17%) responded. Median age was 46. Most were female (58%), white (81%), and in academic practice (64%). Over 50% had heard the term MAID and have had a patient ask about it. Few (20%) reported living in a state where MAID is legal and 61% of these respondents provided MAID. Sixty percent lived in a state that had not legalized MAID and 18% did not know if MAID was legal in their state. 36% of respondents living in a state where MAID was illegal/unknown legality indicated they would provide MAID if it were legal in their state, 30% would not, and 34% were uncertain. The majority (69%) of respondents believed MAID should be legal. Female respondents were more likely to support legalization of MAID (OR 2.44, p=<0.05). Respondents practicing in the southern U.S. were less likely to support legalization of MAID (OR 0.42, p=<0.05). Over 75% of respondents stated an SGO position statement on MAID would be helpful.
MAID is a highly relevant topic for gynecologic oncologists. Gaps in MAID-related knowledge exist among SGO members and there is a desire for additional education and guidance regarding MAID.
An abstract of a study by Podgurski et al demonstrating the feasibility and acceptability of a communication skills training workshop for gynecologic oncology (GO) providers and evaluating the impact ...of the training on perceived preparedness to address communication challenges and anticipated impact on clinical practice is presented. Participants showed statistically-significant increase in perceived preparedness for 13 out of 14 challenging communication scenarios described in the pre-post questionnaire. Among those 13 topics, magnitude of improvement in proportion rating preparedness 4 or 5 out of 5 ranged from 0.4 to 1 (all p<0.05). All participants recommend the course to others and all strongly agreed that this training should be required of all GO clinicians.
Palliative Care in Obstetrics and Gynecology Lefkowits, Carolyn; Solomon, Caroline
Obstetrics and gynecology (New York. 1953),
2016-December, 2016-12-00, 20161201, Volume:
128, Issue:
6
Journal Article
Peer reviewed
Palliative care is specialized care for people with life-limiting illness; it focuses on symptom management and quality of life and ensures that a patientʼs care is concordant with her goals and ...values. Unlike end-of-life care, palliative care can be offered concurrently with disease-directed therapies, including when the goal is cure. Obstetrics and gynecology patients for whom palliative care is most appropriate include women with gynecologic cancer and women with a fetus or neonate with a potentially life-limiting illness. Integration of palliative care for these patients offers both clinical and health care utilization benefits, including improved symptom management, improved quality of life, and high-value care. Palliative care can be provided by palliative care specialists (specialty palliative care) or by the team treating the life-limiting illness (primary palliative care), depending on the complexity of the need. Health care providers caring for patients with life-limiting illness, including obstetrician–gynecologists, must possess a basic primary palliative care skill set, including symptom management for common symptoms such as pain and nausea and communication skills such as breaking bad news. This skill set must be taught and evaluated during training and used consistently in practice to ensure that our patients receive truly comprehensive care.
•In a cohort of patients with borderline ovarian tumor (BOT), rate of uterine involvement was 6.0%.•In patients with BOT grossly confined to ovaries, rate of uterine involvement was 0%.•Hysterectomy ...may be able to be safely excluded from non-fertility-sparing BOT surgery.
Forgoing hysterectomy as part of borderline ovarian tumor (BOT) staging is considered appropriate for fertility preservation. We evaluated whether forgoing hysterectomy may also be acceptable in non-fertility-sparing surgery by evaluating the frequency of uterine involvement and the rate of recurrence involving the uterus. A review of all BOTs at one institution over ten years (2009–2019) was performed. Patients with hysterectomy prior to BOT diagnosis were excluded. Data were abstracted from electronic medical records. Bivariate statistics were used to compare groups.
129 patients with BOT on final pathology were identified. 67 cases included hysterectomy. Reasons for no hysterectomy (n = 62) included fertility preservation (40), benign intraoperative frozen pathology (4), patient preference (3), comorbidities (7), and unknown (8). Four of 67 (6.0%) uterine specimens had non-invasive serosal implants, of which two had grossly visible uterine involvement and all four had grossly visible extrauterine peritoneal disease. 12 of 129 (9.3%) patients had documented recurrence, of which all had uterine preservation at the time of initial surgery. Of the 12 recurrences with uterus in situ, none were documented to involve the uterus, and all were composed of non-invasive implants. In patients with BOT grossly confined to ovaries at the time of surgery, we found no cases of uterine involvement. We found no cases in which microscopic uterine serosal involvement changed stage and no cases of recurrence involving the uterus. Hysterectomy may be able to be safely excluded from non-fertility-sparing surgery for BOTs, particularly when disease is grossly confined to the ovaries.
In gynecologic oncology (GO) fellowship, devoting sufficient time to learning communication skills can be challenging due to required time and logistics. A two day workshop was previously piloted at ...a single institution with GOs and found to be beneficial. We sought to implement that curriculum in a condensed form. We conducted two four-hour sessions with 4 GO fellows at a single institution over 4 months. Sessions consisted of a didactic in communication skills led by faculty with VitalTalk™ training, followed by application with a simulated patient. Cases were developed and previously used in a two-day workshop at another institution. Fellows were surveyed prior to both sessions and after the second session. Perceived confidence was assessed on a Likert scale (1 to 5). An improvement was defined by an increase of ≥1 in Likert score. All fellows reported that the educational quality of the sessions was “excellent,” that the time in between sessions was “just right,” allowing them to apply skills learned in the first session prior to the second. After both sessions, at least three of the four fellows reported an improvement in confidence in nearly 50% (10/21) of the communication topics assessed. GO fellows perceived improvements in communication skills with condensed half-day training seminars.
•A condensed communication skills workshop was conducted with four gynecologic oncology (GO) fellows.•At least 75% of the fellows reported an improvement in confidence in nearly half of the communication topics.•GO fellows perceived improvements in communication skills with half-day training seminars.
PDF
