Review: The optimal organization of gynecologic oncology services: a systematic review

open access - Current Oncology

Abstract

Background

A system-level organizational guideline for gynecologic oncology was identified by a provincial cancer agency's (Ontario, Canada) a key priority based on input from stakeholders, data showing more limited availability of multidisciplinary or specialist care in lower-volume than in higher-volume hospitals in the relevant jurisdiction, and variable rates of staging for ovarian and endometrial cancer patients.

Methods

A systematic review assessed the relationship of the organization of gynecologic oncology services with patient survival and surgical outcomes. The electronic databases medline and embase (ovid: 1996 through 9 January 2015) were searched using terms related to gynecologic malignancies combined with organization of services, patterns of care, and various facility and physician characteristics. Outcomes of interest included overall or disease-specific survival, short-term survival, adequate staging, and degree of cytoreduction or optimal cytoreduction (or both) for ovarian cancer patients by hospital or physician type, and rate of discrepancy in initial diagnoses and intraoperative consultation between non-specialist pathologists and gyne-oncology–specialist pathologists.

Results

One systematic review and sixteen additional primary studies met the inclusion criteria. The evidence base as a whole was judged to be of lower quality; however, a trend toward improved outcomes with centralization of gynecologic oncology was found, particularly with respect to the gynecologic oncology care of patients with advanced-stage ovarian cancer.

Conclusions

Improvements in outcomes with centralization of gynecologic oncology services can be attributed to a number of factors, including access to specialist care and multidisciplinary team management. Findings of this systematic review should be used with caution because of the limitations of the evidence base; however, an expert consensus process made it possible to create recommendations for implementation.

RESEARCH QUESTIONS

• □ Are outcomes better for patients with gynecologic cancer treated in designated centres (“centralized care”) compared with non-designated centres (“decentralized care”)?
• □ Are outcomes better for patients treated by gynecologic oncologists than by non-subspecialist physicians?

CONCLUSIONS

The evidence found in the present review is consistent with previous research showing a likely benefit from the delivery of gynecologic oncology care in specialized centres with subspecialists working as part of a multidisciplinary team—particularly for patients with more advanced ovarian cancer. It should be cautioned, however, that unlike other disease sites such as pancreas and esophagus4, the evidence for this finding is far from strong.

Because of the lower-quality nature of the evidence base, an expert consensus process was used to create an organizational guideline, the results of which are published separately40.

Views of family physicians about survivorship care plans to provide breast cancer follow-up care

 Blogger's Note/Opinion: this is not the first research paper on this issue with the conclusions being basically the same (eg. communication...); given the complexities of genetics today this paper is limited in its scope

open access - breast cancer follow-up care Current Oncology

 Cancer Rehabilitation and Survivorship

Views of family physicians about survivorship care plans to provide breast cancer follow-up care: exploration of results from a randomized controlled trial

Background

The U.S. Institute of Medicine recommends that cancer patients receive survivorship care plans, but evaluations to date have found little evidence of the effectiveness of such plans. We conducted a qualitative follow-on study to a randomized controlled trial (rct) to understand the experiences of family physicians using survivorship care plans to support the follow-up of breast cancer patients.

Methods

A subset of family physicians whose patients were enrolled in the parent rct in Ontario and Nova Scotia were eligible for this study. In interviews, the physicians discussed survivorship care plans (intervention) or usual discharge letters (control), and their confidence in providing follow-up cancer care.

Results

Of 123 eligible family physicians, 18 (10 intervention, 8 control) were interviewed (Halifax, Hamilton, Toronto). In general, physicians receiving a survivorship care plan found only the 1-page care record to be useful. Physicians who received only a discharge letter had variable views about the letter’s usefulness; several indicated that it lacked information about potential cancer- or treatment-related problems. Most physicians were comfortable providing care 3–5 years after diagnosis, but desired timely and informative communication with oncologists.

Conclusions

Although family physicians did not find extensive survivorship care plans useful, discharge letters might not be sufficiently comprehensive for follow-up breast cancer care. Effective strategies for two-way communication between family physicians and oncologists are still lacking.

 

INTRODUCTION

The safety of follow-up breast cancer care delivered exclusively by family physicians (fps) has been established in two randomized trials1,2.

Commentary: Professionalism (Current Oncology)

Commentary -  Current Oncology

I have been reading medical literature since 1970. I started medical school in 1970, and from then to this present day, I find it shocking how little is written in medical literature and how little education is required about professional behavior.

The doctor–patient relationship—or rather the lack thereof—is a very important factor in litigation. However, that fact should not be the “prime mover” causing practitioners to abide by very high ethical standards. We should not be threatened into professionalism and ethical behavior. Our pride, our professionalism, and our inherent integrity as physicians and surgeons should motivate us. There are few, if any other, professions in which so much emphasis is placed on integrity, honesty, and good relations.

