Palliative care in gynaecological oncology

Women with a gynaecological malignancy often suffer significant symptom burden, both physically and psychologically, throughout the course of their disease. Despite advances in treatment, up to 25% of women diagnosed with a gynaecological malignancy will die from recurrent disease. Early palliative care involvement can provide a holistic approach to care with the benefit of improving symptom control and quality of life for both the patient and carer as well as lowering resource utilisation at the end of life. Palliative care can be offered alongside curative or life prolonging treatment as well as at end of life. This article reviews the management of common physical symptoms and complications experienced by patients with advanced gynaecological malignancy.     

Palliative care in gynaecological oncology

More than 20,000 new gynaecological malignancies are diagnosed each year. Sadly in many cases the disease is too advanced to be cured and management focuses on prolonging life and palliation of symptoms. Palliative care is a holistic approach to caring for individuals with advanced disease. It is multidisciplinary and aims to improve the overall quality of life for patients and their families. Provision of palliative care is not universal and management of symptoms both physical and psychological has been found to be suboptimal in many settings in the UK and worldwide. The World Health Organisation has targeted palliative care as a clinical priority.This article reviews management of physical symptoms; including pain, psychological and social support, and discusses issues around end of life care.     

Should we centralise care for the patient suspected of having ovarian malignancy?

Objectives

Outcome of ovarian cancer is better when surgery is provided by a gynaecological oncologist than by a general gynaecologist. However, when all patients with an adnexal mass have to be operated by gynaecological oncologists, this requires a change in the organisation of care, which generates additional costs. In this study, we assess the costs and effects of centralised and regular care for women with an ovarian malignancy in the Netherlands.

Methods

We performed a cost-effectiveness analysis. We considered three strategies. In the first strategy, patients were operated by a general gynaecologist (general care strategy). In the second strategy, patients were operated by a gynaecological oncologist (specialised care strategy). In the third strategy, evaluation of the adnexal mass took place prior to surgery by means of the Risk of Malignancy Index (diagnostic strategy). Patients at high risk for malignancy were supposed to be operated in a specialised care setting, whereas low risk patients were supposed to be operated in a general care setting. For each strategy we calculated life expectancy and incremental costs per life year gained (LYG).

Results

Mean life expectancy of a patient with an ovarian malignancy in the general strategy was 2.7 years, in the diagnostic strategy 3.0 years and in the specialised strategy 3.1 years. The incremental costs to gain one additional life year with specialised surgery as compared to the diagnostic strategy were €61,871 per LYG.

Conclusion

In women with an adnexal mass, a diagnostic strategy prior to the decision for surgery by a general gynaecologist or a gynaecological oncologist provides the best balance between costs and effects.     

Palliative care in gynaecological oncology

Gynaecological malignancy accounts for significant patient morbidity and mortality. Clinical aims focus upon palliative management and supportive care when potentially curative treatment options are exhausted. Patients with recurrent, advancing or terminal disease may suffer severe and distressing physical and psychological effects associated with both cancer diagnosis and treatments. It is of paramount importance that patients, families and carers are provided with the assistance they need to have as high a quality of life as possible.This review focuses upon the provision of relief from pain and other distressing symptoms commonly associated with gynaecological malignancy. In addition, we highlight some of the important aspects of psychosocial care.     

Palliative care in gynaecological oncology

Gynaecological malignancy accounts for significant patient morbidity and mortality. Clinical aims focus upon palliative management and supportive care when potentially curative treatment options are exhausted. Patients with recurrent, advancing or terminal disease may suffer severe and distressing physical and psychological effects associated with both cancer diagnosis and treatments. It is of paramount importance that patients, families and carers are provided with the assistance they need to have as high a quality of life as possible.This review focuses upon the provision of relief from pain and other distressing symptoms commonly associated with gynaecological malignancy. In addition, we highlight some of the important aspects of psychosocial care.     

Imaging malignant gynaecological conditions

Radiology continues to play an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilised to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

Imaging malignant gynaecological conditions

Radiology plays an essential role in the management of malignant gynaecological conditions. Multiple imaging modalities are utilized to investigate suspected gynaecological malignancy including: ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. Each modality has a different role in diagnosis, staging, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging of malignant gynaecological disease. The imaging findings of common female pelvic pathology are discussed and illustrated.     

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.     

