Predictors of palliative care consultation on an inpatient gynecologic oncology service: Are we following ASCO recommendations?

Objective

Determine predictors of inpatient palliative care (PC) consultation and characterize PC referral patterns with respect to recommendations from the American Society of Clinical Oncology (ASCO).

Methods

Women with a gynecologic malignancy admitted to the gynecologic oncology service 3/2012–8/2012 were identified. Demographic information, disease and treatment details and date of death were abstracted from medical records. Student's t-test, Fischer's exact test or χ²-test was used for univariate analysis. Binomial logistic regression was used for multivariate analysis.

Results

Of 340 patients analyzed, 82 (24%) had PC consultation. Univariate predictors of PC consultation included race, cancer type and stage, recurrent disease, admission frequency, admission for symptom management or malignant bowel obstruction (MBO), discharge to skilled nursing facility (SNF) and number of lines of chemotherapy. On multivariate analysis, significant predictors of PC consultation were recurrent disease (OR 2.4, 95% CI 1.1–5.3), number of admissions (≥ 3, OR 10.9, 95% CI 3.4–34.9), admission for symptom management (OR 19.4, 95% CI 7.5–50.1), discharge to SNF (OR 5, 95% CI 1.9–13.5) and death within 6 months (OR 16.5, 95% CI 6.9–39.5). Of patients considered to meet ASCO guidelines, 53% (63/118) had PC referral. Of patients referred to PC, 51.2% (42/82) died within 6 months of last admission.

Conclusions

Patients referred to inpatient PC have high disease and symptom burden and poor prognosis. High-risk patients, including those meeting ASCO recommendations, are not captured comprehensively. We continue to use PC referrals primarily for patients near the end of life, rather than utilizing early integration as recommended by ASCO.     

Epidemiologic profile,survival, and maternal prognosis factors among women at an obstetric intensive care unit

Objective

To identify the epidemiologic profile, maternal survival, and prognosis factors that might affect survival rates in the obstetric intensive care unit (ICU).

Methods

A prospective cohort study was conducted between January 2007 and February 2009 in a tertiary referral ICU, Belo Horizonte, Brazil. Critical patients during pregnancy and puerperium were followed from admission until discharge or death. Maternal survival was assessed in association with the cause of ICU admission, grouped into direct or indirect obstetric causes, by Kaplan–Meier curves and log-rank tests.

Results

Among 298 patients admitted to the ICU during the study period, mortality was 4.7% (n = 14). Hypertensive disorders (46.0%), hemorrhage (15.9%), sepsis (14.2%), and heart disease (5.7%) were the main causes of admission. Half of the patients who died were admitted for direct obstetric reasons (n = 7). Survival was statistically linked to the cause of admission: most survivors were admitted for a direct obstetric cause (75.5%; P = 0.044). Maternal survival rates of patients admitted for indirect obstetric causes were lower than those admitted for direct obstetric causes (27.8 and 19.6 days, respectively; P = 0.019).

Conclusion

The main cause of admission was a decisive factor for maternal survival in the obstetric ICU. Direct obstetric complications had a better prognosis.     

Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers

Objectives

To evaluate some health indicators in women with advanced breast or gynecological cancers (ABGCs) after discontinuation of active cancer treatment in function of the model of care received.

Methods

This prospective study included patients who were discontinuing anticancer treatment to be followed up only with palliative care (PC). Patients who had been evaluated at least once in PC were categorized as the integrated care model (ICM); those who had not been consulted by the PC team before, as the traditional care model (TCM). Data were analyzed using chi-square, Mann–Whitney, Kaplan–Meier, and Cox regression model.

Results

Among the 87 patients included in the study, 37 (42.5%) had been previously evaluated by the PC team (ICM). Patients who were followed up under an ICM exhibited better QoL (global health, p = 0.02; emotional functioning, p = 0.03; social functioning, p = 0.01; insomnia, p = 0.02) and less depression (p = 0.01). The communication process had no issues in 73% of cases from the ICM group compared with 42% of cases from the TCM group (p = 0.004). Patients who were not previously evaluated in PC received more chemotherapy in the last 6 weeks of life compared to those who had already been evaluated (40% versus 5.9%, p = 0.001). Early evaluation in PC was one of the independent prognostic factors of overall survival.