Nothing breeds more contempt and suspicion than a lack of transparency and a perception by patients that “I was not heard” or “My interaction was played down.”

A patient with a very anxious demeanor and four pressing questions went to see a physician. During consultation, the physician took over the conversation and pre-emptively answered the questions that physicians expect the patient to ask. The patient went home with none of the important questions (to that patient) answered.....

Commentary: Is it time to offer BRCA1 and BRCA2 testing to all Jewish women?

Commentary-Current Oncology

 It was 2007 when Women’s College Hospital first began to test for BRCA1 and BRCA2 mutations among all Jewish women in Ontario. On a research basis, testing was performed regardless of personal or family history of cancer for three recurrent Jewish founder BRCA mutations1. To date, more than 7000 women have been tested, and the program remains active. Recently, two studies have supported the conclusion that population-based testing is a rational approach to identifying BRCA mutation carriers. In an Israeli study of 8105 unselected Jewish men2 and a British study of 1034 unselected Jewish men and women3, more than one half of the identified mutation carriers failed to qualify for genetic testing based on family history.......

 SUMMARY

Given that the prevalence of BRCA1 and BRCA2 mutations in unselected Jewish women is 1%–2%; that most women with a BRCA mutation identified through population screening would not qualify for testing based on current testing criteria; that population-based genetic testing results in the identification of more unaffected BRCA mutation carriers than does clinical testing (which relies on personal or family history of cancer) and is less expensive; that women identified with a BRCA mutation through population screening opt for intensive breast screening and preventive surgeries; that preventive oophorectomy and mastectomy reduce cancer deaths dramatically; that cancer-related distress is transient; and that almost all tested women are satisfied with testing, we consider genetic testing of the general population of Jewish women to be justified.

BRCA1/2 population screening: embracing the benefits

Blogger's Note: register for free access

Editorial-Current Oncology

 Whether all adult Ashkenazi women should be offered population screening for recurrent BRCA1 and BRCA2 founder mutations is an important question to me both personally as an Ashkenazi Jewish woman and professionally. I was a junior faculty member and a newly certified medical geneticist in 1995 when I participated in the first research study offering 185delAG mutation testing (the other two founders weren’t known at the time) to the Ashkenazi Jewish community in Houston1........

.... The remaining obstacles to population screening are those of cost and appropriate staffing or counselling guides. Instituting population screening in the United States without a national health care system (such as in Canada or Israel) will be more challenging. Insurance coverage of genetic testing will likely begin only if a guideline from a professional medical organization recommends population screening. But, there were obstacles when population screening for Tay–Sachs carriers was first recommended in the 1970s, and medical professionals and the Ashkenazi Jewish community found ways to overcome those barriers to effectively perform population screening and drastically reduce births of children with Tay–Sachs disease16. I hope that, in 2015, professional societies will thoughtfully embrace the potential benefits of adult population screening for Ashkenazi founder mutations in BRCA1 and BRCA2, with the goal of decreasing the untimely death of individuals from breast and ovarian cancer.

SMARCA4 (BRG1) Loss of Expression Is a Useful Marker for the Diagnosis of Ovarian Small Cell Carcinoma of the Hypercalcemic Type....

abstract

 SMARCA4 (BRG1) Loss of Expression Is a Useful Marker for the Diagnosis of Ovarian Small Cell Carcinoma of the Hypercalcemic Type (Ovarian Rhabdoid Tumor): A Comprehensive Analysis of 116 Rare Gynecologic Tumors, 9 Soft Tissue Tumors, and 9 Melanomas

Ovarian small cell carcinoma of the hypercalcemic type (SCCOHT)/ovarian rhabdoid tumor is a rare and highly malignant tumor that typically occurs in young women. Up until now the diagnosis has been made on the basis of morphology without any specific immunohistochemical (IHC) markers. However, several authors have shown recently that SCCOHTs are characterized by inactivation of the SMARCA4 gene (encoding the BRG1 protein) resulting in a loss of BRG1 protein expression in IHC. We evaluated BRG1 and INI1 expression in 12 SCCOHTs and in a series of 122 tumors that could mimic SCCOHT morphologically: 9 juvenile granulosa cell tumors, 47 adult granulosa cell tumors, 33 high-grade ovarian serous carcinomas,

Identification of germline variants in cancer susceptibility genes in patients with multiple primary cancers

Abstract 4663

 The occurrence of multiple primary (MP) cancers in a patient suggests a genetic predisposition to tumor formation. Multiplex panel testing may be an efficient way of evaluating MP patients for the presence of germline mutations in cancer susceptibility genes. However the spectrum of mutations in many cancer susceptibility genes in the MP patient population is largely unknown. We performed massively parallel sequencing using targeted capture of 15 genes with well-established risks of breast and/or other cancers, specifically TP53, CDH1, PTEN, STK11, ATM, CHEK2, MRE11A, NBN, RAD50, PALB2, MLH1, MSH2, MSH6, PMS2, and MUTYH. Our patient cohort consisted of 221 BRCA1/2 negative patients diagnosed with breast cancer and at least one other primary cancer, excluding non-melanoma skin cancer. Patients diagnosed with contralateral breast cancer were included.

