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Objective: Enhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019), and Society of Gynecologic Oncology of Canada (GOC) education events., Methods: A survey was created and developed through the GOC Communities of Practice ERAS section and distributed to all members between March and November 2021. The results of this survey were compared with the survey performed in 2015 RESULTS: The initial GOC survey in 2015 included 77/92 active gynecologic oncologists (84%) representing all provinces in Canada. The current updated survey had responses from 59/118 active gynecologic oncologists (51%) also from every province. Compared with the original survey there was a statistically significant improvement in uptake of 10 ERAS recommendations: smoking/alcohol cessation, modern fasting guidelines (allowance of clear fluids and solid food pre-operatively), carbohydrate loading, pre-operative warming, early feeding, post-operative laxative use, avoidance of nasogastric tubes and abdominal drains, foley catheter removal at 6 hours, and active mobilization (all p<0.003). Only two fields (stopping oral contraceptive medications pre-operatively and foley catheter removal post-operative day 1) showed worsening uptake across the two surveys (p<0.01). The ERAS recommendations that did not change in the examined time frame included routine use of mechanical bowel preparation, venous thromboembolism prophylaxis, pre-operative antibiotics, and additional antibiotic dosing for prolonged surgery., Conclusions: This survey demonstrates increased uptake of 10 of the ERAS guideline recommendations among Canadian gynecologic oncology providers. These findings may translate to improvements in clinical outcomes and healthcare system-level benefits including increased hospital capacity and cost savings., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Our study aimed to analyze recurrence and survival outcomes in stage II endometrial cancer patients treated with adjuvant radiotherapy at CancerCare Manitoba, a Canadian provincial cancer program., Methods: This retrospective population-based cohort study identified all International Federation of Gynecology and Obstetrics (FIGO) 2009 stage II endometrioid type endometrial carcinoma diagnosed between January 1995 and December 2019. All patients underwent surgery followed by vaginal vault brachytherapy alone or external beam pelvic radiotherapy plus vaginal vault brachytherapy. We used Kaplan-Meier curves to describe overall survival and recurrence-free survival, and cumulative incidence to describe recurrence. Cox regression was used to predict overall survival and recurrence-free survival competing risk regression to predict recurrence., Results: A total of 121 patients were included (78 vaginal brachytherapy alone and 43 external beam pelvic radiotherapy plus vaginal brachytherapy) with a median age of 62 (range 24-85). The median follow-up was 55.2 months (range 7.1-147.9) in the vaginal brachytherapy group and 41.9 months (range 7.4-127.0) in the pelvic radiotherapy group. Lymph node dissection was performed in 79 (65.3%) patients. There were 14 (17.9%) recurrences (8 vaginal vault, 3 pelvic, 3 distant) with vaginal brachytherapy and 7 (16.3%) recurrences (3 vaginal vault, 2 pelvic, 2 distant) with external beam pelvic radiotherapy. The 5 year overall survival was 73.1% with vaginal vault brachytherapy vs 73.7% with external beam pelvic radiotherapy plus vaginal brachytherapy (p=0.31), the 5 year recurrence-free survival was 65.0% vs 68.2% (p=0.61), and the 5 year recurrence risk was 20.3% vs 19.4% (p=0.94). On univariable and multivariable analysis, only age was a statistically significant predictor for overall survival and recurrence-free survival (p<0.05), but not lymphovascular space invasion (HR, 2.97; 95% CI, 0.99 to 8.93 for overall survival, p=0.15). The type of adjuvant radiotherapy did not predict for recurrence (p=0.94)., Conclusions: There was no significant difference in overall survival, recurrence-free survival, and recurrence risk between vaginal vault brachytherapy vs external beam pelvic radiotherapy plus vaginal vault brachytherapy in patients with stage II endometrial cancer., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aim of this study was to review the treatment and outcomes of low-risk gestational trophoblastic neoplasia (GTN) in Manitoba over more than 3 decades, with a focus on those treated with alternating methotrexate and dactinomycin, a protocol that has only rarely been described., Materials and Methods: We retrospectively reviewed all patients with GTN referred to CancerCare Manitoba from January 1977 to December 2012. Cases were classified as low risk as per the modified WHO-FIGO prognostic scoring system (score, ≤6). Demographic, treatment, and outcomes data were abstracted, and descriptive statistics and time-to-event analysis were