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Background: Massive obstetric hemorrhage can be catastrophic, with considerable maternal morbidity and mortality. Case: A 41-year-old term gravida experienced massive postpartum hemorrhage attributed to an amniotic fluid embolism with rapid development of disseminated intravascular coagulation and resultant abdominal compartment syndrome. In this critically ill patient, a fascial prosthesis used for abdominal wall closure was placed to expedite multiple abdominal explorations and packing. Additionally, this device facilitated fascial closure once the abdominal compartment syndrome was resolved. Conclusion: Abdominal compartment syndrome resulting from overwhelming obstetric hemorrhage may necessitate emergent decompressive laparotomy to alleviate increased intra-abdominal pressure and end-organ dysfunction. The fascial prosthesis allows a staged abdominal wall closure to be performed once the abdominal compartment syndrome is resolved. [ABSTRACT FROM AUTHOR]

Early presentation of endometrial cancer permits effective management with excellent clinical outcome. The addition of hysteroscopy to dilatation and curettage (D&C) in the evaluation of postmenopausal bleeding adds little to the detection of malignancy. Imaging studies such as computed tomography, magnetic resonance imaging, and positron-emission tomography may be of use in determining the presence of extrauterine disease in patients medically unfit for surgical staging. However, these studies are not sufficiently sensitive to replace surgical staging and have little role in routine preoperative evaluation. Clinical staging alone is clearly inadequate, as 23% of preoperative clinical stage I/II patients are upstaged with comprehensive surgical staging. Preoperative tumor grade from D& C or office biopsy may be inaccurate and lead to an underestimate of tumor progression if used to determine which patients should be surgically staged. Clinical estimation of depth of invasion, with or without frozen section, is inaccurate and may lead to underestimation of disease status when surgical staging is not performed. The practice of resecting only clinically suspicious nodes should be discouraged as it is no substitute for comprehensive surgical staging. Comprehensive surgical staging provides proper guidance for postoperative adjuvant therapy, avoiding needless radiation in 85% of clinical stage I/II patients. Finally, resection of occult metastasis with surgical staging may improve survival. [ABSTRACT FROM AUTHOR]

Objective: The evaluation of abnormal cervical cytologic results is time consuming and costly. Most patients with high-grade squamous intraepithelial lesion (HSIL)-cervical intraepithelial neoplasia 3 (CIN 3) Pap smear results require an excisional procedure for diagnostic or therapeutic reasons. "See and treat" is a surgical procedure that involves a loop electrosurgical excisional procedure (LEEP) simultaneously to diagnose and to treat premalignant cervical disease in one visit. This procedure eliminates a second visit that typically is required for treatment. Data is lacking on the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear result. The objective of this study was to determine the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear using a see-and-treat protocol.Methods: Women referred from local health departments to our university-based colposcopy clinic for evaluation of an HSIL (CIN 2) Pap smear result were evaluated for inclusion in a see and treat protocol. All eligible patients underwent colposcopy to rule out an obvious cervical carcinoma followed by an immediate LEEP to remove the transformation zone. A colposcopic impression was made using the Reid colposcopic index. Pathologic specimens were analyzed for the presence of CIN and the incidence of CIN 2 and CIN 3 was determined.Results: To date, 51 patients have been enrolled in the study. Exclusion criteria included age less than 19 years, pregnancy, or medical contraindications. The mean age of the patients was 26 years (range, 19-45 years). Forty-seven percent were white, 47% were black, and 6% were Hispanic. Of the 51 patients who underwent LEEP, 43 of 51 (85%) had satisfactory colposcopy and no patient had a lesion suspicious for cervical carcinoma. The average Reid colposcopic index was 3.5. Of the 51 LEEP specimens, 4 of 51 had no evidence of CIN (8%), 4 of 51 (8%) had CIN 1, 18 of 51 (35%) had CIN 2, and 25 of 51 (49%) had CIN 3. Eighty-four percent of patients had either CIN 2 or CIN 3, resulting in an overtreatment rate (CIN 1 or less) of 16%.Conclusions: The use of a see and treat protocol for patients with HSIL (CIN 2) Pap smear results may be an acceptable treatment option because of a high incidence of CIN 2 and CIN 3. [ABSTRACT FROM AUTHOR]

Objective: To assess the costs and usefulness of colposcopy using three screening strategies for cervical intraepithelial neoplasia (CIN).Materials and Methods: A decision model compared three screening strategies for CIN: (1) patients were screened annually with a conventional Pap smear, (2) patients were screened annually with a liquid-based cytologic method and reflex human papillomavirus testing for atypical squamous cells of undetermined significance results, and (3) patients were screened biennially with a liquid-based cytologic method and reflex human papillomavirus testing for atypical squamous cells of undetermined significance results.Results: Biennial liquid-based screening was the least expensive strategy with a cost of $9.5 million per 100,000 patients. Annual liquid-based screening was the most expensive strategy at $13.7 million. Annual conventional screening had an intermediate cost of $11.6 million. Biennial liquid-based screening referred the fewest patients to colposcopy (11.8%), followed by annual conventional screening and annual liquid-based screening (15.2% and 15.6%, respectively).Conclusions: Each of these treatment strategies is reasonable; however, biennial liquid-based screening would reduce medical costs significantly. [ABSTRACT FROM AUTHOR]

BACKGROUND: The differential diagnosis in an elderly woman with a complex pelvic mass includes benign and malignant diseases. CASE: A woman in her ninth decade was discovered to have both a breast mass and a pelvic mass at examination. After diagnostic breast biopsy results that confirmed invasive breast carcinoma, pelvic examination and ultrasonography were performed. The ultrasonogram demonstrated a large complex pelvic mass. The patient underwent an exploratory laparotomy at the time of her mastectomy. The pelvic mass was a protrusio acetabuli resulting from a prior right total hip arthroplasty. CONCLUSION: A complex pelvic mass secondary to protrusio acetabuli is a rare clinical finding. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to compare operative outcomes and complications for patients with endometrial cancer who underwent staging by laparoscopy vs laparotomy in a low-volume facility. STUDY DESIGN: Research was conducted with a retrospective cohort of surgical patients with clinical stage I endometrial cancer from 2004-2009. RESULTS: Eighty-six demographically similar patients (50 laparotomy and 36 laparoscopy) were identified. Laparoscopy had less estimated blood loss (339 vs 558 mL; P = .013) and lower rates of transfusion (5.6% vs 24%; P = .02). Laparoscopy was longer (281 vs 202 minutes; P < .0005) but required a shorter hospital stay (2.2 vs 5.5 days; P < .0005). Laparoscopy patients had fewer overall complications (16.7% vs 32%; P = .11). No differences in final surgical stage or lymph node yields between the groups were present. CONCLUSION: Although a longer procedure, laparoscopy had fewer complications and shorter hospital stays. Prolonged operative time, compared with published experience, is potentially the result of unique factors in our center. [ABSTRACT FROM AUTHOR]

Objective: Peripartum cardiomyopathy (PPCM) and acute fatty liver of pregnancy (AFLP) are rare complications of pregnancy affecting approximately 1/10,000 pregnancies each. We describe a patient who had biopsy-proven AFLP complicated by PPCM.Methods: Chart review and literature search.Results: The patient is a 22-year-old G5P1213 obese African-American female who presented at 30 weeks gestation with abdominal pain. She had normal blood pressures and mildly elevated liver enzymes. After completion of a 24 hour urine protein collection that was consistent with pre-eclampsia, an induction of labor with uncomplicated vaginal delivery was accomplished. Following delivery, a computed tomography scan of the abdomen revealed significant cardiomegaly. An echocardiogram revealed global dysfunction with an ejection fraction of 10%. Liver biopsy showed AFLP. Attempts to establish a unifying etiology were unrevealing. The PPCM was treated with diuretics and intravenous immunoglobulin. The patient's clinical status deteriorated, eventually requiring continuous dialysis, intubation, pharmacologic and mechanical inotropic support, and a feeding tube. The patient was discharged to a long-term care facility where she subsequently passed away from multiorgan failure.Conclusion: AFLP and PPCM are rare complications of pregnancy. We present a patient who had both. Both diseases carry a high mortality rate, and together, are likely fatal. [ABSTRACT FROM AUTHOR]