Conclusion

When followed up concurrently by a PC and clinical oncology team, patients reported better QoL and less depression, received less chemotherapy within the last 6 weeks of life and survived longer than those followed up under a TCM.     

Development and pilot of an advance care planning website for women with ovarian cancer: A randomized controlled trial

Objective

Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer.

Methods

Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation.

Results

At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p = 0.220) or palliative care consultation (p = 0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p = 0.054) and quality (p = 0.119) of information and when they accessed the website, used it longer (p = 0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers.

Conclusions

A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research.     

The utilization of palliative care in gynecologic oncology patients near the end of life

Background

Palliative and supportive care services provide excellent care to patients near the end of life. It is estimated that enrollment in such services can reduce end-of-life costs; however, there is limited data available regarding the impact of palliative services in end-of-life care in gynecologic oncology patients. We examined the use of palliative services in gynecologic oncology patients during the last six months of life.

Methods

After IRB approval, a retrospective chart review of patients with a diagnosis of a gynecologic malignancy who died between June 2007 and June 2010 was performed. Abstracted data included demographics, admission and procedural history, use of anti-cancer therapy, and palliative care utilization during the last six months of life.

Results

268 patients were identified. Most patients were white (76.9%) and had ovarian cancer (56.7%). During the last six months of life, 155 (57.8%) patients underwent anti-cancer therapy with chemotherapy, 19 (7.1%) patients were treated with radiation therapy, and 17 patients (6.3%) underwent treatment with both. 218 patients (81.3%) had at least one admission during this time (range 0-14). The most common reason for admission was gastrointestinal complaints (37.1%), followed by admissions for procedures (18.3%). The median time between the last admission and death was 32 days. 157 patients (58.6%) underwent at least one procedure during the last six months of life (range 0-11). The most common procedure performed was paracentesis (22.6%). 198 (73.9%) patients died at home or in a palliative care unit. 189 (70.5%) patients were referred to hospice or palliative care. 3.2% underwent a procedure or treatment with chemotherapy or radiation after hospice enrollment. The median time between hospice enrollment and death was 22 days. 55% of patients were enrolled in hospice less than 30 days before death. Of the 79 patients not referred to hospice, only 16.5% had documentation of refusing hospice services.

Conclusions

During the last six months of life, the majority of gynecologic oncology patients receive anticancer therapy and many have repeated hospital admissions. While the majority of patients are referred for palliative care, it appears that most patients spend less than 30 days on hospice. Earlier referral could decrease the number of hospital admissions and procedures while providing invaluable support during this end of life transition.     

Missed opportunities: Patterns of medical care and hospice utilization among ovarian cancer patients

Objectives

To assess aggressive medical care, hospice utilization, and advance care documentation among ovarian cancer patients in the final thirty days of life.

Methods

Ovarian, fallopian tube, or primary peritoneal cancer patients registered at our institution during 2007–2011 were identified. Statistical analyses included Wilcoxon–Mann–Whitney, Chi-square analysis, and multivariate analysis.

Results

183 patients met inclusion criteria. Median age at diagnosis was 58. Most were white and had advanced ovarian cancer.Fifty percent had experienced at least one form of aggressive care during the last 30 days of life. Patients with provider recommendations to enroll in hospice were more likely to do so (OR 27.7, p = < 0.001), with a median hospice stay of 18 days before death.Seventy-five percent had an in-hospital DNR order and 33% had an out-of-hospital DNR order. These orders were created a median of 15 and 12 days prior to death, respectively. Twenty-eight percent had a Medical Power of Attorney and 20% had a Living Will. These documents were created a median of 381 and 378 days prior to death, respectively.

Conclusions

Many ovarian cancer patients underwent some form of aggressive medical care in the last 30 days of life. The time between hospice enrollment and death was short. Patients created Medical Power of Attorney and Living Will documents far in advance of death. DNR orders were initiated close to death.     

High-volume ovarian cancer care: Survival impact and disparities in access for advanced-stage disease

Objective

To characterize the impact of hospital and physician ovarian cancer case volume on survival for advanced-stage disease and investigate socio-demographic variables associated with access to high-volume providers.