Histology-specific patterns of DNA methylation in Lynch-associated and sporadic ovarian cancer

Abstract 2964

 Epithelial ovarian cancer is a heterogeneous group of cancers, and molecular tools are urgently needed for a better understanding and targeted management of this often lethal disease. Since epigenetic methods can offer new tools for the management of ovarian cancer, our aim was to investigate epigenetic mechanisms in ovarian tumorigenesis representing different histological types. Expression profiling of ovarian and endometrial cancer cell lines treated with demethylating agents as well as literature were used to select gene candidates for epigenetic regulation. A methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) assay was constructed for thirteen genes to study methylation in 104 (85 sporadic and 19 Lynch syndrome-associated) ovarian carcinomas. 

Increased methylation (hypermethylation) was characteristic of ovarian cancer tissues relative to the corresponding normal tissues and hypermethylation was consistently more prominent in non-serous than serous tumors. The highest frequencies of hypermethylation were detected in Lynch-associated clear cell ovarian carcinomas.

Canadian Medical Association members ready to lead principles-based discussion on end-of-life care -- OTTAWA, Aug. 17, 2015

press release

Canadian Medical Association: A Canadian Approach to Assisted Dying: A CMA Member Dialogue Summary Report

pdf 

Social Workers as Patient Navigators: A Review of the Literature

abstract

In recent decades, patient navigation has emerged as a promising strategy to address health disparities. This literature review assesses the involvement of social work in the field of patient navigation and identifies gaps in the literature that future social work research can address. Eighteen publications met authors’ inclusion criteria, of which 13 were research studies that used social workers as patient navigators and five were studies that used social workers solely in the training, support, or supervision of patient navigators. Only one of the 18 articles was published in a social work journal, and 69% of the research studies were authored by one group of authors. Although implementation of the 2010 Patient Protection and Affordable Care Act provides enhanced opportunities for patient navigation, the paucity of research involving social workers suggests that social work scholars and professionals are not yet well positioned to take advantage of these new opportunities. The limited evidence showing social work’s impact on patient outcomes is encouraging, but social workers need to increase their contributions in this area and more convincingly demonstrate their effectiveness as patient navigators.

TP53 mutations, tetraploidy and homologous recombination repair defects in early stage high-grade serous ovarian cancer

open access (somewhat technical - worth reading)

Conclusions 

.....Despite heterogeneity in somatic sequence variations, CNAs and structural variations, none of these somatic genotypes appears to be associated with clinical outcome. Only stage appears to be strongly linked to patient survival, as six of eight patients with stage I HGS ovarian carcinomas are still alive (median follow-up 101 months), whereas only two of eight with stage 2 disease are still alive (median follow-up 79 months). Collectively, these observations provide new insight into the biology and likely pathogenesis of early stage HGS ovarian cancer.

Assessing the carcinogenic potential of low-dose exposures to chemical mixtures in the environment: the challenge ahead

open access
 About the Journal
Carcinogenesis: Integrative Cancer Research is a multi-disciplinary journal that brings together all the varied aspects of research that will ultimately lead to the prevention of cancer in man.....

Introduction

Cancer is a burden on humanity and among the leading causes of morbidity and mortality worldwide, with ~14 million new cases and 8.2 million cancer-related deaths in 2012 (1). In general, both genetic and environmental factors play a role in an individual’s cancer susceptibility (2,3), so there has been a long-standing emphasis on avoidable ‘lifestyle’ factors (i.e. those that can be modified to reduce the incidence of the disease) and a parallel focus on exogenous chemical exposures (e.g. agricultural, occupational and so on) (4). But advances in our understanding of the complexity of cancer biology have resulted in serious critiques of current risk assessment practices related to exogenous exposures (5) along with calls for an expanded focus on research that will allow us to evaluate the (potentially carcinogenic) effects of in-utero exposures and low-level exposures to combinations of chemicals that occur throughout our lifetime (6,7).....