Background: Undifferentiated uterine sarcomas are rare malignancies often presenting at advanced stage.Case: A female in her ninth decade presented to our MEDCEN emergency department complaining of onset of severe right arm pain while performing activities of daily living. A pathologic humeral fracture was diagnosed and subsequent orthopedic evaluation resulted in a biopsy and placement of her arm in a cooptation splint and sling. An abdominal exam revealed a 10-cm mass in the right lower quadrant that was thought to originate from the uterus. Computed tomography imaging was concerning for a primary endometrial process and she was referred to gynecologic oncology. Her humeral biopsy was consistent with a poorly differentiated metastatic sarcoma. An endometrial biopsy was consistent with undifferentiated uterine sarcoma, the origin of her humeral lesion.Conclusion: Humeral metastasis is an uncommon presentation for undifferentiated endometrial sarcomas. [ABSTRACT FROM AUTHOR]

Background: Synchronous primary gynecologic tumors are relatively uncommon with the diagnosis often made following initial surgery.Case: A multiparous female in her 50s with postmenopausal bleeding was referred to our institution with a biopsy-proven diagnosis of endometrial cancer. Preoperative physical exam revealed a suspicious cervical lesion and upon biopsy she was found to have a signet-ring cell carcinoma of the cervix. Secondary to morbid obesity, the patient was not a candidate for a radical hysterectomy and was treated with curative radiation for stage IB 1 cervical carcinoma and clinical stage I endometrial carcinoma.Conclusion: Cervical signet-ring cell carcinoma is an extremely rare pathologic diagnosis. The preoperative discovery of synchronous primary gynecological tumors necessitates individualized planning and treatment. [ABSTRACT FROM AUTHOR]

Objective: The primary aim of this study was to determine if metformin, an oral biguanide administered with first-line chemotherapy and continued as maintenance therapy, improves progression-free survival (PFS) for patients with advanced-stage ovarian cancer., Methods: Patients with pathologically confirmed advanced-stage ovarian cancer undergoing primary debulking or neoadjuvant platinum-based chemotherapy followed by surgery were eligible to participate. Patients were randomized 1:1 to receive platinum/taxane-based chemotherapy with metformin 850 mg orally twice per day or placebo, followed by maintenance therapy (metformin or placebo) for two years from the date of randomization., Results: 108 evaluable patients were enrolled; 54 were randomly assigned to metformin, and 54 to placebo. Sixty-six percent (n = 71) received neoadjuvant therapy, 31 % (n = 33) primary debulking surgery, and 88 % (n = 93) had tumors of high-grade serous histology. The primary endpoint, PFS, was not significantly different between the treatment groups (1-sided p-value = 0.31; adjusted hazard ratio [HR] = 0.87, 95 % confidence interval [CI]: 0.56-1.36). Median PFS was 15.4 months (95 % CI: 11.2-23,5) for metformin and 14.3 months (95 % CI: 11.6-18.0) for placebo. Overall survival (OS) was not significantly different (2-sided p-value = 0.21; adjusted HR = 1.49, 95 % CI: 0.86-2.59), with a median of 40.7 months (95 % CI: 28.0-48.2) for metformin versus 43.8 months (95 % CI: 35.3-57.2) for placebo. The addition of metformin was well tolerated, and there were no differences in toxicity between the two groups., Conclusion: Although it was well-tolerated, adding metformin to first-line platinum/taxane-based therapy does not improve PFS or OS for patients with newly diagnosed advanced stage ovarian cancer., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: G.F. serves as institutional PI for pharma-sponsored trials from the following sponsors: Iovance, Sermonix, Compugen, AstraZeneca, Astellas, K group beta, Pfizer, Artios, Blueprint, Duality Bio, Sanofi. E.L. receives funding from Abbvie for preclinical studies unrelated to metformin. S.D.Y. serves as Deputy Editor for Gynecologic Oncology. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier Inc.)

Objective: The goal of this study was to evaluate the impact of a formalized research team and screening process on racial disparities associated with clinical trial enrollment at a tertiary academic center., Methods: We conducted a retrospective cohort study of patients with gynecologic malignancies approached for clinical trial enrollment from March 2018 to February 2022. A dedicated research navigator team and protocol were implemented to review and approach all (potentially) eligible clinical trial patients. The control group consisted of patients enrolled prior to the research navigator team. A survey was also performed in the research navigator team group to evaluate the reasons why patients decline clinical trials. Analysis was performed using SPSS version 26., Results: A total of 411 patients were included in this cohort with 187 in the control group and 224 in the research navigator team. There was a high rate of minority inclusion with 27.3% of patients being Black. Enrollment in the clinical trials increased from 15.0% to 36.9% after the initiation of the research navigator team. Patients were more likely to enroll if they had recurrent disease vs primary disease (p < .001). The most common reasons for patients declining clinical trials were the desire to receive treatment locally (25.0%), concern about the trial (21.7%), and wanting to receive the standard of care treatment (15.0%)., Conclusions: Using a dedicated research navigator team increased the identification of eligible patients and decreased racial disparities in clinical trial enrollment at our tertiary academic center. The most common reason women declined enrollment was to receive treatment locally. Continued identification of barriers to trial enrollment remains paramount in working to improve outcomes for gynecologic oncology patients., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2024 European Society of Gynaecological Oncology and the International Gynecologic Cancer Society. Published by Elsevier Inc. All rights reserved.)

Purpose: We assessed the efficacy of cediranib, olaparib, and cediranib/olaparib compared with standard-of-care chemotherapy (SOC) in platinum-resistant or platinum-refractory epithelial ovarian cancer (PROC)., Patients and Methods: NRG-GY005 is an open-label, four-arm, phase II/III superiority trial enrolling patients with high-grade serous/endometrioid PROC and one to three previous therapies. Key exclusion criteria included previous receipt of poly(ADP-ribose) polymerase inhibitor or receipt of antiangiogenic therapy in the recurrent setting. Treatment arms (SOC [once weekly paclitaxel, topotecan, or pegylated liposomal doxorubicin], cediranib, olaparib, or cediranib/olaparib) were equally randomized. A preplanned interim futility analysis on the basis of progression-free survival (PFS) selected treatment arms to advance to phase III. PFS and overall survival (OS) were phase III coprimary end points, with hierarchical testing of PFS followed by OS to preserve type 1 error control, designed to have 90% power for a 0.625 PFS hazard ratio (HR). OS was tested after PFS in the multiple hierarchical testing procedure. Secondary end points included objective response rate (ORR) and patient-reported outcomes., Results: Five hundred sixty-two eligible patients were enrolled for phase II/III. Three arms met PFS criteria to carry forward to phase III (SOC, cediranib/olaparib, and cediranib). Median PFS was 3.4, 5.2, and 4 months with SOC, cediranib/olaparib, and cediranib, respectively, with a median follow-up duration of 42.2 months. PFS HR estimates for cediranib/olaparib and cediranib ( v SOC) were 0.796 (98.3% CI, 0.597 to 1.060) and 0.972 (98.3% CI, 0.726 to 1.300), respectively. Median OS was 13.6, 12.8, and 10.5 months, and of 443 patients with measurable disease, ORR was 8.6%, 24.7%, and 13.1% for SOC, cediranib/olaparib, and cediranib, respectively. No new safety signals were identified. In patients receiving cediranib/olaparib, no statistically significant difference was observed on the NFOSI-DRS-P subscale compared with SOC (98.3% CI, -1.3 to 1.5, P = .8725)., Conclusion: The cediranib-containing arms demonstrated clinical activity on the basis of PFS but were not superior compared with SOC.

Olaparib treatment significantly improved objective response rate (primary end point) and progression-free survival versus nonplatinum chemotherapy in patients with BRCA-mutated platinum-sensitive relapsed ovarian cancer in the open-label phase III SOLO3 trial (ClinicalTrials.gov identifier: NCT02282020). We report final overall survival (OS; prespecified secondary end point), post hoc OS analysis by number of previous chemotherapy lines, and exploratory BRCA reversion mutation analysis. Two hundred sixty-six patients were randomly assigned 2:1 to olaparib tablets (300 mg twice daily; n = 178) or physician's choice of single-agent nonplatinum chemotherapy (pegylated liposomal doxorubicin, paclitaxel, gemcitabine, or topotecan; n = 88). OS was similar with olaparib versus chemotherapy (hazard ratio [HR], 1.07 [95% CI, 0.76 to 1.49]; P = .71, median 34.9 and 32.9 months, respectively, full analysis set). OS with olaparib was favorable in patients with two previous chemotherapy lines (HR, 0.83 [olaparib v chemotherapy] [95% CI, 0.51 to 1.38]; median 37.9 v 28.8 months); however, a potential detrimental effect was seen in patients with at least three previous chemotherapy lines (HR, 1.33 [95% CI, 0.84 to 2.18]; median 29.9 v 39.4 months). BRCA reversion mutations might have contributed to this finding. No patient randomly assigned to olaparib with a BRCA reversion mutation detected at baseline (6 of 170 [3.5%]) achieved an objective tumor response.