Methods

Consecutive patients with stage IIIC/IV epithelial ovarian cancer (1/1/96–12/31/06) were identified from the California Cancer Registry. Disease-specific survival analysis was performed using Cox-proportional hazards model. Multivariate logistic regression analyses were used to evaluate for differences in access to high-volume hospitals (HVH) (≥ 20 cases/year), high-volume physicians (HVP) (≥ 10 cases/year), and cross-tabulations of high- or low-volume hospital (LVH) and physician (LVP) according to socio-demographic variables.

Results

A total of 11,865 patients were identified. The median ovarian cancer-specific survival for all patients was 28.2 months, and on multivariate analysis the HVH/HVP provider combination (HR = 1.00) was associated with superior ovarian cancer-specific survival compared to LVH/LVP (HR = 1.31, 95%CI = 1.16–1.49). Overall, 2119 patients (17.9%) were cared for at HVHs, and 1791 patients (15.1%) were treated by HVPs. Only 4.3% of patients received care from HVH/HVP, while 53.1% of patients were treated by LVH/LVP. Both race and socio-demographic characteristics were independently associated with an increased likelihood of being cared for by the LVH/LVP combination and included: Hispanic race (OR = 1.72, 95%CI = 1.22–2.42), Asian/Pacific Islander race (OR = 1.57, 95%CI = 1.07–2.32), Medicaid insurance (OR = 2.51, 95%CI = 1.46–4.30), and low socioeconomic status (OR = 2.84, 95%CI = 1.90–4.23).

Conclusions

Among patients with advanced-stage ovarian cancer, the provider combination of HVH/HVP is an independent predictor of improved disease-specific survival. Access to high-volume ovarian cancer providers is limited, and barriers are more pronounced for patients with low socioeconomic status, Medicaid insurance, and racial minorities.     

Patterns of care,predictors, and outcomes of chemotherapy in elderly women with early-stage uterine carcinosarcoma: A population-based analysis

Objective

To examine the patterns of care, predictors, and impact of chemotherapy on survival in elderly women diagnosed with early-stage uterine carcinosarcoma.

Methods

The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women 65 years or older diagnosed with stage I–II uterine carcinosarcomas from 1991 through 2007. Multivariable logistic regression and Cox-proportional hazards models were used for statistical analysis.

Results

A total of 462 women met the eligibility criteria; 374 had stage I, and 88 had stage II uterine carcinosarcomas. There were no appreciable differences over time in the percentages of women administered chemotherapy for early stage uterine carcinosarcoma (14.7% in 1991–1995, 14.9% in 1996–2000, and 17.9% in 2001–2007, P = 0.67). On multivariable analysis, the factors positively associated with receipt of chemotherapy were younger age at diagnosis, higher disease stage, residence in the eastern part of the United States, and lack of administration of external beam radiation (P < 0.05). In the adjusted Cox-proportional hazards regression models, administration of three or more cycles of chemotherapy did not reduce the risk of death in stage I patients (HR: 1.45, 95% CI: 0.83–2.39) but was associated with non-significant decreased mortality in stage II patients (HR: 0.83, 95% CI: 0.32–1.95).

Conclusions

Approximately 15–18% of elderly patients diagnosed with early-stage uterine carcinosarcoma were treated with chemotherapy. This trend remained stable over time, and chemotherapy was not associated with any significant survival benefit in this patient population.     

Quality of life of infertile Tunisian couples and differences according to gender

Objective

To compare quality-of-life gender differences within infertile couples from Tunisia and between infertile couples and controls.

Methods

The present case–control study included 100 couples with primary infertility who, during 2009, underwent assisted reproductive technology at Farhat Hached Hospital in Sousse, Tunisia, and 100 control couples. The 36-item Short-Form Health Survey (SF-36) was administered to assess quality of life.

Results

Compared with male controls, men in the infertility group had lower scores in the mental dimension (P = 0.020), social functioning (P = 0.007), and role–emotional (P < 0.001) categories of the SF-36. Women in the infertility group had lower mental and physical dimension scores (P < 0.001) and lower vitality (P = 0.022), social functioning (P < 0.001), role–emotional (P < 0.001), and mental health (P < 0.001) scores than female controls. Within infertile couples, female partners had lower total (P = 0.01) and mental dimension (P < 0.001) scores than their spouses. Delay of the first consultation was correlated with bodily pain, vitality, and mental health among women in the infertility group.

