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Background: High-risk human papillomavirus (HR-HPV) infection is a risk factor for anal cancer, yet no anal cancer screening guidelines exist for women with lower genital tract HPV-related disease. We sought to describe the prevalence of anal HR-HPV or cytologic abnormalities in such women. Methods: This cross-sectional study was performed between October 2018 and December 2021. Inclusion criteria were =21 years of age and a prior diagnosis of high-grade dysplasia/cancer of the cervix, vagina, or vulva. Participants underwent anal cytology and anal/cervicovaginal HR-HPV testing. Women with abnormal anal cytology were referred for high-resolution anoscopy (HRA). Results: 324 evaluable women were enrolled. Primary diagnosis was high-grade dysplasia/cancer of the cervix (77%), vagina (9%), and vulva (14%). Anal HR-HPV was detected in 92 patients (28%) and included HPV-16 in 24 (26%), HPV-18 in 6 (7%), and other HR-HPV types in 72 (78%) patients. Anal cytology was abnormal in 70 patients (23%) and included atypical squamous cells of undetermined significance (80%), low-grade squamous intraepithelial lesion (9%), high-grade intraepithelial lesion (HSIL; 1%), and atypical squamous cells-cannot rule out HSIL (10%). Of these patients, 55 (79%) underwent HRA. Anal biopsies were performed in 14 patients: 2 patients had anal intraepithelial neoplasia (AIN) 2/3, 1 patient had AIN 1, and 11 patients had negative biopsies. Both patients with AIN 2/3 had a history of cervical dysplasia. Conclusions: Our results suggest an elevated risk of anal HR-HPV infection and cytologic abnormalities in women with lower genital tract dysplasia/cancer. Impact: These results add to the growing body of evidence suggesting the need for evaluation of screening methods for anal dysplasia/cancer in this patient population to inform evidence-based screening recommendations. [ABSTRACT FROM AUTHOR]

Background: The mortality index is a quality metric that measures the ratio of observed mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on documentation of patient risks and comorbidities. A mortality index of <1.0 represents fewer patients dying while admitted to the hospital than expected. We aimed to decrease the mortality index in our department by 10% in 6 months. Methods: We formed a multidisciplinary team from Gynecologic Oncology, Health Information Management, Office of Performance Improvement, Revenue Operations, Coding and Institutional Compliance. We educated providers on documentation of patient comorbidities, standardized documentation templates, focused coder analysis and in-depth review and discussion as a department of all inpatient deaths. Pre-intervention 8/2017-7/2018 and post-intervention 11/2018-2/2020 outcomes were compared using the Mann Whitney U test. Results: The median mortality index decreased by 44% from 0.84 to 0.47 (p = 0.03). The median expected mortality increased by 37% from 2.94 to 4.02 (p = 0.002). The median number of inpatient deaths, or observed mortalities, was unchanged though there was a non-significant decreasing trend. Conclusions: Inpatient mortality index is an important quality metric that can be improved through education, standardized documentation, focused review and discussion of all inpatient mortalities. [ABSTRACT FROM AUTHOR]

The article offers information on improving the prevalence of human immunodeficiency virus (HIV) Testing Among Patients in a Gynecologic Oncology Department. It mentions that patients with HIV infection have a higher risk of developing cancers, including both Acquired immunodeficiency syndrome (AIDS)-defining malignancies and non–AIDS-defining malignancies; and also mentions the aims of the study were to increase the rate of HIV testing from a baseline rate of 3 up to 50 percent in 1 year.

Objective: The objective of this article was to develop and validate a scale that assesses the readiness of gynecologic oncology patients to engage in advance care planning. Methods: The Advance Care Planning Readiness Scale (ACPRS) was validated across 3 independent samples of gynecologic oncology patients. In step I, patients underwent cognitive interviewing to determine if the scale items were comprehensible and applicable to patients. Based on this, modifications to the scale (addition, removal, and merger of items) were completed. In step II, the revised scale was administered to a new sample of patients to assess scale reliability and validity. An exploratory factor analysis determined if the scale loaded onto unique factors. In step III, the revised scale was administered to a third sample of patients, and a confirmatory factor analysis was conducted to test the factor structure proposed in step II. Associations between ACPRS score and completion of advance directives were evaluated. Results: Based on patients' responses, the original ACPRS used in step I was modified to the ACPRS used in step II. The final 8-item ACPRS is a valid, reliable (Cronbach α = 0.81) scale and has 2 primary factors. Women with medical power of attorney documents and living wills had higher ACPRS total scores than those who did not have these advance directives (P = 0.0030). Women with do-not-resuscitate (DNR) orders had higher ACPRS total scores than women without DNRs (P = 0.0176). Conclusions: The ACPRS is a valid and reliable 8-item scale that assesses the readiness of gynecologic oncology patients to discuss advance care planning issues. [ABSTRACT FROM AUTHOR]