The NCCN Guidelines for Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer provide multidisciplinary diagnostic workup, staging, and treatment recommendations for this disease. These NCCN Guidelines Insights detail how the evolution of the use of PARP inhibitors as maintenance and single-agent regimens for the treatment of ovarian cancer informed panel recommendations in the guidelines.

Introduction: Cervical cancer, while highly preventable, remains an international public health challenge especially in under resourced regions. Although early-stage cervix confined cancers are often amenable to surgical resection, larger tumors deemed locally advanced cervical cancer (LACC) necessitate systemic therapy as part of chemoradiation therapy. Moreover, systemic therapy is the standard therapeutic approach for those presenting with primary metastasis or recurrence., Areas Covered: While several agents have been approved to treat recurrent cervical cancer including checkpoint inhibitors as well as both biomarker agnostic and specific antibody drug conjugates, the development of agents added to chemoradiation has been less fruitful. Until recently, the addition of novel therapies to chemoradiation has been negative in terms of improving outcomes; however, results of a recent Phase III clinical trial (NCT04221945) in LACC demonstrated that the addition of pembrolizumab to standard of care chemoradiation was associated with an improvement in progression-free survival and resulted in an FDA approval for this therapy. This observation led to the first change in treating LACC since the early 2000s., Expert Opinion: Improvements in systemic therapy both alone and in combination with chemoradiation for cervical cancer have been realized. Ongoing research is needed for therapeutic options following immunotherapy.

Objective: Due to limited data on homologous recombination deficiency (HRD) in older patients (≥ 70 years) with advanced stage high grade serous ovarian cancer (HGSC), we aimed to determine the rates of HRD at diagnosis in this age group., Methods: From the Phase 3 trial VELIA the frequency of HRD and BRCA1/2 pathogenic variants (PVs) was compared between younger (< 70 years) and older participants. HRD and somatic(s) BRCA1/2 pathogenic variants (PVs) were determined at diagnosis using Myriad myChoice® CDx and germline(g) BRCA1/2 PVs using Myriad BRACAnalysis CDx®. HRD was defined if a BRCA PV was present, or the genomic instability score (GIS) met threshold (GIS ≥ 33 & ≥ 42 analyzed)., Results: Of 1140 participants, 21% were ≥ 70 years. In total, 26% (n = 298) had a BRCA1/2 PV and HRD, 29% (n = 329) were HRD/BRCA wild-type, 33% (n = 372) non-HRD, and 12% HR-status unknown (n = 141). HRD rates were higher in younger participants, 59% (n = 476/802), compared to 40% (n = 78/197) of older participants (GIS ≥ 42) [p < 0.001]; similar rates demonstrated with GIS ≥ 33, 66% vs 48% [p < 0.001]. gBRCA PVs observed in 24% younger vs 8% of older participants (p < 0.001); sBRCA in 8% vs 10% (p = 0.2559), and HRD (GIS ≥ 42) not due to gBRCA was 35% vs 31% (p = 0.36)., Conclusions: HRD frequency was similar in participants aged < 70 and ≥ 70 years (35% vs 31%) when the contribution of gBRCA was excluded; rates of sBRCA PVs were also similar (8% v 10%), thus underscoring the importance of HRD and BRCA testing at diagnosis in older patients with advanced HGSC given the therapeutic implications., Competing Interests: Declaration of competing interest The following authors have no disclosures relating to this manuscript: Omali Pitiyarachchi, Laura Holman, Paul DiSilvestro, Mark Morgan, William Tew, Christine Lee, Meredith Newton, Babak Edraki, Thomas Reid and Jay Carlson. Peter J. Ansell and Minh H Dinh are AbbVie employees receiving stock or stock options. Robert L. Coleman: has received grants or contracts from AstraZeneca, Clovis, Genelux, Genmab, Merck, Immunogen, Roche/Genentech, Karyopharm; consulting fees from Agenus, Alkermes, AstraZeneca, Clovis, Deciphera, Genelux, Genmab, GSK, Immunogen, OncoQuest, Onxerna, Regeneron, Karyopharm, Roche/Genentech, Novocure, Merck, Abbvie, Novocure; royalties or licenses with Up-To-Date; payment or honoraria for speakers bureaus from AstraZeneca, Clovis, Roche/Genentech, Merck; participation in data safety monitoring or advisory boards from NRG Oncology, Elsai/BMS; leadership or fiduciary role in Onxeo/Valerio, Vaniam Group, GOG Foundation, International Gynecologic Cancer Society, OCNA, Ovarcome. Charles A. Leath III: Grant to institution provided by National Institutes of Health (NCI UG1 CA233330). Theresa Werner has received consulting fees from Mersana; and research funding to the institution - AbbVie, Acrivon, Astra Zeneca, BluePrint, Clovis Oncology, Genmab, GSK-Tesaro, Mersana, Repare Therapeutics, Roche-Genentech. Mary Cunningham: funds to institution provided by Abbvie, AstraZeneca, Clovis Oncology, Tesaro, Vascular Biogenics; and spouse is a stockholder of Intuitive Surgical. Peter Lim: has received payment or honoraria for Speakers Bureau from Astra Zeneca and Merck and is on Advisory Boards for Astra Zeneca, Clovis, Mersana, OncoC4, Immunogen. Joyce Barlin: has received payment/honoraria for Speakers Bureaus from Astra Zeneca and Merck and is on Advisory Boards for Astra Zeneca, Clovis, Mersana, OncoC4, Immunogen. Nicola M. Spirtos: has received institutional grants from NRG and the GOG Foundation. Krishnansu S. Tewari: reports grants to institution (UC Irvine) provided by AbbVie; consulting fees from Merck, Astra Zeneca, Eisai, Seagen, GSK; and payment/honoraria for Speakers Bureaus from Merck, Astra Zeneca, Eisai, Seagen, GSK. Mitchell Edelson: has received funding to attend meetings from Intuitive Surgical; received stock options from Merck when employed. Spouse was a salaried employee at Merck until 8/2022 and spouse is a salaried employee at Pfizer since 3/2023. Michael Friedlander: has received consulting fees from Astra Zeneca, Novartis and GSK; has consulted without payment for Incyclix; has received payment or honoraria for Speakers Bureaus from Astra Zeneca, GSK and MSD; has participated on Data Safety Monitoring or Advisory Boards for AGITG IDSMB and ENDO-3; received institutional support in the form of research grants from Astra Zeneca, Beigene and Novartis., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Despite advances in cervical cancer (CC) prevention, detection, and treatment in the US, health disparities persist, disproportionately affecting underserved populations or regions. This study analyzes the geographical distribution of both CC and recurrent/metastatic CC (r/mCC) in the US and explores potential risk factors of higher disease burden to inform potential strategies to address disparities in CC and r/mCC., Methods: We estimated CC screening rates, as well as CC burden (number of patients with CC diagnosis per 100,000 eligible enrollees) and r/mCC burden (proportion of CC patients receiving systemic therapy not in conjunction with surgery or radiation), at the geographic level between 2017-2022 using administrative claims. Data on income and race/ethnicity were obtained from US Census Bureau's American Community Survey. Brachytherapy centers were proxies for guideline-conforming care for locally advanced CC. Associations among demographic, socioeconomic, and healthcare resource variables, with CC and r/mCC disease burden were assessed., Results: Between 2017-2022, approximately 48,000 CC-diagnosed patients were identified, and approximately 10,000 initiated systemic therapy treatment. Both CC and r/mCC burden varied considerably across the US. Higher screening was significantly associated with lower CC burden only in the South. Lower income level was significantly associated with lower screening rates, higher CC and r/mCC burden. Higher proportion of Hispanic population was also associated with higher CC burden. The presence of ≥1 brachytherapy center in a region was significantly associated with a reduction in r/mCC burden (2.7%)., Conclusion: CC and r/mCC disparities are an interplay of certain social determinants of health, behavior, and race/ethnicity. Our findings may inform targeted interventions for a geographic area, and further highlight the importance of guideline-conforming care to reduce disease burden., Competing Interests: Tara Castellano has received consulting fees from Glaxo-Smith-Klein; Andrew K. ElHabr and Ezgi Berksoy are paid employees of Value Analytics Labs, a healthcare consultancy company; Jie Ting and Yitong J. Zhang are employees and stack holders of Pfizer Inc.; Kathleen Moore has participated in data monitoring or advisory boards for Astra Zeneca, Aravive, Alkemeres, Aadi, Blueprint pharma, Clovis, Caris, Duality, Elevar, Eisai, EMD Serono, GSK/Tesaro, Genentech/Roche, Hengrui, Immunogen, Janssen, Lilly, Mersana, Merck, Myriad, Mereo, Novartis, OncXerna, Onconova, SQZ, Tarveda, VBL Therapeutics, Verastem and Zentalis, received support for attending meetings from Astra Zeneca, GSK/Tesaro, and BioNTech, and holds a leadership role with GOG partners; Leslie Randall reports personal fees from Seagen Inc. for an educational webinar at drug launch and speaker’s bureau and personal fees from Merck for an unbranded educational video for cervical cancer. Her institute receives research funding for clinical research from Seagen and Merck. She reports personal fees from BluPrint Oncology, PER, CurioScience, Projects in Knowledge, AstraZeneca, Tesaro, Merck, Mersana, Agenus, Rubius Therapeutics, Myriad Genetics, EMD Serono, Genentech/Roche, Seattle Genetics, Novartis, and Eisai, all outside the submitted work; Jagpreet Chhatwal and Turgay Ayer are co-owners of Value Analytics Labs; Charles A. Leath III has received consulting fees from Seagen Inc. for service on Scientific Advisory boards, cervical cancer research funding from Agenus, Rubius Therapeutics, and Seagen Inc., and funding from the NCI UG1 CA23330 and P50 CA098252; Fernanda Musa and Christina Washington have no competing interests to disclose., (Copyright: © 2024 Castellano et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: To assess efficacy and toxicity of cisplatin (C) and gemcitabine (G) with intensity-modulated radiation therapy (IMRT) in patients with locally advanced vulvar cancer not amenable to surgery., Methods: Patients enrolled in a single-arm phase II study. Pretreatment inguinal-femoral nodal assessment was performed. Sixty-four Gy IMRT was prescribed to the vulva, with 50-64 Gy delivered to the groins/low pelvis. Radiation therapy (RT) plans were quality-reviewed pretreatment. C 40 mg/m 2 and G 50 mg/m 2 were administered once per week throughout IMRT. Complete pathologic response (CPR) was the primary end point. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and adverse events were assessed with Common Terminology Criteria for Adverse Events v 4.0., Results: Fifty-seven patients enrolled, of which 52 were evaluable. The median age was 58 years (range, 25-58), and 94% were White. Forty (77%) had stage II or III disease, and all had squamous histology. A median of six chemotherapy cycles (range, 1-8) were received. Eighty-five percent of RT plans were quality-reviewed with 100% compliance to protocol. Seven patients came off trial because of toxicity or patient withdrawal. Of 52 patients available for pathologic assessment, 38 (73% [90% CI, 61 to 83]) achieved CPR. No pelvic exenterations were performed. With a median follow-up of 51 months, the 12-month PFS was 74% (90% CI, 62.2 to 82.7) and the 24-month OS was 70% (90% CI, 57 to 79). The most common grade 3 or 4 adverse events were hematologic toxicity and radiation dermatitis. There was one grade 5 event unlikely related to treatment., Conclusion: Weekly C and G concurrent with IMRT sufficiently improved CPR in women with locally advanced vulvar squamous cell carcinoma not amenable to surgical resection.