Conclusion

Women in infertile couples had a lower quality of life than their spouses, and infertile couples had a lower quality of life than controls. These findings confirm the need for psychological support for infertile couples.     

Economic analysis comparing induction of labour and expectant management for intrauterine growth restriction at term (DIGITAT trial)

Objective

Pregnancies complicated by intrauterine growth restriction (IUGR) are at increased risk for neonatal morbidity and mortality. The Dutch nationwide disproportionate intrauterine growth intervention trial at term (DIGITAT trial) showed that induction of labour and expectant monitoring were comparable with respect to composite adverse neonatal outcome and operative delivery. In this study we compare the costs of both strategies.

Study design

A cost analysis was performed alongside the DIGITAT trial, which was a randomized controlled trial in which 650 women with a singleton pregnancy with suspected IUGR beyond 36 weeks of pregnancy were allocated to induction or expectant management. Resource utilization was documented by specific items in the case report forms. Unit costs for clinical resources were calculated from the financial reports of participating hospitals. For primary care costs Dutch standardized prices were used. All costs are presented in Euros converted to the year 2009.

Results

Antepartum expectant monitoring generated more costs, mainly due to longer antepartum maternal stays in hospital. During delivery and the postpartum stage, induction generated more direct medical costs, due to longer stay in the labour room and longer duration of neonatal high care/medium care admissions. From a health care perspective, both strategies generated comparable costs: on average €7106 per patient for the induction group (N = 321) and €6995 for the expectant management group (N = 329) with a cost difference of €111 (95%CI: €−1296 to 1641).

Conclusion

Induction of labour and expectant monitoring in IUGR at term have comparable outcomes immediately after birth in terms of obstetrical outcomes, maternal quality of life and costs. Costs are lower, however, in the expectant monitoring group before 38 weeks of gestation and costs are lower in the induction of labour group after 38 weeks of gestation. So if induction of labour is considered to pre-empt possible stillbirth in suspected IUGR, it is reasonable to delay until 38 weeks, with watchful monitoring.     

Impact of facility volume on therapy and survival for locally advanced cervical cancer

Objective

Chemosensitizing radiation with brachytherapy is standard of care for treatment of locally advanced cervical cancer, an increasingly rare disease. Treatment facility volume has been correlated with outcome in many diseases. Treatment outcome and likelihood of receiving standard therapy in locally advanced cervical cancer based on facility volume were examined using a large national cancer database.

Methods

The National Cancer Data Base was queried for patients with stage IIB – IIIB cervical cancer from 1/1998 through 12/2010. Facility volumes were tallied. Overall survival was estimated using Kaplan–Meier method. Univariate and multivariable analyses were performed to determine variables affecting survival, receiving standard therapy, and total duration of radiotherapy.

Results

We identified a total of 27,660 patients who were treated at 1361 facilities. Thirty of the facilities (2.2%) treated the highest quartile volume of patients (> 9.4 patients annually) while 1072 facilities (78.8%) treated < 2.4 patients annually. The median age of patients was 53, the majority were Caucasian, treated in a metropolitan area, and of squamous cell histology. Median survival of patients treated at lowest- and highest-volume centers were 42.3 months (95% CI 39.8–44.8) and 53.8 months (50.1–57.5), respectively (p < 0.001). The proportions of patients receiving brachytherapy and chemotherapy were 54.8% and 79.9%, respectively. On multivariable analysis, higher facility volume independently predicted improved survival (p = 0.022), increased likelihood of receiving brachytherapy (p < 0.0005) and chemotherapy (p = 0.013), and shorter time to radiotherapy completion (p < 0.0005).

Conclusions

Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy, complete therapy sooner, and experience better survival.     

Obstetric and neonatal outcomes of twin pregnancies conceived by assisted reproductive technology compared with twin pregnancies conceived spontaneously: a prospective follow-up study

Objective

To compare the obstetric and neonatal outcomes of twin pregnancies conceived by assisted reproduction technology (ART) with spontaneously conceived (SC) twin pregnancies.

