(Abstracted from J Clin Oncol 2025;43(7):868–891 Diagnosis and treatment of ovarian cancer are challenging due to the lack of effective screening tools for advanced stages of disease. Advanced ovarian cancer, classified as the International Federation of Gynecology and Obstetrics stage III or IV, is traditionally treated with primary cytoreductive surgery (PCS) followed by chemotherapy.

PURPOSE:To provide updated guidance regarding neoadjuvant chemotherapy (NACT) and primary cytoreductive surgery (PCS) among patients with stage III-IV epithelial ovarian, fallopian tube, or primary peritoneal cancer (epithelial ovarian cancer [EOC]). METHODS:A multidisciplinary Expert Panel convened and updated the systematic review. RESULTS:Sixty-one studies form the evidence base. RECOMMENDATIONS:Patients with suspected stage III-IV EOC should be evaluated by a gynecologic oncologist, with cancer antigen 125, computed tomography of the abdomen and pelvis, and chest imaging included. All patients with EOC should be offered germline genetic and somatic testing at diagnosis. For patients with newly diagnosed advanced EOC who are fit for surgery and have a high likelihood of achieving complete cytoreduction, PCS is recommended. For patients fit for PCS but deemed unlikely to have complete cytoreduction, NACT is recommended. Patients with newly diagnosed advanced EOC and a high perioperative risk profile should receive NACT. Before NACT, patients should have histologic confirmation of invasive ovarian cancer. For NACT, a platinum-taxane doublet is recommended. Interval cytoreductive surgery (ICS) should be performed after ≤four cycles of NACT for patients with a response to chemotherapy or stable disease. For patients with stage III disease, good performance status, and adequate renal function treated with NACT, hyperthermic intraperitoneal chemotherapy may be offered during ICS. After ICS, chemotherapy should continue to complete a six-cycle treatment plan with the optional addition of bevacizumab. Patients with EOC should be offered US Food and Drug Administration-approved maintenance treatments. Patients with progressive disease on NACT should have diagnosis reconfirmed via tissue biopsy. Patients without previous comprehensive genetic or molecular profiling should be offered testing. Treatment options include alternative chemotherapy regimens, clinical trials, and/or initiation of end-of-life care.Additional information is available at www.asco.org/gynecologic-cancer-guidelines.This guideline has been endorsed by the Society of Gynecologic Oncology.

Germline and somatic genetic testing have become critical components of care for people with ovarian cancer. The identification of germline and somatic pathogenic variants as well as homologous recombination deficiency can contribute to the prediction of treatment response, prognostic outcome, and suitability for targeted agents (e.g. poly (ADP-ribose) polymerase (PARP) inhibitors). Furthermore, identifying germline pathogenic variants can prompt cascade genetic testing for at-risk relatives. Despite the clinical benefits and consensus recommendations from several organizations calling for universal genetic testing in ovarian cancer, only about one third of patients complete germline or somatic genetic testing. The members of the Society of Gynecologic Oncology (SGO) Clinical Practice Committee have composed this statement to provide an overview of germline and somatic genetic testing for patients with epithelial ovarian cancer, focusing on available testing modalities and options for care delivery.

