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To determine whether Black race is associated with treatment and survival among women with low-risk endometrial cancer. Black and White women with Stage IA grade 1–2 endometrioid endometrial carcinoma diagnosed from 2010 to 2016 in the SEER 18 dataset were identified (n = 23,431), and clinical and socioeconomic attributes obtained. Five-year cancer-specific survival (CSS) and relative survival (RS) were calculated using SEER*Stat 8.3.9. Cox proportional hazards model was used to determine predictors of overall survival (OS) and CSS. There was a significantly higher proportion of Black women who did not have surgery compared to White women (3% vs 1%, respectively; p < 0.0001). Residing in the South, being insured with Medicaid, and residing in a county with low median income were also associated with non-receipt of surgery. Black women remained less likely to undergo hysterectomy on multivariable analysis (OR 0.44, 95% CI 0.32–0.60). Non-receipt of hysterectomy was predictive of decreased CSS (HR 0.14, 95% CI 0.09–0.21) and OS (HR 0.18, 95% 0.14–0.23) on adjusted analysis. Black race was also an independent predictor of increased cancer-specific death (HR 2.07, 95% CI 1.50–2.86) as well as death from any cause (HR 1.74, 95% CI 1.44–2.09) on adjusted analysis. Black women with low-risk endometrial cancer were less likely to undergo hysterectomy and experienced decreased survival relative to White women. Further investigation is warranted to better understand the socioeconomic, geographic, and biologic factors that influence this disparity. • Black race, low socioeconomic status, and residing in the South were associated with non-receipt of cancer-directed surgery. • Five-year cancer-specific and relative survival were lower for Black women compared to White women. • Black race and receipt of hysterectomy were independent predictors of decreased cancer-specific and overall survival. [ABSTRACT FROM AUTHOR]

Clostridium difficile infection (CDI) is a major cause of nosocomial diarrhea with the potential for significant morbidity and mortality. Colonization in a susceptible individual, with risk factors such as prior antibiotic use, advanced age, or medical comorbidities, may result in symptomatic infection. Although patients with a gynecologic malignancy may be at a higher risk of developing CDI due to an increased likelihood of having one or more risk factors, data do not consistently support the idea that chemotherapy or cancer itself are independently associated with CDI. For diagnosis of CDI, we recommended using a multi-step approach, with a highly sensitive initial rapid test such as the enzyme immunoassay (EIA) for glutamate dehydrogenase (GDH) or nucleic acid amplification testing (NAAT), followed by confirmatory testing with of the above two tests or EIA toxin A/B, which has high specificity. Treatment varies based on the severity of disease. We recommend vancomycin as first-line therapy for an initial episode of mild/moderate or severe CDI, with consideration of fidaxomicin for patients at particularly high risk for recurrence. Rectal vancomycin may play an adjunctive role for some severe cases, while surgical intervention is indicated for fulminant CDI if no improvement six or more days after initiating medical therapy. For non-severe recurrent disease, the initial treatment regimen should be repeated, while subsequent episodes are more appropriately treated with a tapered and pulsed dose of vancomycin, fidaxomicin, or fecal microbiota transplantation. [ABSTRACT FROM AUTHOR]