Purpose: We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities., Methods: Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC)., Results: This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively)., Conclusions: Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors., Competing Interests: Declaration of competing interest Chad A. Hamilton reported personal fees from GlaxoSmithKline outside the submitted work. Yovanni Casablanca cited personal fees from AstraZeneca outside the submitted work. John K. Chan reported personal fees from Agenus, AstraZeneca, Eisai, Genmab, GlaxoSmithKline, Immunogen, Mersana, Molecular Targeting Technologies, Myriad, Roche, and Seagen outside the submitted work. Thomas P. Conrads is a ThermoFisher Scientific, Inc. SAB member and receives research funding from AbbVie outside the submitted work. Charles A. Leath, III received funding from the NIH UG1 CA23330 and P50 CA098252, contracted research with Agenus and Seattle Genetics, and served on a scientific advisory board for Seattle Genetics, all outside of the submitted work. The other authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: This study investigated the risk of an aggressive endometrial cancer (EC) diagnosis by race, ethnicity, and country of origin to further elucidate histologic disparities in non-Hispanic Black (NHB), Hispanic, Asian/Pacific Islander (API), American Indian/Alaskan Native (AIAN) vs. non-Hispanic White (NHW) patients, particularly in Hispanic or API subgroups., Methods: Patient diagnosed between 2004 and 2020 with low grade (LG)-endometrioid endometrial cancer (ECC) or an aggressive EC including grade 3 EEC, serous carcinoma, clear cell carcinoma, mixed epithelial carcinoma, or carcinosarcoma in the National Cancer Database were studied. The odds ratio (OR) and 95% confidence interval (CI) for diagnosis of an aggressive EC histology was estimated using logistic modeling., Results: There were 343,868 NHW, 48,897 NHB, 30,013 Hispanic, 15,015 API and 1646 AIAN patients. The OR (95% CI) for an aggressive EC diagnosis was 3.07 (3.01-3.13) for NHB, 1.08 (1.06-1.11) for Hispanic, 1.17 (1.13-1.21) for API and 1.07 (0.96-1.19) for AIAN, relative to NHW patients. Subset analyses by country of origin illustrated the diversity in the OR for an aggressive EC diagnosis among Hispanic (1.18 for Mexican to 1.87 for Dominican), Asian (1.14 Asian Indian-Pakistani to 1.48 Korean) and Pacific Islander (1.00 for Hawaiian to 1.33 for Samoan) descendants. Hispanic, API and AIAN patients were diagnosed 5-years younger that NHW patients, and the risk for an aggressive EC histology were all significantly higher than NHW patients after correcting for age. Insurance status was another independent risk factor for aggressive histology., Conclusions: Risk of an aggressive EC diagnosis varied by race, ethnicity, and country of origin. NHB patients had the highest risk, followed by Dominican, South/Central American, Cuban, Korean, Thai, Vietnamese, and Filipino descendants., Competing Interests: Declaration of competing interest Stuart S. Winkler, Chunqiao Tian, Nicholas W. Bateman, Suzanne Jokajtys, Calen W. Kucera, Christopher M. Tarney, Michael T. Richardson, Daniel Kapp, Cheng-I Liao, Megan Reddy, Michele L Cote, Timothy D. O'Connor, Nathaniel L. Jones, Matthew A. Powell, John Farley, Craig D. Shriver, Neil T. Phippen, G. Larry Maxwell and Kathleen M Darcy do not have any potential conflicts to disclose. Chad A. Hamilton reported personal fees from GlaxoSmithKline outside the submitted work. Yovanni Casablanca cited personal fees from AstraZeneca outside the submitted work. John K. Chan reported personal fees from Agenus, AstraZeneca, Eisai, Genmab, GlaxoSmithKline, Immunogen, Mersana, Molecular Targeting Technologies, Myriad, Roche, and Seagen outside the submitted work. Thomas P. Conrads is a ThermoFisher Scientific, Inc. SAB member and receives research funding from AbbVie outside the submitted work. Charles A. Leath, III received funding from the NIH UG1 CA23330 and P50 CA098252, contracted research with Agenus and Seattle Genetics, and served on a scientific advisory board for Seattle Genetics, all outside of the submitted work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The aim of the study is to evaluate the use of a bipolar electrocautery device for complete salpingectomy at cesarean to improve procedure completion rates, operative time, and surgeon reported satisfaction as compared with standard bilateral tubal ligation (BTL) and suture-cut-tie salpingectomy., Study Design: This is a prospective cohort study of women undergoing planned, non-emergent cesarean with desired sterilization with complete salpingectomy utilizing a bipolar electrocautery device. Study patients were compared with historic controls from a randomized controlled trial (RCT) of complete salpingectomy via suture-cut-tie method versus BTL conducted at our institution (SCORE trial, NCT02374827). Outcomes were compared with groups from the original RCT., Results: Thirty-nine women were consecutively enrolled (12/2018-11/2019) into the device arm of the study and compared with the original SCORE cohort ( n  = 40 BTL, n  = 40 salpingectomy without a device). Salpingectomy performance with the bipolar electrocautery device was successfully completed in 100% (39/39) of enrolled women, with one device failure requiring the use of a second device, as compared with 95% (38/40) in the BTL ( p  = 0.49) and 67.5% (27/40) in salpingectomies without a device ( p  < 0.001). Mean operative time of sterilization procedure alone demonstrated device use as having the shortest operative time of all (device salpingectomy 5.0 ± 3.6 vs. no device 18.5 ± 8.3 minutes, p  < 0.001; and vs. BTL 6.9 ± 5.0, p  = 0.032). Mean sterilization procedure endoscopic band ligation (EBL) was demonstrated to be significantly different between each group, least amongst BTL followed by device (6.3 ± 4.8 vs. 8.4 ± 24.8, p  < 0.001), and most by suture-cut-tie method (17.7 ± 14.3, p  < 0.001 compared with device). Surgeon reported attitudes of complete salpingectomy performance in general practice outside an academic setting was greater with a device than without (79.5 vs. 35.3%; p  < 0.001)., Conclusion: Use of a bipolar electrocautery device improved operative times and surgeon satisfaction for salpingectomy at cesarean over standard suture ligation. Device use improved surgeon reported outcomes and may improve incorporation of complete salpingectomy at cesarean., Key Points: · Electrocautery bipolar device use was safe at the time of salpingectomy during cesarean.. · Greater surgeon satisfaction occurs using a device than without.. · Decreased surgical time with device use is seen making the procedure equal to BTL.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Investigate racial disparities in outcomes and molecular features in Black and White patients with endometrioid endometrial carcinoma (EEC)., Methods: Black and White patients diagnosed with EEC who underwent hysterectomy ± adjuvant treatment in SEER, National Cancer Database (NCDB), the Genomics Evidence Neoplasia Information Exchange (GENIE) project (v.13.0), and eight NCI-sponsored randomized phase III clinical trials (RCTs) were studied. Hazard ratio (HR) and 95% confidence interval (CI) were estimated for cancer-related death (CRD), non-cancer death (NCD), and all-cause death., Results: Black (n = 4397) vs. White (n = 47,959) patients in SEER had a HR (95% CI) of 2.04 (1.87-2.23) for CRD and 1.22 (1.09-1.36) for NCD. In NCDB, the HR (95% CI) for death in Black (n = 13,468) vs. White (n = 155,706) patients was 1.52 (1.46-1.58) dropping to 1.29 (1.23-1.36) after propensity-score matching for age, comorbidity, income, insurance, grade, stage, LVSI, and treatment. In GENIE, Black (n = 109) vs. White (n = 1780) patients had fewer PTEN, PIK3R1, FBXW7, NF1, mTOR, CCND1, and PI3K-pathway-related gene mutations. In contrast, TP53 and DNA-repair-related gene mutation frequency as well as tumor mutational burden-high status were similar in Black and White patients. In RCTs, Black (n = 187) vs. White (n = 2877) patients were more likely to have advanced or recurrent disease, higher grade, worse performance status and progressive disease. Risk of death in Black vs. White patients in RCTs was 2.19 (1.77-2.71) persisting to 1.32 (1.09-1.61) after matching for grade, stage, and treatment arm while balancing age and performance status., Conclusions: Differences exist in clinical presentation, outcomes, and molecular features in Black vs. White patients with EEC in real-world registries and RCTs. Targeted-drug development, strategies to modify social determinants, and diverse inclusion in RCTs are approaches to reduce disparities., Competing Interests: Declaration of interests Zachary A. Kopelman, Chunqiao Tian, Jordyn Tumas, Neil T. Phippen, Christopher M. Tarney, Erica R. Hope, Stuart S. Winkler, Suzanne Jokajtys, Calen W. Kucera, Michael T. Richardson, Daniel S. Kapp, Nathaniel L. Jones, Rodney P. Rocconi, John H. Farley, Angeles Alvarez Secord, Casey M. Cosgrove, Matthew A. Powell, Ann Klopp, Joan L Walker, Gini F. Fleming, Nicholas W. Bateman, G. Larry Maxwell, and Kathleen M. Darcy do not have any conflicts to report. John K. Chan reported personal fees from Agenus, AstraZeneca, Eisai, Genmab, GlaxoSmithKline, Immunogen, Mersana, Molecular Targeting Technologies, Myriad, Roche, and Seagen outside the submitted work. Chad A. Hamilton reported personal fees from GlaxoSmithKline outside the submitted work. Charles A. Leath, III received funding from the NIH UG1 CA23330 and P50 CA098252, contracted research with GSK and Merck, and served on a scientific advisory board for GSK and Merck, all outside of the submitted work. Thomas P. Conrads is a ThermoFisher Scientific, Inc. SAB member and receives research funding from AbbVie outside the submitted work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To investigate IMT use and survival in real-world stage IVB cervical cancer patients outside randomized clinical trials., Methods: Patients diagnosed with stage IVB cervical cancer during 2013-2019 in the National Cancer Database and treated with chemotherapy (CT) ± external beam radiation (EBRT) ± intracavitary brachytherapy (ICBT) ± IMT were studied. The adjusted hazard ratio (AHR) and 95% confidence interval (CI) for risk of death were estimated in patients treated with vs. without IMT after applying propensity score analysis to balance the clinical covariates., Results: There were 3164 evaluable patients, including 969 (31%) who were treated with IMT. The use of IMT increased from 11% in 2013 to 46% in 2019. Age, insurance, facility type, sites of distant metastasis, and type of first-line treatment were independently associated with using IMT. In propensity-score-balanced patients, the median survival was 18.6 vs. 13.1 months for with vs. without IMT ( p < 0.001). The AHR was 0.72 (95% CI = 0.64-0.80) for adding IMT overall, 0.72 for IMT + CT, 0.66 for IMT + CT + EBRT, and 0.69 for IMT + CT + EBRT + ICBT. IMT-associated survival improvements were suggested in all subgroups by age, race/ethnicity, comorbidity score, facility type, tumor grade, tumor size, and site of metastasis., Conclusions: IMT was associated with a consistent survival benefit in real-world patients with stage IVB cervical cancer.