ObjectiveAlthough approximately one-fifth of obstetrics and gynecology (OBGYN) residents matriculate from osteopathic or international medical schools, most literature regarding the transition to residency focuses on allopathic medical school graduates. To create comprehensive interventions for this educational transition, we must understand the needs of all incoming residents. Our objective was to examine OBGYN residents’ perceptions of their transition to residency, and to understand how residents’ background and medical school environment influence their perceived sense of readiness.DesignA 16-item survey asked questions about demographics, the transition to residency, resident well-being, burnout, and the transition to fellowship. Perception of preparedness was assessed with the question “I felt that I was well-prepared for the first year of residency” (1=strongly agree, 5=strongly disagree). Chi-squared and Fisher's exact tests and logistic regression explored association of perceived preparedness with residents’ backgrounds.SettingSurvey administered at time of the in-training examination in 2022.ParticipantsAll OBGYN residents.ResultsOf 5761 eligible participants, 3741 (64.9%) provided consent and completed the survey. Of the 3687 participants who answered the question, 2441 (66.2%) either agreed or strongly agreed that they felt well-prepared. Fewer osteopathic graduates reported feeling prepared compared to allopathic graduates (379/610, 62.1% vs 1,924/2,766, 69.6%) (OR 0.72, 95%CI 0.60-0.86, p < 0.01). International medical school graduates were seven times less likely to report feeling prepared compared to those from allopathic institutions (137/304, 45.1% vs 1924/2776, 69.6%) (OR 0.60, 95%CI 0.53-0.68, p < 0.01). Respondents from underrepresented racial and ethnic backgrounds were less likely to report feeling prepared compared to White respondents (276/535, 51.6% vs 1738/2387, 72.8%) (OR 0.39, 95%CI 0.33-0.48, p < 0.01).ConclusionsDifferences in residents’ perceptions of their transition to residency highlight the need to begin offsetting pervasive inequities with comprehensive and accessible resources.

INTRODUCTION:Our cancer program adopted a method for carboplatin desensitization (4-step 2-bag method) that administers the same intensity of drug exposure with a simplified approach to product management in comparison to a published protocol (4-step 4-bag method).METHODS:The intensity of carboplatin administration for 1:1,000, 1:100, 1:10, and 1:1 dilutions and concomitant fluid administration were compared for the 4-step 2-bag (bags A, B) and 4-step 4-bag (bags 1, 2, 3, 4) methods. Pharmacy preparation of bags A and B is described. A succinct overview of the desensitization procedure is provided. Important considerations germane to pharmacy practice are presented. Chart review of patients who underwent carboplatin desensitization with the 4-step 2-bag method between 7/13/2021 and 11/22/2023 was performed to demonstrate institutional use.RESULTS:The 4-step 2-bag method delivers similar rates of drug intensity from start of desensitization to completion of the planned dose as the previously published 4-step 4-bag method. Accuracy of regimen-based dose administration is assured by infusion of bag B contents irrespective of infusion interruptions or rate changes necessitated by patient tolerance. Bag A provides the 1:1000 dilution in a pharmaceutically elegant manner using administration rates and volumes compatible with clinical practice.CONCLUSION:The 4-step 2-bag method for carboplatin desensitization administers controlled drug titration corresponding to 1:1000, 1:100, 1:10, and 1:1 dilutions for dose administration using two compounded admixture bags. Inaugural clinical use of the 4-step 2-bag method for carboplatin desensitization at our healthcare facility has proceeded with expected patient tolerance.

Objective. We aimed to characterize delays to care in patients with endometrioid endometrial cancer and the role healthcare access plays in these delays. Methods. A chart review was performed of patients with endometrioid endometrial cancer who presented with postmenopausal bleeding at a diverse, urban medical center between 2006 and 2018. The time from symptom onset to treatment was abstracted from the medical record. This interval was subdivided to assess for delay to presentation, delay to diagnosis, and delay to treatment. Results. We identified 484 patients who met the inclusion criteria. The median time from symptom onset to treatment was 4 months with an interquartile range of 2 to 8 months. Most patients had stage I disease at diagnosis (88.6%). There was no significant difference in race/ethnicity or disease stage at time of diagnosis between different groups. Patients who had not seen a primary care physician or general obstetrician-gynecologist in the year before symptom onset were more likely to have significantly delayed care (27.7% vs 14.3%, p = 0.02) and extrauterine disease (20.2% vs 4.9%, p < 0.01) compared to those with established care. Black and Hispanic patients were more likely to experience significant delays from initial biopsy to diagnosis. Conclusions. Delays exist in the evaluation of endometrial cancer. This delay is most pronounced in patients without an established outpatient primary care provider or obstetrician-gynecologist. (c) 2024 Elsevier Inc. All rights reserved.