Study design

A prospective cohort study compared all dichorionic twin pregnancies in nulliparous women following fresh in vitro fertilization/intra-cytoplasmic sperm injection (ICSI) or ICSI cycles at Royan Institute (n = 320) with SC dichorionic twin pregnancies in nulliparous women at Arash Women's hospital (n = 170) from January 2008 to October 2010. These pregnancies were followed-up until hospital discharge following delivery. Obstetric and neonatal outcomes of SC and ART twin pregnancies were compared.

Results

Multivariate analysis, adjusted for maternal age and body mass index, revealed that the obstetric outcomes were similar in both groups. However, the risks of very preterm birth [odds ratio (OR) 5.2, 95% confidence interval (CI) 2.1–12.9], extremely low birth weight (OR 2.2, 95% CI 1.0–3.9), admission to a neonatal intensive care unit (OR 2.0, 95% CI 1.2–3.2) and perinatal mortality (OR 2.3, 95% CI 1.2–4.0) were higher in the ART group.

Conclusions

The maternal outcomes of ART dichorionic twins were comparable with those of SC twins. However, despite the same obstetric management, the rates of very preterm birth, extremely low birth weight, admission to a neonatal intensive care unit and perinatal mortality were significantly higher in the ART group.     

Surgical outcomes and national comprehensive cancer network compliance in advanced ovarian cancer surgery in a low volume military treatment facility

Objective

To evaluate the optimal cytoreduction (OPT) rate, National Comprehensive Cancer Network (NCCN) treatment guideline compliance rate and patient outcomes for advanced stage epithelial ovarian cancer (EOC) patients at our low volume institution.

Methods

Following IRB approval, records of patients with Stage III-IV EOC, primary peritoneal, or fallopian tube carcinoma completing both primary surgery and adjuvant chemotherapy were reviewed. Patient demographics, clinicopathologic variables, cytoreduction status (optimal or suboptimal), NCCN treatment guideline compliance, and survival were reviewed. Standard statistical tests including the t-test, Chi-square or Fisher's exact test and Kaplan–Meier Survival curves were utilized.

Results

Overall, 48 patients met all inclusion criteria. 35(73%) and 13 (27%) achieved optimal and suboptimal cytoreduction, respectively. Median overall survival (OS) for all patients was 37.1 months (95% CI 23.2 – 51.1 months) and NCCN treatment guideline compliance was 85.4%. Compared to sub-optimally cytoreduced patients the optimally cytoreduced patients were significantly older (62.2 vs. 53.5 yrs; p = 0.015); no other significant clinicopathologic differences were observed between the two groups. 19 of 48 (39.6%) patients enrolled in an upfront cooperative group trial. Median OS was 43.4 months for optimally compared to 15.6 months in sub-optimally cytoreduced patients (p = 0.012).

Conclusions

NCCN treatment guideline compliance, OPT, and median OS rates in our low volume institution are similar to those reported nationally, and argue against using volume alone as a rationale for centralization of care.     

The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications

Objective

This study aimed to report the feasibility and safety of same-day discharge after robotic-assisted hysterectomy.

Methods

Same-day discharge after robotic-assisted hysterectomy was initiated 07/2010. All cases from then through 12/2012 were captured for quality assessment monitoring. The distance from the hospital to patients' homes was determined using http://maps.google.com. Procedures were categorized as simple (TLH +/− BSO) or complex (TLH +/− BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy). Urgent care center (UCC) visits and readmissions within 30 days of surgery were captured, and time to the visit was determined from the initial surgical date.

Results

Same-day discharge was planned in 200 cases. Median age was 52 years (range, 30–78), BMI was 26.8 kg/m² (range, 17.4–56.8), and ASA was class 2 (range, 1–3). Median distance traveled was 31.5 miles (range, 0.2–149). Procedures were simple in 109 (55%) and complex in 91 (45%) cases. The indication for surgery was: endometrial cancer (n = 82; 41%), ovarian cancer (n = 5; 2.5%), cervical cancer (n = 8; 4%), and non-gynecologic cancer/benign (n = 105; 53%). One hundred fifty-seven (78%) had successful same-day discharge. Median time for discharge for these cases was 4.8 h (range, 2.4–10.3). Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. UCC visits occurred in 8/157 (5.1%) same-day discharge cases compared to 5/43 (11.6%) requiring admission (P = .08). Readmission was necessary in 4/157 (2.5%) same-day discharge cases compared to 3/43 (7.0%) requiring admission (P = .02).