Objective: We aimed to assess the impact of preoperative steroid administration and perioperative glycemic control on postoperative complications in diabetic gynecologic oncology patients undergoing laparotomy., Methods: This retrospective cohort study included gynecologic oncology patients with Type I and Type II diabetes (DM) undergoing laparotomy for any gynecologic indication at a single academic center from 10/2017 to 09/2020. The primary outcome was the rate of postoperative complications. Preoperative steroid administration and 24-hour postoperative average serum blood glucose (BG) ≥ 180 mg/dL were the studied exposures. Data was analyzed with SPSS Statistics v.28., Results: 225 patients met inclusion criteria; 47.6 % had postoperative complications. Patient demographics were similar between patients with and without postoperative complications. Patients with complications had higher BMIs (36.8 vs. 34.0; p = 0.03), bowel surgery (33.0 % vs. 17.1 %; p = 0.008), operative time ≥ 240 min (14.2 % vs. 5.1 %; p = 0.02) and average BG ≥ 180 (63.6 % vs. 40.2 %; p < 0.01). On multivariate analysis, bowel surgery (OR 2.4 (1.2-4.8); p = 0.01) and average BG ≥ 180 (OR 2.8 (1.6-4.9); p < 0.01) remained significant predictors of postoperative complications. There were no differences in complication rates (42.3 % vs. 42.6 %; p = 1.0) between patients who received preoperative steroids and those who did not. When stratified by average postoperative BG < 180 mg/dL vs. BG ≥ 180 mg/dL, there was no difference in Clavien-Dindo classification, 30-day readmission rate (28.2 % vs. 22.1 %; p = 0.49) or 30-day mortality rate (2.9 % vs. 0.0 %; p = 0.53)., Conclusion: The administration of preoperative steroids did not increase complication rates. Perioperative hyperglycemia was associated with an increased risk of postoperative complications. Optimizing perioperative glycemic control is imperative to decrease postoperative complications., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Financial support for Charles Leath was supported in part by the UG1 CA23330. Kaitlyn Kincaid, Teresa Boitano, Matthew Scalise, Samantha Patton, John M. Straughn, and Haller Smith have nothing to disclose., (© 2024 The Authors. Published by Elsevier Inc.)