The clinical nurse specialist in gynaecological oncology-the role in vulval cancer

Gynaecological malignancy has an immense impact on the well-being of women. In order for these women clearly to understand their disease, investigations, treatment options and prognosis, it is essential that high-quality information be delivered in an appropriate environment. Effective communication is the essence of good relationships between the health professional and the patient. Patients' psychological, social and sexual rehabilitation following treatment for gynaecological cancer demand a holistic, pro-active approach by professionals who are skilled in the provision of this care. Within a multidisciplinary team (MDT), the clinical nurse specialist (CNS) is in a key position to be able to address these often complex and sensitive issues. This chapter explores the unique role of the CNS in the care of gynaecological cancer patients, and the care of vulval cancer patients in particular. The successful development of medical/nursing partnerships enables women with gynaecological cancer to gain proper access to essential expert knowledge and information and thereby to make informed decisions.     

Gastrointestinal problems in patients with advanced gynaecological malignancy

Gastrointestinal problems are among the most common problems encountered in the management of women with far advanced gynaecological malignancy. They frequently have a multifactorial aetiology and may require a number of different strategies for effective management. Recognition of the central role of alimentary function in human life is essential to effective treatment. Elucidation of the probable cause of each problem is essential. A thorough knowledge of the natural history of the disease and the patient's current status and future prospects is needed to ensure the highest standard of care for the individual suffering from the problem.     

Ovarian cancer: current management and future directions

Of all the gynaecological malignancies ovarian cancer has the highest mortality. Different types of ovarian cancer vary significantly in their clinical and molecular characteristics and Epithelial ovarian cancer (EOC) is the most common subtype. Up to 20% of women with epithelial ovarian cancer have an inherited predisposition. The fallopian tubes are a potential source of high-grade serous cancer and risk reducing surgery can be an option. Routine screening with serum CA 125 and pelvic ultrasonography is still unproven. Diagnosis of ovarian tumours is usually made by pelvic ultrasonography and serum CA 125. The risk of malignancy index (RMI) is then calculated in order to decide where treatment takes place. Treatment of advanced ovarian cancer usually involves primary debulking surgery and adjuvant chemotherapy but neo-adjuvant chemotherapy with interval debulking surgery is equally effective. Survival is improved if surgery is performed by a specialist gynaecological oncologist. Recent evidence supports the value of radical surgery aiming to excise all macroscopic disease. Standard first line chemotherapy for epithelial ovarian cancer remains carboplatin with paclitaxel. BRAC mutation testing is frequently used to direct second line chemotherapy and molecular targeted treatments such as bevacizumab and PARP inhibitors have been added to the armoury against ovarian cancer. Treatment of advanced disease may prolong life and palliate symptoms but it is rarely curative. Novel drugs and approaches such as ultra-radical surgery, intra-peritoneal chemotherapy, and surgery for recurrent disease are being assessed.     

Implications of obesity on gynaecological surgery

Obesity is a global health epidemic with a rising trend. There are well-established links between obesity and benign gynaecological pathology, premalignant gynaecological conditions and gynaecological malignancy. Obese women may need surgery just as non-obese women do, hence clinicians should be well versed with the impact of obesity on the woman's physiology, the surgical challenges and the effects of obesity on surgical outcomes. Clinicians should be able to counsel women regarding the risks of surgery as well optimizing their perioperative care whilst working within a multidisciplinary team. Current evidence highlights the efficacy and safety of minimally invasive surgery in obese women and it should be offered in preference to laparotomy when possible. All forms of surgery are more challenging in the obese population and routine techniques may need to be modified as described in this review.     

Endometrial cancer – an update

Endometrial cancer incidence rates are continuing to rise and approximately 40 % of all cases being preventable. A major contributing factor to this is the current obesity epidemic. Surgery remains the cornerstone of treatment and minimal access techniques have established themselves as the gold-standard. Routine lymphadenectomy for all disease stages has not been demonstrated to benefit overall survival. Risk stratification and personalized approaches to patient treatment are becoming more of a necessity, especially in younger women who may wish to preserve their fertility. Genomic profiling is starting to change the way we consider endometrial cancer, which may help direct treatment modalities in the future. Priority setting the research agenda will help guide future research and allow us to further tackle this common gynaecological malignancy.     