Knowledge and attitudes regarding medical research studies among patients with breast cancer/gynecological diseases

open access

The present study investigated the general level of knowledge on the topic of “clinical studies” in a group of patients being treated at a university gynecology department. In addition, the way in which they perceived the design and conduct of studies and their attitudes to them were also noted.

eg.: selected key items
 Table 1. Characteristics of the patients

Table 2. Summary of statements to assess patients’ level of knowledge about the design and conduct of studies (questions on the rating scale are marked in bold type)

Fig. 1. Analysis of patients’ knowledge about clinical studies (relative frequencies of numbers of correct answers)

Patients who presented in the department due to pregnancy or birth had an average of 2.3 answers right; patients with gynecological diseases had 1.79; patients with breast cancer had 1.97; patients attending for fertility treatment had 2.11; patients with endometriosis had 1.9; and patients with benign gynecological diseases had 2.04 (P < 0.001) (Fig. 2).

 The amount of information desired by patients is also important in the context of autonomy when participating in a study. The majority of patients in the present group (95.9 %) wanted to receive all of the available information during the consultation process. A similar picture has also been described in other studies [5], [15]. Patients who do not believe that they have fully understood the implications of a study may ultimately feel regret about their decision to participate [19].

 Altruistic motivations generally play an important role in study participation, as has often been shown in other studies [20], [21].

 Conclusions

This study shows that women with gynecological diseases have only moderate knowledge about clinical studies.

Oral Contraceptive Use and Reproductive Characteristics Affect Survival in Patients With Epithelial Ovarian Cancer: A Cohort Study

abstract

OBJECTIVES:

Prognostic risk factors influencing survival in patients with epithelial ovarian cancer (EOC) include tumor stage, grade, histologic subtype, debulking, and platinum status. Little is known about the impact of hormonal milieu and reproductive factors before cancer diagnosis on clinical outcome. We sought to evaluate whether oral contraceptive (OC) use carries any prognostic significance on overall survival (OS) in patients with EOC.

METHODS:

Newly diagnosed patients with EOC, fallopian tube, and primary peritoneal cancers between 1982 and 1998 were prospectively evaluated with a comprehensive epidemiologic questionnaire. A retrospective chart review was performed to abstract clinicopathologic data, including OS. A Kaplan-Meier analysis was performed to compare survival across various exposures. A Cox regression model was used to compute adjusted hazards ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS:

We identified 387 newly diagnosed cancers with evaluable information in this cohort. Decreased risk of death was observed in women who reported prior use of OC, previous pregnancy, or a live birth after adjusting for age at diagnosis, stage, and histologic subtype. Oral contraceptive use was associated with a crude reduced risk of death, with reported median OS of 81 months in OC users versus 46 months in nonusers. Patients who reported a single live birth experienced the largest potential survival advantage. Oral contraceptive use and prior pregnancy were associated with improved survival across all strata.

CONCLUSIONS:

Oral contraceptive use may have lasting effects on epithelial ovarian tumor characteristics conferring favorable prognosis. Putative mechanisms that affect tumor biology include complex interactions between ovarian cells, host immune cells, and hormonal microenvironment during carcinogenesis. Future efforts should be directed to determine the role of reproductive factors in antitumor immunity.

Integrated multidisciplinary screening for patients with Lynch syndrome at 33 US-based cancer centers

abstract

 Integrated multidisciplinary screening for patients with Lynch syndrome at 33 US-based cancer centers designated by the National Cancer Institute

Objective

To assess the availability and capacity of US-based integrated centers for the management of Lynch syndrome.

Methods

A cross-sectional survey of practice patterns in the care of patients with Lynch syndrome was conducted at 33 National Cancer Institute-designated cancer centers in the USA from March 1 to June 1, 2013. Each cancer center was contacted by telephone and the caller used a uniform scripted greeting and survey format.

Results

All centers routinely recommended colonoscopy. Other recommended screening modalities were hysterectomy and bilateral salpingo-oophorectomy (29/33; 88%), endoscopy (27/33; 82%), urinalysis (23/33; 70%), endometrial sampling (21/33; 64%), dermatologic examination (19/32; 59%), pelvic ultrasonography (18/33; 55%), serum CA125 level (14/33; 42%), urine cytology (14/33, 42%), computed tomography (1/33; 3%), and magnetic resonance imaging (1/33; 3%). Each center had a multidisciplinary team but the composition õvaried. A designated team leader was present at 21 centers (64%). Having a team leader was associated with an increased likelihood of recommending endoscopy (P = 0.04) and dermatologic surveillance (P = 0.01). Only 23 centers (70%) had a system in place for communicating follow-up with patients.

Conclusion

The lack of consensus in practice patterns recorded among participating centers probably reflected the limited existing evidence on the usefulness of most screening modalities.