(Abstracted from Gynecol Oncol 2024;181:170–178 Identification of germline and somatic pathogenic variants as well as homologous recombination deficiency (HRD) can contribute to the prediction of treatment response, prognostic outcome, and suitability for targeted agents. Germline genetic testing can also serve to inform risk for other malignancies and prompt risk management for at-risk relatives.

Background. Cancer associated venous thromboembolism (VTE) is associated with significant morbidity and mortality. Direct oral anticoagulants (DOACs) have emerged as alternatives to injectable medications for both thromboprophylaxis and treatment of VTE. Several recent clinical trials have demonstrated safety and efficacy of DOACs in high risk patients receiving systemic chemotherapy as well as postoperative prophylaxis after sur-gery for gynecologic cancer. Major consensus guidelines from multiple organizations support the use of DOACs for these indications but prescription practices are not well characterized.Methods. A survey study was sent concurrently to members of the Society of Gynecologic Oncology (SGO) and American Society of Clinical Oncology (ASCO) Research Survey Pool between May and June of 2021. The study was designed to assess DOAC prescription practices amongst members of these societies who routinely prescribe chemotherapy. Bivariate analyses comparing responses from ASCO participants and SGO participants were com-pared using chi-squared and Fisher exact tests.Results. A total of 103 physicians were included in the ASCO group and 139 in the SGO group. A majority of participants in both groups reported familiarity with prescribing DOACs (99% of ASCO and 96% of SGO respon-dents). ASCO respondents were more likely to consider DOACs as first line therapy for treatment of cancer -associated VTE than SGO members (82% vs 63%, p < 0.01) and SGO members were more likely to consider low molecular weight heparin (LMWH) the standard of care treatment (66% vs 25% p < 0.01). Most respondents in both groups (75%) felt DOACs were equally safe and effective compared to LMWH but more ASCO members felt DOACs were cost effective (70% vs 49%, p < 0.01). More SGO respondents reported having prescribed prophy-lactic anticoagulation during chemotherapy than ASCO members (53% vs 35%, p < 0.01).Conclusion. ASCO respondents were more likely to prescribe DOACs for both treatment and prophylaxis of cancer-associated VTE than SGO members. However, SGO members were more likely to prescribe prophylactic anticoagulation to high risk patients initiating chemotherapy compared to ASCO members.(c) 2023 Elsevier Inc. All rights reserved.