Objectives: Perioperative hyperglycemia is associated with adverse postoperative outcomes. Lack of standardization leads to inconsistent detection and management of patients with diabetes during the perioperative period. Our objective was to improve perioperative glycemic control among patients with Type II diabetes mellitus undergoing open gynecologic surgery through a quality improvement initiative. Methods: We assembled a multidisciplinary team and implemented standardized screening guidelines, including obtaining a preoperative hemoglobin A1C in all patients before surgery. Algorithms were developed for patients with diabetes, and those at high risk were referred to Endocrinology to optimize glucose control in the preoperative period. We also standardized the intraoperative and postoperative management by increasing the frequency of intraoperative glucose monitoring and developing weight-based postoperative insulin order sets with basal, prandial, and correctional insulin. Outcomes were compared between a baseline (BL) group (February 2015-August 2017) and a post-implementation (PI) group (February 2018-April 2021). Summary statistics were used to describe the clinical and demographic characteristics. BL and PI groups were compared using the Chi-square test, Fisher's exact test, t-test, or Wilcoxon rank-sum test. A linear mixed effect model was constructed based on hours since initial preop measurement, time period measurement took place, and group (BL vs PI). Results: There were 81 patients in the BL group and 119 in the PI group. The BL and PI groups were similar in age, race, and indication for surgery (benign vs malignant). The PI group had lower median BMI (PI 32.7kg/m2 vs BL 35.3mg/m2; p=0.02), higher median Charlson Comorbidity Index (PI 4 vs BL 3; p=0.004), and surgical time (PI 258 minutes vs BL 197 minutes; p=0.009). The rate of obtaining a hemoglobin A1c prior to surgery increased from BL 14.8% to PI 89.0% (p<0.001). The rate of intraoperative glucose monitoring also increased from BL 50.6% to PI 76.5% (p<0.001). The linear mixed-effects model found PI estimated average glucose values decreased by 8.13mg/dL compared to BL levels (p=0.046). The percentage of postoperative glucose values that were at goal (<180mg/ dL) improved from BL 83% to PI 86% (p=0.008). There were no episodes of hypoglycemia or other safety events associated with the postoperative insulin order sets. Conclusions: The SUGAR initiative successfully increased compliance with preoperative screening for diabetes as well as improved perioperative monitoring and management of hyperglycemia. The impact of this initiative on glycemic control is evident not only by the improvement in average glucose values across all time periods but also by the percentage of glucose values that are at goal. This protocol safely improved perioperative glycemic control among patients with diabetes undergoing open gynecologic surgery. [ABSTRACT FROM AUTHOR]

Purpose Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. Methods We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher's exact test. Results Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). Conclusion There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates. [ABSTRACT FROM AUTHOR]

Surgeons have significant choices when selecting specific disposable operating room (OR) equipment and supplies, while most are unaware of the costs associated with these choices. We used a cost transparency tool to demonstrate an impact on discretionary OR spending for disposable supplies. Patients undergoing laparoscopic hysterectomy or debulking within a gynecologic oncology department were included in this prospective, single-institution study. The operating room staff as well as the surgeons were informed of the cost of disposable equipment including the lowest-cost alternatives for commonly used supplies. Intraoperative supply cost feedback for all included procedures were provided to all surgeons in the department via a custom dashboard and monthly email reports with itemized costs. The results for all surgeons were transparent to all other surgeons in the department and the lowest cost surgeons were highlighted monthly. The primary outcome was percentage change in the cost of disposable supplies in the intervention year (11/1/2018-10/31/2019) as compared to baseline (11/1/2017-10/31/2018). Major postoperative complications including return to OR, wound dehiscence and wound infection were also collected. A total of 21 surgeons performed 539 laparoscopic hysterectomies and a total of 18 surgeons performed 119 debulkings between 11/1/2017-10/31/2019. For laparoscopic hysterectomy, there was an overall average cost increase of 4.6% between the baseline year and the intervention year. Five (28%) of 18 surgeons with surgeries in both years demonstrated average decreases in costs by more than 5%. For debulking, there was an overall average cost decrease of 12.9% from baseline to the intervention year. Eight (53%) of the 15 surgeons with surgeries in both years demonstrated decreased costs by more than 5%. Complication rates did not change significantly over the study period (p=0.83). Transparency in the cost of disposable OR equipment and supplies may result in significant decrease in OR spending without affecting major postoperative complications. [ABSTRACT FROM AUTHOR]