Conclusions

Same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe.     

Incidence and risk factors for early neonatal mortality in newborns with severe perinatal morbidity in Uganda

Objective

To determine the incidence and risk factors for early neonatal death among newborns with severe perinatal morbidity.

Methods

A prospective cohort study was performed of 341 newborns with severe perinatal morbidity admitted to the neonatal intensive care unit of Mulago Hospital, Uganda. All newborns were followed up for 7 days or until time of death. Information surrounding the mother’s obstetric history and pregnancy, the birth, and the neonatal history was collected using an interviewer-administered questionnaire and by review of relevant records. Multivariate logistic regression analysis was performed to assess factors independently associated with early neonatal death.

Results

A total of 37 (10.9%) neonates died within 7 days, giving an incidence of early neonatal death of 109 deaths per 1000 live births (3 per 100 person-days). In multivariate analysis, respiratory distress (adjusted risk ratio [aRR] 31.29; 95% CI, 4.17–234.20; P = 0.001) and inadequate fetal heart monitoring during labor (aRR 6.0; 95% CI 1.40–25.67; P = 0.016) were significantly associated with an increased risk of early neonatal death.

Conclusion

Approximately one in 10 neonates with severe perinatal morbidity died within 7 days of birth. Respiratory distress and poor monitoring of labor were risk factors for early neonatal death.     

The value of imaging of the lungs in the diagnostic workup of patients with endometrial cancer

Objective

Imaging of the lungs is part of the routine diagnostic workup of patients with endometrial cancer. The present study aimed to determine the incidence of lung metastases in patients with endometrial cancer and to evaluate the clinical relevance of preoperative chest imaging in this population.

Methods

A retrospective cross-sectional study was performed in four regional and one university hospital in the southeastern part of the Netherlands. A total of 784 patients with epithelial endometrial cancer diagnosed between 2002 and 2010 in five hospitals were included. Patients were followed up for at least 1 year.

Results

Of 784 patients, 541 (69.0%) underwent thoracic imaging and 11 showed findings suspicious for metastases perioperatively or during the 1-year follow-up period. In eight patients, the thoracic metastases were related to their endometrial cancer, resulting in an overall incidence of 1.0% (8/784, 95% CI = 0.3–1.7%). These eight patients had high-risk subtypes of endometrial cancer (serous, clear cell or poorly differentiated endometrioid), and the incidence was 4.1% (8/193, 95% CI = 1.9–8.3%) for these subtypes. Lung metastases were not detected in any of the patients with low-risk subtypes of endometrial cancer (n = 566) at the time of diagnosis (95% CI = 0–0.8%).

Conclusions

The probability of detecting thoracic metastases during the diagnostic workup of patients with endometrial cancer is low. The present data suggest that thoracic imaging could be omitted from the diagnostic workup of patients with low-risk endometrial cancer.     

Integrating a complementary medicine consultation for women undergoing chemotherapy

Objective

To explore oncology healthcare providers’ (HCPs’) patterns of referral of women undergoing chemotherapy to a complementary medicine (CM) consultation integrated within a conventional oncology service.

Methods

Oncology HCPs used a structured referral system for referral to an integrative physician (IP) for CM consultation. Referral goals were in accordance with a specified list of quality-of-life (QOL) outcomes.

Results

In total, the study HCPs referred 282 female patients, of whom 238 (84.4%) underwent CM consultation by the study IP: 59 (24.8%) with gynecologic cancer and 179 (75.2%) with non-gynecologic cancer. Use of CM for cancer-related outcomes was significantly higher among referred patients with gynecologic cancer than those with non-gynecologic cancer (69.5% vs 46.9%; P = 0.003). Oncologists initiated most of the referrals in the gynecologic oncology group, whereas oncologic nurses referred most patients in the non-gynecologic oncology group. Among patients with gynecologic cancer, the correlation between HCP indication and patient expectation was high for gastrointestinal concerns (κ 0.41).