performed. The low-risk protocol used at CancerCare Manitoba consists of alternating single-agent use of methotrexate and dactinomycin, each for 5 days, on a 14-day cycle., Results: Sixty-seven cases of GTN were identified, of which 52 were low risk. Thirty-nine patients were initiated on alternating methotrexate and dactinomycin. Thirty-four (87.2%) achieved primary cure on this regimen, with a median of 4.4 cycles administered (range, 2-7). Median time to response was 56 days. One patient achieved cure after receiving a repeat course of methotrexate as their final cycle. Second-line multiagent chemotherapy was required by 4 patients. Two patients experienced grade 3 toxicities, and none greater than grade 3. There were no recurrences., Conclusions: Alternating methotrexate and dactinomycin is an effective treatment protocol for low-risk GTN, with high rates of primary cure and acceptable toxicity.

Objective: The primary objectives of this study were to analyze data on time to diagnosis and correlate this with overall survival. We secondarily analyzed the effects of emergency room visits, symptoms, incidental findings, residence, socioeconomic status, and residual disease on overall survival., Methods: This retrospective population-based descriptive cohort study examined all invasive ovarian cancer cases in Manitoba, Canada, between 2004 and 2010. Clinicopathologic, socioeconomic, and outcome data were collected. Analysis was performed with Cox and logistic regression stratified by early and late stage., Results: Six hundred eighty-seven ovarian cancer patients were identified, with a final cohort of 601 patients: 210 with early-stage (1/2) and 391 with late-stage (3/4) disease. No presenting symptoms were associated with survival outcome. Poorer survival was associated with increasing age (P = 0.0016) and neoadjuvant chemotherapy (P = 0.0037). Higher income within the urban setting was also associated with a survival advantage (P = 0.0037), whereas initial presentation to the emergency room (P = 0.0399) was associated with decreased survival. Finally, for advanced-stage disease, incidental diagnosis had a significantly improved overall survival (hazard ratio, 0.424; 95% confidence interval, 0.27-0.67; P = 0.0003), even when accounting for confounding factors. Time from first presentation to diagnosis was associated with survival (P = 0.0309)., Conclusions: This study found that time to diagnosis did not negatively impact overall survival, although there was an association. Age, morphology, treatment type, residual disease, medical comorbidities, and income were significant prognostic factors. This is the first study to show a survival advantage to incidentally finding an ovarian cancer. Further research is needed on the outcomes of pelvic examination.

Objective: The aim of this study was to evaluate clinicopathologic characteristics, treatment outcome, and reproductive function in women diagnosed with ovarian immature teratoma (IT). Our standard chemotherapy regime is currently etoposide/cisplatin (EP), creating a unique opportunity to evaluate this protocol in ovarian ITs., Materials and Methods: This study is a retrospective analysis. Twenty-seven women older than 18 years with ovarian IT stages IA to IIIC were identified and included in this study. Patients were treated at 1 institution, Health Sciences Center, Women's Hospital, Winnipeg, Manitoba, Canada, between 1983 and 2013., Results: The median age at diagnosis was 27.0 years (range, 18-36 years). Twenty-two (82%) presented with an International Federation of Gynecology and Obstetrics stage I disease, 3 (11%) had stage II, and 2 patients (7%) had stage III disease. The histologic grade distribution was grade I in 9 patients (33%), grade II in 3 patients (11%), and grade III in 15 patients (56%). Initial management was surgical for all patients: 3 (11%) hysterectomy and bilateral salpingo-oophorectomy, 1 (4%) cystectomy only, and 23 (85%) unilateral salpingo-oophorectomy. Twenty-one patients (78%) received adjuvant therapy. The median follow-up was 60 months (range, 36-72 months). One patient recurred (histological grade III) 6 months after surgery and had a complete clinical response to 4 cycles of EP chemotherapy. Twelve patients reported an attempt to conceive resulting in 10 pregnancies (8 after chemotherapy)., Conclusions: Ovarian IT is a curable disease. Fertility-sparing surgery should be offered. Adjuvant treatment with cisplatinum-based chemotherapy, typically with bleomycin, etoposide, and cisplatin, is still considered the standard in stages greater than stage IA grade I. Etoposide/cisplatin as a primary chemotherapy regime for early- or advanced-stage disease is an effective treatment with minimal adverse effects and high tolerability. This is the first published study examining EP as a primary treatment modality for IT. Further studies are needed to strengthen these findings.