To determine whether Black race is associated with treatment and outcomes among a favorable cohort with low-risk endometrial cancer. All Black and White women with Stage IA grade 1-2 endometrioid endometrial carcinoma diagnosed from 2010 to 2016 in the SEER 18 dataset were identified (n=23431), and clinical and socioeconomic attributes obtained. Five-year cancer-specific survival (CSS) and relative survival (RS) were calculated using SEER*Stat 8.3.8. Statistical analyses were performed with independent t-test, Chi-Square test, and Cox proportional hazard regression. Although the majority of patients underwent surgery, there was a significantly higher proportion of Black women who did not have surgery compared to White women (1% vs 3%, respectively; p<0.0001). Reasons for having not undergone surgery were similar between the two groups: not recommended, Blacks 74% vs Whites 75%; medically contraindicated, Blacks 16% vs Whites 9%; patient refusal, Blacks 16% vs Whites 10%; p=0.293. Black women were overrepresented in groups where more women did not undergo hysterectomy: women residing in the South (2.1% vs 1.3%, p=0.002) and those with Medicaid (3.4%) or no insurance (2.1%) compared to those with private insurance or Medicare (1.3%, p<0.0001). However, Black women remained less likely to undergo hysterectomy after adjusting for age, ethnicity, geography, grade, insurance status, and socioeconomic status (OR 0.379, p<0.0001). Five-year CSS was favorable in both groups, though significantly lower among Black women (CSS 95.0%, 95% CI 93.2-96.4%) compared to White women (CSS 97.8%, 95% CI 97.5-98.1%). A similar trend was noted for 5-year RS, with 95.4% for Black women (95% CI 92.2%-97.3%) versus 100% for White women. Black race was an independent predictor of increased cancer-specific death (HR 1.76, 95% CI 1.46-2.12) as well as all-cause mortality (HR 2.14, 95% CI 1.54-2.98) on adjusted analysis. We found that, even in a good prognostic group, Black women are less likely to undergo hysterectomy and have an increased risk of death among women with low-risk endometrial cancer. This bolsters prior work demonstrating that the association of race and poor outcomes is not only due to higher grade, more aggressive histologic type, and more advanced stage at diagnosis. [ABSTRACT FROM AUTHOR]

Patients may use crowdfunding to solicit donations, typically from multiple small donors using internet-based means, to offset the financial toxicity of cancer care. To describe crowdfunding campaigns by gynecologic cancer patients and to compare campaign characteristics and needs expressed between patients with cervical, uterine, and ovarian cancer. We queried the public crowdfunding forum GoFundMe.com for "cervical cancer," "uterine cancer," and "ovarian cancer." The first 200 consecutive posts for each cancer type fundraising within the United States were analyzed. Data on campaign goals and needs expressed were manually extracted. Descriptive statistics and bivariate analyses were performed. Among the 600 fundraising pages, the median campaign goal was $10,000 [IQR $5000–$23,000]. Campaigns raised a median of 28.6% of their goal with only 8.7% of campaigns reaching their goal after a median of 54 days online. On average, ovarian cancer campaigns had higher monetary goals, more donors, and larger donation amounts than cervical cancer campaigns and raised more money than both cervical and uterine cancer campaigns. Campaigns were fundraising to support medical costs (80–85%) followed by lost wages (36–56%) or living expenses (27–41%). Cervical cancer campaigns reported need for non-medical costs more frequently than uterine or ovarian cancer campaigns. States without Medicaid expansions (31% of the national population) were over-represented among cervical cancer and uterine cancer, but not ovarian cancer campaigns. Crowdfunding pages reveal patients fundraising for out-of-pocket costs in the thousands of dollars and a wide range of unmet financial needs based on cancer type. • Patients crowdfunding for gynecologic cancer care had a median campaign goal of $10,000 and raised a median of $2800. • Campaigns raised a median of 28.6% of their goal. After a median of 54 days online, only 8.7% had reached their goal. • 82% of campaigns fundraised for medical expenses, while 32% fundraised for non-medical living expenses. • 32% of campaigns fundraised to offset lost wages, which was more common among cervical cancer campaigns. • States without an implemented Medicaid expansion were over-represented among cervical and uterine cancer campaigns. [ABSTRACT FROM AUTHOR]