We sought to explore the intrafamilial communication and cascade genetic testing (CGT) experiences of patients with hereditary cancer from diverse, medically underserved populations and their relatives. Participants included patients receiving oncology care at an urban, safety net hospital in Texas or comprehensive cancer center in Alabama and their first-degree relatives. In-depth semi-structured qualitative interviews were completed wherein patients shared their experiences with genetic counseling (GC), genetic testing (GT), and communicating their results to relatives. Relatives shared their experiences receiving information from the patient and considering CGT. Interviews were transcribed, coded, and themes were identified. Of 25 participating patients, most recalled key aspects of GC and their GT results. Most (80%) patients shared their results with relatives, but only some relatives underwent CGT; patients reported low perceived susceptibility to hereditary cancer as a common barrier to CGT for their relatives. Of 16 participating relatives, most reported feeling distress upon learning the patient's GT results. Relatives were fearful of learning their own CGT results but identified prevention and early detection as CGT benefits. Interviews identified opportunities during family communication to improve relatives' perceived susceptibility to hereditary cancer. Tailored resources may support patients and relatives experiencing distress and fear during GT., Prevention Relevance: This study of intrafamilial communication and cascade genetic testing experiences of patients with hereditary cancer and their relatives from diverse, medically underserved populations identified relatives' perceived susceptibility to hereditary cancer risks, distress, and fear as frequent reactions and barriers to testing. These results may inform future hereditary cancer prevention efforts., (©2023 American Association for Cancer Research.)

Despite effective screening strategies and the development and implementation of prophylactic high-risk human papillomavirus vaccination, cervical cancer remains a significant public health burden. This burden is most pronounced in under-resourced countries without fully developed screening and vaccination programs, although the disease remains present worldwide, including in industrialized countries. To that end, the World Health Organization (WHO) has an active focus on the elimination of cervical cancer, with objective metrics to be achieved by countries by the year 2030. Although increased vaccination and screening will be needed to approach potential eradication of cervical cancer, as recognized by the WHO initiative, treatment will need to continue to not only be effective in the near term, but to improve outcomes as well. Accordingly, assessments to improve primary treatment options, including surgery for women with early-stage disease, modification of chemoradiation for those with locally advanced cervical cancer, and systemic therapy for those with recurrent or metastatic presentations, are ongoing. Accordingly, we highlight important areas of both recent and ongoing focus as they relate to improving cervical cancer outcomes., Competing Interests: Financial Disclosure Charles A. Leath has received funding from the NIH UG1 CA23330 and P50 CA098252, contracted research with Agenus and Seattle Genetics, and served on a scientific advisory board for Seattle Genetics. He also indicated that tisotumab vedotin-tftv has accelerated approval pending confirmatory studies, as noted in this article. The other authors did not report any potential conflicts of interest. In accordance with the College policy, all faculty and planning committee members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to article topics. Such disclosures allow the participant to evaluate better the objectivity of the information presented in the articles., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the impact of a mobile health patient engagement technology (PET) on postoperative outcomes in gynecologic oncology patients., Methods: All gynecologic oncology patients undergoing laparotomy on an enhanced recovery program (ERP) were approached from July 2019 to May 2021 to enroll in a PET, which can be accessed by computer, tablet, or smart phone. This platform provides enhanced pre- and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbidities and were asked to complete daily health checks during the postoperative period. Participants in the PET were compared to patients who opted out as well as to a historical cohort from prior to PET implementation. Patient and procedure-level factors were recorded. The primary outcomes were length of stay (LOS) and 30-day readmission rate. Analysis was performed using SPSS v.26., Results: 682 women met inclusion criteria during the study time; 347 in the PET group and 335 in the control group. Demographic and other factors including race, BMI (kg/m 2 ), Charlson Comorbidity Index (CCI), surgical complexity, and insurance status were not different between the PET and control group; however, patients in the PET cohort were slightly younger (55.0 yo vs. 57.2 yo; p = 0.04). Patients in the PET group had a significantly shorter LOS (2.9 days vs. 3.6 days; p < 0.01) and lower readmission rate (4.3% vs. 8.6%; p < 0.01) when compared with the control group., Conclusions: Use of a PET in our gynecologic oncology patients decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors other than age. Furthermore, there was a 50% reduction in readmission rates in the PET group. The use of a PET allows for healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate trends in prevalence of cervical cancer (CC) and rates of recurrent or metastatic cervical cancer (r/mCC) treatment initiation at the state and metropolitan statistical area (MSA) levels among Medicaid enrolled females from 2016 to 2019., Methods: Retrospective analyses of nationwide Medicaid claims data were used to identify adult CC and r/mCC patients from 2016 to 2019. CC prevalence was estimated as the proportion of females diagnosed with CC out of all adult female Medicaid beneficiaries, and r/mCC by the proportion of CC patients who initiated a systemic treatment not associated with surgery or radiation to the number of enrollees with CC diagnosis in each state or MSA. Overall and annual rates were calculated for each state and MSA from 2016 to 2019., Results: The analytic cohort included 70,865 adult female Medicaid beneficiaries with CC from 2016 to 2019, among whom 3375 were identified as r/mCC patients. Nationwide annual prevalence of CC remained relatively stable from 2016 to 2019, while r/mCC decreased slightly over the study period. Several MSAs experienced increasing rates of r/mCC from 2016 to 2019, including Mayaguez, PR, Aguadeilla-Isabela, PR, and Green Bay, WI., Conclusions: Claims data demonstrate areas in the United States with disproportionately high or increasing CC or r/mCC burden, indicating a potential gap in preventative care for females and an unmet need for education and health care resource allocation. Future research should evaluate associations between community-level factors and r/mCC burden., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Standard first-line chemotherapy for endometrial cancer is paclitaxel plus carboplatin. The benefit of adding pembrolizumab to chemotherapy remains unclear., Methods: In this double-blind, placebo-controlled, randomized, phase 3 trial, we assigned 816 patients with measurable disease (stage III or IVA) or stage IVB or recurrent endometrial cancer in a 1:1 ratio to receive pembrolizumab or placebo along with combination therapy with paclitaxel plus carboplatin. The administration of pembrolizumab or placebo was planned in 6 cycles every 3 weeks, followed by up to 14 maintenance cycles every 6 weeks. The patients were stratified into two cohorts according to whether they had mismatch repair-deficient (dMMR) or mismatch repair-proficient (pMMR) disease. Previous adjuvant chemotherapy was permitted if the treatment-free interval was at least 12 months. The primary outcome was progression-free survival in the two cohorts. Interim analyses were scheduled to be triggered after the occurrence of at least 84 events of death or progression in the dMMR cohort and at least 196 events in the pMMR cohort., Results: In the 12-month analysis, Kaplan-Meier estimates of progression-free survival in the dMMR cohort were 74% in the pembrolizumab group and 38% in the placebo group (hazard ratio for progression or death, 0.30; 95% confidence interval [CI], 0.19 to 0.48; P<0.001), a 70% difference in relative risk. In the pMMR cohort, median progression-free survival was 13.1 months with pembrolizumab and 8.7 months with placebo (hazard ratio, 0.54; 95% CI, 0.41 to 0.71; P<0.001). Adverse events were as expected for pembrolizumab and combination chemotherapy., Conclusions: In patients with advanced or recurrent endometrial cancer, the addition of pembrolizumab to standard chemotherapy resulted in significantly longer progression-free survival than with chemotherapy alone. (Funded by the National Cancer Institute and others; NRG-GY018 ClinicalTrials.gov number, NCT03914612.)., (Copyright © 2023 Massachusetts Medical Society.)