The article describes the case of a 33-year-old woman who was presented to the gynecologic oncology clinic for evaluation of infertility due to failure to conceive after a vaginal delivery in 2009. The patient's obstetric history included a fetal death at 21 weeks of gestation and abortion at six weeks of gestational age. She was diagnosed with placental site trophoblastic tumor. A total abdominal hysterectomy was performed due to the difficulty in locating the site of the tumor on laparoscopy.

The article describes the case of a 39-year-old pregnant woman with chronic neutrophilic leukemia, who was brought to the hospital at 26 weeks of gestation because of progressive leukocytosis, anemia and thrombocytopenia. She was discharged at 27 weeks of gestation after treatment with prednisone, intravenous immunoglobulin G, and pegylated interferon alfa. At 35 weeks of gestation, she delivered a healthy female neonate by repeat cesarean section under general anesthesia.

To compare out-of-pocket cost between apixaban and enoxaparin for prevention of postoperative venous thromboembolism (VTE) in gynecologic oncology patients. Current guidelines recommend low molecular weight heparin for thromboprophylaxis following gynecologic cancer surgery, but new evidence suggests that oral apixaban may provide another safe and effective alternative. Recent publications have suggested apixaban more cost-effective, however these data do not evaluate out-of-pocket cost. This retrospective study was approved by the institutional QIAB. Patients undergoing open surgery for gynecologic malignancy qualified for this study. Test claims for apixaban 2.5 mg by mouth twice daily and enoxaparin 40 mg subcutaneously daily for 28 days were submitted for each patient prior to surgery. Patient copays, number of patients requiring prior authorization, and number of patients without prescription insurance were collected. A total of 86 consecutive patients had test claims sent for both apixaban and enoxaparin thromboprophylaxis between July 2020 and October 2020. The average patient out-of-pocket cost to complete 28 days of apixaban prophylaxis was $73.95 (median $42.84, range $0-448.45). The average patient cost to complete 28 days of enoxaparin prophylaxis was $38.08 (median $10, range $0-260.91). Partial fills were allowed for 4 of 5 enoxaparin prescriptions that required prior authorization. A total of 5 apixaban prescriptions (5.8%) required prior authorization for full 28 days. A total of 5 patients (5.8 %) did not have prescription insurance. Cash price for enoxaparin was nearly double the cash price of apixaban. A total 6 patients' (7 %) insurance was not contracted with our pharmacy. A single patient (1.2%) required enoxaparin via specialty pharmacy. A total of 2 patients (2.3 %) were enrolled in the institution's financial assistance per the institution. [Display omitted] Patients prescribed extended-duration venous thromboembolism prophylaxis may face higher out-of-pocket costs with apixaban than with enoxaparin. Prior authorizations can often take 48 to 72 hours for approval. Sending test claims prior to surgery can help identify prescriptions that will need prior authorizations so prescriptions can be sent earlier to avoid discharge delays and patient nonadherence. There may not be a one size fits all solution and individualized patient care should be considered. Future research areas should evaluate patient adherence with a twice daily oral pill vs a once daily injection. [ABSTRACT FROM AUTHOR]