Conclusion

The integration of a structured and informed process of referral to CM consultation may enhance patient-centered care and QOL during chemotherapy.     

Maternal and neonatal outcomes following additional doses of vaginal prostaglandin E2 for induction of labour: a retrospective cohort study

Objective

To assess maternal and neonatal outcomes following the use of additional doses of vaginal prostaglandins (PGE2) above the recommended dose for induction of labour in post-dates pregnancies.

Study design

Retrospective cohort study set in Aberdeen Maternity Hospital, Aberdeen, UK. A total of 3514 nulliparous women with labour induced with vaginal PGE2 (3 mg tablet or 2 mg gel) for a post-dates singleton pregnancy from January 1994 to December 2009 were included. Women receiving ≤ 2 doses of PGE2 were compared with those receiving > 2 doses (maximum 5 doses). Binary logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Primary outcomes included mode of delivery, terbutaline use, indication for CS, postpartum haemorrhage, neonatal unit admission, and Apgar score < 7. A further analysis was conducted which stratified for number of doses of PGE2 given.

Results

Of the 3514 women who met inclusion criteria, 605 (17%) received PGE2 that exceeded the licensed dose. They were more likely to deliver by caesarean section (53.4% vs. 31.8%, OR 2.2, 95% CI 1.8–2.6), have a caesarean section for ‘failed’ induction of labour (11.4% vs. 1.9%, OR 4.1, 95% CI 1.3–13.2) or lack of progress in labour (37% vs. 17%, OR 2.8, 95% CI 2.3–3.4), but not for fetal concerns (8.2% vs. 8.8% OR 0.9, 95% CI 0.7–1.3). Terbutaline use and postpartum haemorrhage was no more likely (0.7% vs. 0.9% OR 0.6 95% CI 0.3–1.5 and 19.8% vs. 18.9% OR1.01, 95% CI 0.97–1.06 respectively). Apgar score < 7 (1.1% vs. 1.3% OR 0.9 95% CI 0.8–1.1) and neonatal unit admission (13.7% vs. 10.7% OR 1.2 95% CI 0.8–1.6) were similar in both groups.

Conclusion

The use of additional doses of vaginal PGE2 above the recommended dose for induction of labour was not associated with increased maternal or neonatal morbidity and almost half of these women achieved a vaginal delivery.     

Does neoadjuvant chemotherapy impair long-term survival for ovarian cancer patients? A nationwide Danish study

Objective

In Denmark, the proportion of women with ovarian cancer treated with neoadjuvant chemotherapy (NACT) has increased, and the use of NACT varies among center hospitals. We aimed to evaluate the impact of first-line treatment on surgical outcome and median overall survival (MOS).

Methods

All patients treated in Danish referral centers with stage IIIC or IV epithelial ovarian cancer from January 2005 to October 2011 were included. Data were obtained from the Danish Gynecological Cancer Database, the Danish National Patient Register and medical records.

Results

Of the 1677 eligible patients, 990 (59%) were treated with primary debulking surgery (PDS), 515 (31%) with NACT, and 172 (10%) received palliative treatment. Of the patients referred to NACT, 335 (65%) received interval debulking surgery (IDS). Patients treated with NACT–IDS had shorter operation times, less blood loss, less extensive surgery, fewer intraoperative complications and a lower frequency of residual tumor (p < 0.05 for all). No difference in MOS was found between patients treated with PDS (31.9 months) and patients treated with NACT–IDS (29.4 months), p = 0.099. Patients without residual tumor after surgery had better MOS when treated with PDS compared with NACT–IDS (55.5 and 36.7 months, respectively, p = 0.002). In a multivariate analysis, NACT–IDS was associated with increased risk of death after two years of follow-up (HR: 1.81; CI: 1.39–2.35).

Conclusions

No difference in MOS was observed between PDS and NACT–IDS. However, patients without residual tumor had superior MOS when treated with PDS, and NACT–IDS could be associated with increased risk of death after two years of follow-up.