BACKGROUND: Cervical cancer is a public health challenge and remains a disease with high unmet need. Previous real-world studies demonstrated significant variability in treatments for patients with recurrent or metastatic cervical cancer (r/mCC). A large proportion of patients with cervical cancer are insured through Medicaid; however, previous studies examining treatment patterns for r/mCC have not included Medicaid patients. As the r/mCC treatment landscape continues to evolve, there is a need to understand current real-world unmet need among patients with r/mCC enrolled in Medicaid. OBJECTIVE: To evaluate treatment patterns and health care resource utilization (HCRU) among Medicaid-enrolled women with r/mCC. METHODS: This is a retrospective analysis of nationwide Medicaid claims to assess patient characteristics, treatment patterns, and HCRU among patients with r/mCC between 2016 and 2019. First-line treatment (1L) for r/mCC was defined by the first administration of systemic therapy without concomitant radiation or surgery. Patient characteristics, treatment patterns, and HCRU were characterized by line of therapy. RESULTS: A total of 3,375 eligible adult female patients initiated systemic treatment for r/mCC between 2016 and 2019. Mean age at treatment initiation was 52.9 (SD ± 12.8) years. Nearly 1,300 (1,294, 38.3%) women had evidence of receiving second-line treatment (2L), with nearly one-third (N = 420) of those also having evidence of third-line treatment. The majority (60.5%) of 1L regimens were doublet chemotherapy ± bevacizumab, consistent with treatment guidelines. In contrast, no clear preferred treatment choice was observed among patients receiving 2L or later (2L+) therapy. Notably, immunotherapy accounted for 21.6% of treatment regimens in 2L/3L overall, with its use increasing substantially over time (<6% in 2016 to 40.8% in 2019). Despite increased use of immunotherapy, however, most patients did not remain on treatment for prolonged durations (immunotherapy median duration 2.2 months vs 2.4 months for nonimmunotherapy; P = 0.5). Across most HCRU measures (inpatient admissions, outpatient visits, emergency department visits, and pharmacy claims), 2L+ patients had significantly less utilization per patient compared with 1L patients in unadjusted analyses. CONCLUSIONS: This analysis found that the majority of Medicaid patients with r/mCC received guideline-recommended standard of care in 1L between 2016 and 2019. However, there was no clear standard of care for patients with 2L+ r/mCC enrolled in Medicaid over this time period. Although immunotherapy use is increasing, short durations of treatment suggest a potential unmet medical need among this population. New therapies should provide meaningful clinical benefit without significant increase in HCRU for Medicaid enrollees needing treatment for r/mCC. DISCLOSURES: Dr Leath has received consulting fees from Seagen Inc. for service on Scientific Advisory Boards, cervical cancer research funding from Agenus, Rubius Therapeutics, and Seagen Inc., and funding from the NCI UG1 CA23330 and P50 CA098252. Dr Ting and Dr Zhang are employees and stock owners of Seagen Inc. Mr Fiori and Dr Pauly are current employees and Ms Nysenbaum is a former employee of Manatt Health Strategies, which received funding from Seagen Inc. to conduct the study described here. Manatt Health Strategies has also previously received consulting fees from other pharmaceutical companies that they are not permitted to publicly disclose. This research was funded by Seagen Inc. Seagen Inc. conceptualized the study approach, methodology, and contributed to article writing and review but was not involved in data acquisition, manipulation, or analysis.

Purpose: The TAPUR Study is a pragmatic basket trial evaluating antitumor activity of commercially available targeted agents in patients with advanced cancers harboring potentially actionable genomic alterations. Data from a cohort of patients with endometrial cancer (EC) with ERBB2 or ERBB3 (ERBB2/3) amplification, overexpression, or mutation treated with pertuzumab plus trastuzumab (P + T) are reported., Methods: Eligible patients had advanced EC, no standard treatment options, measurable disease (RECIST v1.1), Eastern Cooperative Oncology Group performance status 0-2, adequate organ function, and tumors with ERBB2/3 amplification, overexpression, or mutation. Simon's two-stage design was used with a primary end point of disease control (DC), defined as objective response (OR) or stable disease (SD) of at least 16 weeks (SD16+) duration. Secondary end points include safety, duration of response, duration of SD, progression-free survival (PFS), and overall survival (OS)., Results: Twenty-eight patients were enrolled from March 2017 to November 2019; all patients were evaluable for efficacy and toxicity. Seventeen patients had tumors with ERBB2/3 amplification and/or overexpression, eight with both ERBB2 amplification and ERBB2/3 mutations, and three with only ERBB2 mutations. Ten patients had DC (two partial response and eight SD16+); all 10 had ERBB2 amplification, and 6 of the 10 patients with DC had >1 ERBB2/3 alteration. DC and OR rates were 37% (95% CI, 21 to 50) and 7% (95% CI, 1 to 24), respectively; the median PFS and median OS were 16 weeks (95% CI, 10-28) and 61 weeks (95% CI, 24-105), respectively. One patient experienced a grade 3 serious adverse event (muscle weakness) at least possibly related to P + T., Conclusion: P + T has antitumor activity in heavily pretreated patients with EC with ERBB2 amplification and warrants additional study.

Purpose: To inform continued development of the novel immune agent GEN-1, we compared ovarian cancer patients' end points from a neoadjuvant single-arm phase IB study with those of similar historic clinical trial (HCT) patients who received standard neoadjuvant chemotherapy., Methods: Applying OVATION-1 trial (ClinicalTrials.gov identifier: NCT02480374) inclusion and exclusion criteria to Medidata HCT data, we identified historical trial patients for comparison. Integrating patient-level Medidata historic trial data (N = 41) from distinct neoadjuvant ovarian phase I-III trials with patient-level OVATION-1 data (N = 18), we selected Medidata patients with similar baseline characteristics as OVATION-1 patients using propensity score methods to create an external control arm (ECA)., Results: Fifteen OVATION-1 patients (15 of 18, 83%) were matched to 15 (37%, 15 of 41) Medidata historical trial control patients. Matching attenuated preexisting differences in attributes between the groups. The median progression-free survival time was not reached by the OVATION-1 group and was 15.8 months (interquartile range, 11.40 months to nonestimable) for the ECA. The hazard of progression was 0.53 (95% CI, 0.16 to 1.73), favoring GEN-1 patients. Compared with ECA patients, OVATION-1 patients had more nausea, fatigue, chills, and infusion-related reactions., Conclusion: Comparing results of a single-arm early-phase trial to those of a rigorously matched HCT ECA yielded insights regarding comparative efficacy prior to a randomized controlled trial. The effect size estimate itself informed both the decision to continue development and the randomized phase II trial (ClinicalTrials.gov identifier: NCT03393884) sample size. The work illustrates the potential of HCT data to inform drug development.

Objective: The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy., Methods: This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used., Results: We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5)., Conclusion: This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS., Competing Interests: Declaration of Competing Interest Dr. Leitao is an ad hoc speaker for Intuitive Surgical, Inc.; outside the submitted work, he is on the Advisory Board of Ethicon/Johnson & Johnson and Takeda; and reports grants paid to the institution by KCI/Acelity. Dr. Martino is a patient safety consultant for Intuitive Surgical, Inc. and Medtronic. Outside the submitted work, Dr. Iasonos reports consulting fees from Mylan; Dr. Abu-Rustum reports institutional grants from GRAIL; Dr. Shahin is a speaker/consultant for GSK/Tesaro, AstraZeneca, and Merck, and consultant for Biom'up and Aspira. All other authors have no potential conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years following diagnosis. The NCCN Guidelines for Ovarian Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with ovarian, fallopian tube, and primary peritoneal cancers. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines, including revised guidance on alternative chemotherapy regimens for patients with advanced age and/or comorbidities, a new algorithm for recurrent low-grade serous carcinoma based on developing research and novel therapeutic agents, and updated language regarding tumor molecular analysis applications in ovarian cancer.

Purpose of Review: In this review, we discuss modern cytokine delivery systems in oncologic care, focusing on modalities being developed in the clinical trials or currently in use. These include pegylation, immune-cytokine drug conjugates, cytokine-expressing plasmid nanoparticles, nonviral cytokine nanoparticles, viral systems, and AcTakines., Recent Findings: Cytokine therapy has the potential to contribute to cancer treatment options by modulating the immune system towards an improved antitumor response and has shown promise both independently and in combination with other immunotherapy agents. Despite promising preliminary studies, systemic toxicities and challenges with administration have limited the impact of unmodified cytokine therapy. In the last decade, novel delivery systems have been developed to address these challenges and facilitate cytokine-based oncologic treatments. Novel delivery systems provide potential solutions to decrease dose-limiting side effects, facilitate administration, and increase the therapeutic activity of cytokine treatments in oncology care. The expanding clinical and translational research in these systems provides an opportunity to augment the armamentarium of immune oncology and may represent the next frontier of cytokine-based immuno-oncology., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