Palliative radiation therapy for gynaecological malignancies

Patients with advanced, recurrent, or metastatic gynaecological malignancies constitute a heterogenous population with diverse symptomatology. Progressive abdominopelvic disease can result in vaginal or diffuse pelvic bleeding, pain, and visceral or lymphovascular obstruction. Gynaecological cancer can also develop debilitating metastases, in particular to bone, central nervous system, or chest. Radiation therapy is a local-regional treatment modality, that, when applied judiciously, can lead to substantial symptomatic relief and tumour response. Individualized application is necessary, balancing efficacy and patient convenience versus treatment intensity, expected duration of palliation and potential toxicity. Important factors to consider are a patient's performance status, extent and sites of tumour, specific symptoms, and life expectancy. The optimal incorporation of radiotherapy is best achieved in the context of a multidisciplinary approach that addresses all facets of palliative care in patients with incurable gynaecological malignancies, to maximize their quality of life and functional level.     

The use of menopausal hormone therapy after cancer

The changing landscape of gynaecological and breast cancers has involved the development of more targeted and effective therapies, and improved survival. Ultimately, these changes result in an increasing number of women surviving their cancer diagnosis, with increasing emphasis on quality-of-life issues by following treatments. Many of these women experience severe menopausal symptoms associated with cancer treatments, but the hormonal nature of many gynaecological and breast cancers complicates the effective management of these symptoms. Generally, there is a paucity of high-quality data directly examining the safety of menopausal hormone therapy (MHT) following many female cancers, and more research is needed with long term follow-up to ensure the provision of comprehensive, patient-focussed care. This article aims to synthesise and evaluate the current evidence to provide comprehensive yet accessible information to clinicians to help guide treatment decisions about the use of MHT in women, who have experienced, or are at increased risk of, both gynaecological and breast cancers. These treatment decisions should often be made in a multi-disciplinary setting which encourages shared decision-making with patients.     

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.     

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.     

Conserving fertility in the management of gynaecological cancers

The quality of cancer treatment is judged by both morbidity and mortality. Patients benefit if morbidity is reduced without compromising mortality. This applies particularly for women who develop gynaecological malignancy during their childbearing years where curative treatment also renders them infertile. This study reviews the increasing role of fertility-sparing surgery in such women. A literature search was undertaken using PubMed, entering the terms endometrial cancer, cervical cancer and ovarian cancer in conjunction with the terms fertility and fertility sparing. Each relevant identified paper was reviewed, references checked and results collated to provide an evidence-based summary of fertility-sparing treatments for gynaecological malignancy. Fertility-sparing surgery is appropriate in many circumstances, and all doctors who advise young women with gynaecological malignancy should be aware of these possibilities. However, data are relatively sparse in many situations, and careful counselling and balanced guidance are essential if patients are to understand the full implications of their choices.     

Palliative and end-of-life care for patients with ovarian cancer

Palliative care improves the quality of life of patients and their families through the prevention and treatment of distressing symptoms while addressing the psychological, social, and spiritual aspects of patient care. Emerging paradigms of delivery promote early involvement in the disease trajectory and specialty approaches to care. Interdisciplinary assessment and shared decision making are important components. Throughout the disease course, aggressive symptom management can improve patients' quality of life and their ability to tolerate and continue treatment. End-of-life care focuses on comfort, control, meaning, and support that become particularly intense when death is imminent.     

Infertility and gynaecological oncology

Infertility and gynaecological cancer are two major problems in the field of women’s health, where both have serious implications on a woman’s physical, social and emotional wellbeing. There are well established links between many aspects of infertility and different types of gynaecological malignancies, including etiology, pathogenesis and disease management. In this special issue there are valuable articles that highlight different aspects of the relationship between infertility and gynaecological oncology. The issue covers conditions that represent risk factors for both infertility and gynaecological neoplasia. There is emphasis on the role of the fallopian tube being a critical organ for both conditions. There is a review on the advances in cancer diagnosis and treatment with consideration of the preservation of patient fertility. The various technologies for fertility preservation are reviewed and their strengths and weaknesses discussed. One of the important fertility preservation techniques is cryopreservation of embryo oocytes or ovarian tissue. This special issue emphasises that fertility preservation is now an important consideration in oncology clinics, and the options available to patients are routinely offered. Future developments will offer women in this difficult situation more options for fertility preservation, with an individualised approach for each patient. Equally, for infertile patients it is important to assess the risk of malignancy so as to provide optimal and timely intervention.