To identify correlations between disease recurrence and adherence to NCCN posttreatment surveillance guidelines in patients who develop recurrent uterine cancer. Retrospective analysis identified patients (n = 60) with recurrent uterine cancer and at least one surveillance visit with a gynecologic oncologist between 2011 and 2020. Adherence to NCCN guidelines and details of recurrence were recorded. Recurrent uterine cancer was identified in 60 patients with an average time to recurrence (TTR) of 25 months. Of those, 39 (65%) were adherent to NCCN surveillance guidelines and 36 (60%) were symptomatic at the time of recurrence diagnosis. Asymptomatic recurrence was diagnosed by imaging in 11 (46%), physical exam in 7 (29%), and blood work in 6 (25%) patients. Patients who were adherent to NCCN guidelines were diagnosed with recurrence on average 11 months earlier (p = 0.0336). Adherence was an independent predictor of TTR for all patients regardless of symptoms. There was no significant effect of age, race, primary language, or stage of disease on adherence. Adherence to NCCN posttreatment surveillance guidelines for uterine cancer is independently associated with an earlier diagnosis of recurrence. • Many patients are not adherent to NCCN surveillance guidelines at time of recurrence detection. • Physical exam is an important for detecting uterine cancer recurrence. • Non-NCCN directed imaging detected almost half of asymptomatic recurrences. • Asymptomatic recurrence is detected earlier in patients who adhere to NCCN posttreatment surveillance guidelines. [ABSTRACT FROM AUTHOR]

Objectives: Endometrial cancer due to loss of mismatch repair proteins may be caused by epigenetic or genetic factors. Complete profiling is not routinely performed in clinical practice. We sought to explore outcomes of women with mismatch repair deficiency (MMRd) due to epigenetic MLH-1 promoter hypermethylation (MMRd-MLH). We hypothesize that MMRd-MLH correlates with worse clinical outcomes in endometrial cancer. Methods: Under an IRB protocol, we retrospectively identified patients with endometrioid endometrial adenocarcinoma undergoing hysterectomy at our institution from 2016-2020. These patients underwent routine immunohistochemical testing for MMRd, with subsequent genetic testing or methylation studies for loss of MMR proteins. We examined patient data in three cohorts: MMR proficient (MMRp), MMRd-MLH, and MMRd deficiency due to germline mutation (MMRd-G). We excluded patients who did not undergo MMR testing and those who were MMR deficient due to other causes. We examined clinical data via univariate and multivariate tests and Kaplan-Meier survival analyses. Results: We identified 327 patients who met the criteria for review. The majority (243, 74%) were MMRp, 74 (23%) were MMRd-MLH, and ten (3%) were MMRd-G. On univariate analysis, we observed no differences in the history of post-menopausal hormone replacement therapy, family history of cancer, personal history of hypertension or diabetes mellitus, or body mass index. We found that when compared to the other two groups, MMRd-MLH patients were more like to have grade 2-3 tumors (p < 0.01) and LVSI (p < 0.001). We identified statistically significant associations between age at surgery (60, 67, and 60 years, respectively) and depth of invasion (0.41cm, 0.67cm, and 0.18cm). We did not observe significant differences in the stage. We identified that MMRd-MLH was associated with pathologic high-intermediate risk factors leading to increased adjuvant therapy in stage I disease (p=0.04). We observed a 4.1% recurrence rate in MMRp compared to 8.1% in the MMRd-MLH group compared to no recurrences in MMRd-G (p = NS). When comparing MMRp and MMRd-MLH in Kaplan-Meier analyses, we observed a statistical difference in disease-free survival favoring those who were MMRp (p = 0.02). Median survival was not reached. There were no significant differences in overall survival between MMRp and MMRd-MLH. We did not identify independent prognostic factors for recurrence when controlling for age, stage, grade, or MMR status. [Display omitted] Conclusions: MMRd-MLH is associated with LVSI, higher grade, deeper tumor invasion, and a significantly higher rate of adjuvant therapy. We observed patients with MMRd-MLH were more likely to recur despite adjuvant therapy. MMRd-MLH may represent a poor prognostic factor and a target for further adjuvant therapy. [ABSTRACT FROM AUTHOR]