In January 2021, the Society of Gynecologic Oncology (SGO) Clinical Practice and Education Committees launched a "Journal Club" webinar series to invite national experts to discuss literature pertaining to common clinical scenarios encountered by the members of SGO. On December 13, 2021, SGO hosted its third journal club focused on the use of immunotherapy in cervical cancer. Charles A. Leath, III from the O'Neal Comprehensive Cancer at the University of Alabama and Leslie M. Randall from Massey Cancer Center at Virginia Commonwealth University discussed the recently published KEYNOTE-826 trial (Colombo et al., 2021) and Jyoti Mayadev from the University of California, San Diego Moores Cancer Center discussed GOG-9929 (Mayadev et al., 2020). Renata Urban from the University of Washington and Christine S. Walsh from the University of Colorado served as moderators. The following is a report of the journal club presentation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Background: This study was performed to evaluate the barriers and facilitators associated with patient presentation for early stage (ES) versus advanced stage (AS) cervical cancer (CC)., Methods: A mixed-method approach was used to collect quantitative (i.e., demographics and medical/screening histories) and qualitative data (individual interviews assessing patients' perceptions regarding their general health, HPV and CC screening, and barriers and facilitators to CC care). Two separate investigators coded the interviews for major themes that occurred with an agreement that 50% or more of the themes would be included., Results: Twenty-five women agreed to participate in the study with 80% completing the interview. Patients with ES disease were classified as Stage IA1-Stage IB3; patients with Stage IIA-IVB disease were classified with AS disease. Frequent barriers in the ES group were lack of knowledge, competing priorities, feeling healthy, lack of time or health insurance, and being embarrassed/uncomfortable. Frequent barriers in the AS group were lack of knowledge, competing priorities, avoidance/procrastination, fear of the healthcare system or finding something wrong, and lack of perceived risk to CC. Facilitators for ES included understanding the importance of the Pap test, having an abnormal Pap test, and knowing someone with CC. Having abnormal symptoms was the only facilitator for AS patients., Conclusions: Structural and intrapersonal barriers to CC care persist but differ between ES and AS patients. Multi-level interventions are needed to address the wide array of issues that women highlighted in this study including potential innovative methods to increase access to care and engagement with the healthcare system., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Objective: To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery., Methods: This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26., Results: Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again., Conclusion: Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients with high-intermediate risk endometrial cancer (H-IR EMCA) have an elevated risk of recurrence compared to low-risk counterparts. Many H-IR EMCA patients are treated with radiation or chemotherapy, but their overall survival is not significantly impacted by treatment. The objective of this study was to compare molecular profiles of H-IR EMCA patients with disease recurrence to those without to identify characteristics that could better predict patient outcomes., Methods: Tissue was acquired from H-IR EMCA patients with disease recurrence (n=15) and without disease recurrence (n=15) who had not received adjuvant therapy and performed DNA and RNA analyses., Results: In recurrent population, 5 patients had matchingrecurrent and initial tumor tissues. Of note, 5/7 (71%) African Americanpatients had disease recurrence compared to 10/23 (43%) White patients. Inaddition, several new mutations were found in individual patient's recurrentcompared to initial tumors., Conclusions: Currently the treatment ofendometrial cancer is rapidly changing with molecular profiling becoming partof the standard of care. Additionally, it and is being incorporated intoclinical trials in this group of patients. The specific gene mutations and RNAexpression signatures that were observed in our small cohort need to bevalidated in larger cohorts to determine their impact., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: GEN-1 (phIL-12-005/PPC), an IL12 plasmid formulated with polyethyleneglycol-polyethyleneimine cholesterol lipopolymer, has preclinical activity when combined with platinum-taxane intravenous chemotherapy and administered intraperitoneally in epithelial ovarian cancer (EOC) models. OVATION I was a multicenter, nonrandomized, open-label phase IB trial to evaluate the safety, preliminary antitumor activity, and immunologic response to GEN-1 in combination with neoadjuvant chemotherapy (NACT) carboplatin-paclitaxel in patients with advanced EOC., Patients and Methods: A total of 18 patients with newly diagnosed stage IIIC and IV EOC were enrolled. A standard 3+3 dose-escalation design tested four GEN-1 doses (36, 47, 61, 79 mg/m 2 ) to determine the maximum tolerated dose and dose-limiting toxicities (DLTs). GEN-1 was administered in eight weekly intraperitoneal infusions starting at cycle 1 week 2 in combination with three 21-day cycles of NACT carboplatin AUC 6 and weekly paclitaxel 80 mg/m 2 ., Results: The most common treatment-emergent adverse events at least possibly related were nausea, fatigue, abdominal pain/cramping, anorexia, diarrhea, and vomiting. Eight patients experience grade 4 neutropenia attributed to NACT. No DLTs occurred. A total of 14 patients were evaluable for response and 12 (85.7%) had radiological response (two complete response and 10 partial response) prior to debulking; nine were R0 at debulking and one patient had complete pathologic response. IL12 and its downstream cytokine, IFNγ, increased in peritoneal washings but not as much in blood. Increased levels of myeloid dendritic cells and T-effector memory cells in peritoneal fluid, plus elevated CD8 + T cells and reduced immunosuppression within the tumor microenvironment were found. A median time to treatment failure of 18.4 months (95% confidence interval, 9.2-24.5) was observed in the intention-to-treat population., Conclusions: Adding GEN-1 to standard NACT is safe, appears active, and has an impact on the tumor microenvironment., (©2021 The Authors; Published by the American Association for Cancer Research.)

Background: Both incidence and mortality of uterine cancer are on the rise and mortality is higher for African American women. The aim of our study was to evaluate how Next Generation Sequencing (NGS) may facilitate identification of and intervention for treatment disparities when integrated into clinical workflows., Results: Our cohort included 159 uterine cancer patients with recurrent/progressive and newly diagnosed advanced stage and/or high-risk histology. The most common tumor histological subtypes included EEC (n = 67), SEC (n = 34), UCS (n = 20), and mixed (n = 14). Black patients were most likely to present with aggressive histology: (SEC, 34.0%) and carcinosarcoma (UCS, 14.0%). The four most common mutations across all subtypes were TP53, PIK3CA, PTEN, and ARID1A. There was racial disparity between Black versus non-Black patients who were initiated on targeted therapy (28.2% vs. 38.2%, respectively) and clinical trial (15% vs. 22.6%, respectively). Compared to non-Black patients, Black patients had a significantly higher percentage TP53 mutations (p < 0.05) and a significantly lower percentage ARID1A mutations (p < 0.05)., Conclusions: NGS for uterine malignancies provides actionable information for targetable mutations and/or clinical trial enrollment in most patients; further investigation is necessary to identify potentially modifiable factors contributing to current disparities that may improve targeted therapy uptake and clinical trial participation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To assess telemedicine readiness of gynecologic oncology patients, particularly those at risk for care access disparities (increased distance to care, rural populations.)., Methods: Patients at all disease/treatment stages completed an anonymous survey during in-person outpatient appointments at an academic comprehensive cancer center from 1/6/2020 to 2/28/2020, conducted prior to the COVID-19 pandemic, before the introduction of telemedicine in this practice., Results: Of 180 patients approached, 170 completed the survey (94.4%). Mean age was 59.6 years; 73.4% identified as White, 23.7% Black, and 2.9% other race. Ovarian cancer was most common (41.2%), followed by endometrial (27.1%), cervical (20.6%), and vaginal/vulvar (7.1%). Most patients traveled > 50 miles for appointments (63.8%); they were more likely from rural counties with significantly higher travel costs/visit ($60.77 vs $37.98, p = 0.026.) The majority expressed interest in using telemedicine (75.7%) or a smartphone app (87.5%) in their care. The majority of patients with difficulty attending appointments (88.9 vs 70.2%, p = 0.02) or from rural counties (88.7% vs 69.6%, p = 0.03) were interested in telemedicine; those with both characteristics reported 100% interest. The majority in both urban and rural counties had home internet access, and reported similarly high rates of daily use (79% vs 75%). Race and age were not associated with differences in internet access or use or telemedicine interest., Conclusions: Telemedicine is attractive to the majority of patients and may offer financial/logistical advantages. Patients have high internet use rates and comfort with using technology for healthcare. Telemedicine should be incorporated into standard practice beyond the COVID-19 pandemic to reduce healthcare access disparities., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: All authors have disclosed any potential conflicts of interest. Dr. Arend is on the Advisory Boards/Data Safety Monitoring Boards for Clovis, Leap Therapeutics, Astra Zeneca, Merck, VBL Therapeutics, Caris Life Sciences, KIYATEC, Glaxo SmithKline, Sutro, and Seagen. Dr. Huh reports consulting fees from LICOR, Astra Zeneca, and DYSIS. He also serves on the Advisory Boards/Data Safety Monitoring Boards for INOVIO and SYNIOS/AGENUS. None of the other authors report a significant conflict of interest related to this study., (© 2021 The Authors.)

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.