Objectives: The objective of this study was to examine the overall and recurrence-free survival in patients with advanced ovarian cancer based on hemoglobin and blood transfusions., Methods: A retrospective chart review was performed between 2003 and 2007 on patients with pathologically confirmed stage 3-4 ovarian, fallopian, or peritoneal cancers. Data were collected on date of diagnosis, recurrence and death, stage, grade, age, surgery, estimated blood loss, hemoglobin (nadir and average levels), and number of blood transfusions., Results: Two hundred sixteen patients were included in the final analysis. In the perichemotherapy, perioperative, and total time frames, 88%, 81%, and 95% of patients were anemic, and 9%, 22%, and 26% of the patients had severe anemia. After adjusting for age, stage, and optimal debulking status, the perichemotherapy hemoglobin level as a continuous variable was weakly associated with recurrence-free survival (adjusted hazard ratio [AHR], 0.98; P = 0.03), and as a categorical variable with both recurrence-free survival (AHR, 2.49; P = 0.003) and overall survival (AHR, 1.91; P = 0.02). The total number of transfusions was also weakly associated with poor recurrence-free survival (AHR, 1.06; P = 0.03)., Conclusions: Our study is a retrospective analysis of the effects of anemia and transfusion on ovarian cancer. The rates of anemia in chemotherapy patients are higher than previously reported. Although maintaining average hemoglobin greater than 80 g/L during chemotherapy portends an improved overall survival, blood transfusion does not have any effect. The role of transfusion should therefore be limited to symptomatic patients while giving 1 unit at a time. Further prospective studies will be needed to confirm these results.

Objectives: Uterine sarcomas are a rare group of mesenchymal tumors with a poor prognosis and aggressive biology. Standard treatment involves surgical staging. The role of further adjuvant treatment is unclear. The goals of this study were to determine the response rates to treatment of patients with uterine sarcomas and to review the currently available literature on the use of aromatase inhibitors (AIs)., Materials and Methods: We performed a retrospective analysis on all patients with uterine sarcoma treated with an AI between 2000 and 2010 at the Tom Baker Cancer Centre in Calgary, Alberta., Results: Four patients with endometrial stromal sarcoma and 3 patients with leiomyosarcoma received treatment with an AI. A literature search resulted in 10 case reports and 4 retrospective studies of patients with endometrial stromal sarcoma and 1 case report and 2 retrospective studies of patients with leiomyosarcoma. On the basis of the available literature, combined with the current findings, the overall response rate of endometrial stromal sarcoma to AIs is 67% (complete response of 7% and partial response of 60%), and the partial response rate of leiomyosarcoma to AIs is 11%, with no reported complete responses., Conclusions: Aromatase inhibitors are a well-tolerated class of medications that are effective in the treatment of endometrial stromal sarcomas. These medications may also have a role to help stabilize disease progression in the treatment of leiomyosarcoma. More large, prospective, multicentered trials will be needed to clarify this issue.