Objectives: Surveillance follow-up for women with vaginal and vulvar cancer, extrapolated by National Comprehensive Cancer Network (NCCN), includes a physical exam every 3-6 months during the first two years, followed by every 6-12 months for three to five years after treatment. For VAIN, general recommendations for follow-up suggest a physical exam every six months for the first two years and yearly after. For VIN, physical exams every six months for the first five years are recommended. Little is known regarding rates of retention for follow-up in these rare cancers and dysplasia. We sought to explore post-treatment retention for patients with vaginal and vulvar cancer and dysplasia at our institution. Methods: After IRB approval, we retrospectively identified patients treated for vaginal and/or vulvar intraepithelial neoplasia or carcinoma between 2011-2016. Baseline demographic, pathologic, treatment, surveillance, and recurrence data were collected. We examined the continuous and total retention of post-treatment surveillance visits for patients diagnosed with cancer VIN, VAIN, or concomitant VIN and VAIN. Continuous retention was defined as sequential visits no longer than one year apart. Descriptive statistics were used to analyze the data. Results: We identified 40 patients who met the criteria for review. The median age of treatment was 60 years old. Most patients were White (75%), followed by Asian (10%), Black (5%), other (8%), and American Indian (3%). The most common diagnoses were VIN III (25%), VAIN III (22%), and squamous cell carcinoma (22%). Most were treated with wide local excision (42.5%), followed by radical surgery (30%), and laser surgery (15%). The median times for total and continuous post-treatment retention were 27.5 and 21 months, respectively. The median number of visits and pap smears in the first post-treatment year were 2 and 1, respectively. The median number of visits and pap smears in the second post-treatment year were 1 and 1, respectively. Only 29% of patients continued with surveillance in the third post-treatment year. Recurrence was noted in ten patients (25%) with a median time of recurrence of 29 months with a range of 1-69 months. The most common primary diagnoses associated with recurrence were VIN III (40%), VAIN III (20%), VIN II (20%), and squamous cell carcinoma (20%). Conclusions: This is the first baseline assessment of post-treatment surveillance retention for VAIN, VIN, or vulvovaginal carcinoma. We observed that our population generally adheres to NCCN surveillance guidelines during the first year; however, the adherence drops in the following years with a median continuous retention rate of less than two years. Further work is needed to enhance post-treatment surveillance and identify barriers to follow-up for patients. [ABSTRACT FROM AUTHOR]

Mutations in BRCA1 and BRCA2 increase the risk of epithelial ovarian cancer (EOC). Emerging evidence suggests obesity may influence BRCA tumor biology; body mass index (BMI) appears to correlate with DNA damage in breast epithelium in BRCA women. We hypothesized that obesity negatively influences tumor biology in BRCA women with EOC, and sought to identify correlations with BMI and clinical outcomes in this population. We performed an IRB approved retrospective study. We identified patients with BRCA -associated EOC diagnosed between 1990-2015. All women underwent surgical resection with platinum-based chemotherapy. We abstracted clinical and pathologic data, and calculated BMI at the time of diagnosis. Obesity was examined per WHO criteria of normal weight, overweight, class I obesity, and class II obesity. We performed descriptive statistics with Kaplan-Meier, Cox Proportional Hazards Regression, and univariate analyses. We identified 179 women meeting criteria. Most were BRCA1 (125, or 70%); 53 (30%) were BRCA2 ; and 1 had both a BRCA1 and BRCA2 mutation. The majority had stage III/IV disease (137, 77%) and grade 3 serous histology (168, 94%); 150 patients underwent optimal cytoreduction (87%). BMI was distributed throughout the WHO strata: 101 women had normal weight; 46 were overweight; 20 had class I obesity; 12 had class II obesity. Age, medical comorbidities, and rates of optimal surgical cytoreduction were similar among these groups. In a subcohort of patients with stage III/IV disease, we identified a significant trend between increased BMI strata and poor disease-free survival (35, 32, 25, and 13.5 months, p =0.003). This was also observed for overall disease-specific survival (132, 144, 112, and 72.5 months, p =0.0306). Multivariable analyses of the entire cohort confirmed that age (p =0.035), stage (p <0.001), and BMI (p =0.017) remained significant independent prognosticators after controlling for grade and optimal cytoreduction. [Display omitted] We identified a significant and independent association between BMI and clinical outcome in BRCA positive women with EOC. Factors associated with obesity may negatively influence BRCA associated ovarian cancer biology, and suggest this may be a modifiable risk factor to target for therapy. [ABSTRACT FROM AUTHOR]