The androgen receptor (AR) is more widely expressed than the estrogen or progesterone receptor in endometrial cancer (EC), including up to 90% of endometrioid type. Enzalutamide binds to the AR thereby nuclear translocation of receptors and blocking the association of the AR with DNA. We sought to evaluate the efficacy of paclitaxel, carboplatin and enzalutamide in a phase II study of advanced or recurrent endometrioid EC. Women with chemo-naïve, advanced-stage or recurrent endometrioid EC with measurable disease and adequate end organ function were eligible. Documented AR expression was not required. A safety lead in of the triplet was performed to confirm dose. In phase II, patients received 28 days of enzalutamide (160mg daily) as a single agent before starting triplet therapy. Pre- and post-treatment biopsies were obtained during the single agent lead in for evaluation of molecular markers including AR receptor expression and activation, expression of AR-related genes/proteins, and DNA copy number alterations and mutations. Patients then received carboplatin (AUC 6 IV Q3wk), paclitaxel (175 mg/m2), and enzalutamide (160mg daily). Response per RECIST 1.1 was assessed every 3 cycles for a maximum of 9 cycles. Evaluable patients received at least 6 cycles of triplet therapy. Progression free survival (PFS) was calculated from date of treatment initiation to earliest date of progression, death, or last contact. This study was approved and funded in part by the National Comprehensive Cancer Network (NCCN) Oncology Research Program from general research support provided by Astellas Pharma Global Development, Inc. A total 81 patients were screened with 49 patients treated to date (safety lead in n=7; phase II n=42). Median age was 64 years (range 41-81) and the majority of patients had grade 2 histology (53.1%) and recurrent disease (81.6%). There were no dose-limiting toxicities observed during the safety lead in. Patients received a median of 9 cycles of triplet therapy (range 0-9). 8 patients (16.3%) did not receive chemotherapy due to rapid progression during single agent enzalutamide (n=3), unrelated death (n=2), withdrawal (n=2), and unrelated stroke (n=1). PFS for the entire cohort was 11.47 months (95% CI 9.86 - 17.94; Figure 1a) and 6-month PFS probability was 0.77 (95% CI 0.61-0.87). Among 35 evaluable patients, confirmed objective response rate was 71% (95% CI 54–85%), 6 months PFS probability was 0.83 (95% CI 0.66-0.92) and median PFS was 14.42 months (95% CI 11.2-25.5; Figure 1B). The most common adverse events were as expected for chemotherapy alone, including neutropenia (20%), anemia (18%), fatigue (18%), neuropathy (10%), hyperglycemia (14%), nausea (8%), and thrombocytopenia (8%). [Display omitted] The combination of enzalutamide, carboplatin, and paclitaxel was tolerable and had promising clinical outcomes in chemo-naïve advanced or recurrent endometrioid EC. Further analyses are ongoing regarding predictors of response and resistance to androgen-inhibitor therapy. NCT02684227. [ABSTRACT FROM AUTHOR]

Objectives: Malignant large bowel obstructions are a frequent complication affecting women with gynecologic cancers and are an indication for possible emergent surgery. However, the life expectancy and subsequent medical care utilization following such a procedure when done for palliative intent are unknown. We sought to estimate overall survival (OS) following surgical formation of a colostomy due to large bowel obstruction with palliative intent and describe subsequent healthcare utilization among patients with recurrent gynecologic malignancies. Methods: We conducted a retrospective analysis of all gynecologic oncology patients with recurrent metastatic gynecologic cancers who underwent colostomy due to large bowel obstruction with a palliative intent at our institution between March 2014 and December 2020. Summary statistics were used to describe the clinical and demographic characteristics of the study population. OS was estimated using the Kaplan-Meier methods, and we defined healthcare utilization at the end of life using criteria published by the national quality forum. Results: A total of 51 women met the inclusion criteria. The median age at the time of surgery was 61 years (range: 34-82), and most patients had a recurrent ovarian, fallopian tube, or primary peritoneal cancer (n =22, 43%), followed by cervical cancer (n =9, 18%), and endometrial cancer (n =4, 8%). The median Charlson comorbidity index was 3, and 54% received chemotherapy in the 60 days prior to surgery. Median surgical time was 94 minutes, and median postoperative length of stay was five days (range: 1-26). The median follow-up for all subjects was 4.5 months (range: 0.2-46.2), and the median OS was 4.5 months (95% CI: 2.37 - 9.43). This includes nine patients (17%) with <30-day OS and 16 (31%) with <60-day OS. Forty- nine percent (n =25) of patients did not receive further chemotherapy after a colostomy. In the last 30 days of life, 67% of patients were re-admitted to the hospital, 58% were seen in the emergency department, and 15% were admitted to an intensive care unit. Conclusions: While palliative surgery with colostomy formation is often offered to gynecologic oncology patients with malignant large bowel obstructions, there are limited data to aid in the shared decision-making regarding palliative surgery at the end of life. In our study, a significant proportion of patients died within 60 days of surgery, and many had high healthcare utilization at the end of life. Additional analysis is planned to assess characteristics associated with shorter OS and increased healthcare utilization at the end of life. Further study is also needed to determine patient-reported outcomes related to palliative colostomy. [ABSTRACT FROM AUTHOR]