Objectives: Endometrial cancer (EC) is the most common gynecologic malignancy in the United States. Historically, EC has been classified into two subtypes based on histologic features. Alterations in genomic methylation patterns are implicated in endometrial carcinogenesis, as evidenced by the recent findings of The Cancer Genome Atlas Network (TCGA). DNA methyltransferase enzymes (DNMT1/3a/3b) promote DNA methylation, while the Ten-Eleven Translocation enzymes (TET1/2/3) facilitate DNA demethylation. Their deregulation leading to aberrant DNA methylation has been demonstrated as etiologic in many other cancers. However, the role of TET and DNMTs in EC remains poorly understood. This study aimed to investigate if DNMT and TET enzymes are deregulated in EC tumor specimens. Methods: Established Type I and Type II human EC cells (HEC1A/Ishikawa/ARK-1/ARK-2) were grown in culture. Archived frozen EC tumor (T) and adjacent non-tumor (NT) specimens were collected from the Montefiore Gynecologic Oncology Tissue Biorepository. This included 15 Type I and 15 Type II EC samples. RNA was extracted from cell lines and tissue samples, reverse transcribed, and real-time quantitative PCR (RTqPCR) was performed to determine the relative mRNA expression of TET and DNMT enzymes in all samples. Using the TCGA database, we then compared the expression of TET and DNMT enzymes in EC subtypes. R and GraphPad Prism 9 software, one-way-Anova and student t-tests were used for calculating statistical significance in all analyses. Results: We found varied expression of TET enzymes among Type I and Type II EC cell lines and tumor specimens. Both HEC1A and ARK-2 cells exhibited significantly lower TET1 expression compared to normal EC cells (p <0.01). Collective evaluation of Type I and Type II EC cell lines did not reveal any significant differences in expression of TET or DNMT enzymes. In patient-derived tumors, TET1 and TET2 were downregulated, while TET3 was upregulated in most Type I and Type II samples compared to NT control samples. There was no significant difference in the expression of TET1/2/3 between Type I and Type II EC samples. DNMT1 and DNMT3a were up- or down-regulated in an almost equal number of Type I and Type II EC samples. DNMT3b was down-regulated in the majority of Type I EC tumors. There were no significant differences in DNMT1/3a/3b expression between Type I and II EC samples. Analysis of 540 EC patient tumor samples from the TCGA database revealed no significant difference between the expression of TET1/2/3 in EC subtypes. However, analysis by stage revealed a significantly higher expression of TET1 and TET3 in Stage III Type II EC samples when compared to Stage III Type I EC samples and DNMT3b in Stage I samples. Conclusions: TET and DNMT enzymes are expressed in both immortalized EC cells and patient-derived tumor samples. They are variably deregulated among EC subtypes. Subgroup analysis of the TCGA TET and DNMT RNA-Seq data by stage revealed significantly increased expression of TET enzymes in higher stages. This suggests that while TET enzymes may not contribute to endometrial carcinogenesis, they may play a role in tumor metastasis. Further analysis is needed to better define the role of TET enzymes in the epigenetic modulation of EC. Objectives: Endometrial cancer (EC) is the most common gynecologic malignancy in the United States. Historically, EC has been classified into two subtypes based on histologic features. Alterations in genomic methylation patterns are implicated in endometrial carcinogenesis, as evidenced by the recent findings of The Cancer Genome Atlas Network (TCGA). DNA methyltransferase enzymes (DNMT1/3a/3b) promote DNA methylation, while the Ten-Eleven Translocation enzymes (TET1/2/3) facilitate DNA demethylation. Their deregulation leading to aberrant DNA methylation has been demonstrated as etiologic in many other cancers. However, the role of TET and DNMTs in EC remains poorly understood. This study aimed to investigate if DNMT and TET enzymes are deregulated in EC tumor specimens. Methods: Established Type I and Type II human EC cells (HEC1A/Ishikawa/ARK-1/ARK-2) were grown in culture. Archived frozen EC tumor (T) and adjacent non-tumor (NT) specimens were collected from the Montefiore Gynecologic Oncology Tissue Biorepository. This included 15 Type I and 15 Type II EC samples. RNA was extracted from cell lines and tissue samples, reverse transcribed, and real-time quantitative PCR (RTqPCR) was performed to determine the relative mRNA expression of TET and DNMT enzymes in all samples. Using the TCGA database, we then compared the expression of TET and DNMT enzymes in EC subtypes. R and GraphPad Prism 9 software, one-way-Anova and student t-tests were used for calculating statistical significance in all analyses. Results: We found varied expression of TET enzymes among Type I and Type II EC cell lines and tumor specimens. Both HEC1A and ARK-2 cells exhibited significantly lower TET1 expression compared to normal EC cells (p <0.01). Collective evaluation of Type I and Type II EC cell lines did not reveal any significant differences in expression of TET or DNMT enzymes. In patient-derived tumors, TET1 and TET2 were downregulated, while TET3 was upregulated in most Type I and Type II samples compared to NT control samples. There was no significant difference in the expression of TET1/2/3 between Type I and Type II EC samples. DNMT1 and DNMT3a were up- or down-regulated in an almost equal number of Type I and Type II EC samples. DNMT3b was down-regulated in the majority of Type I EC tumors. There were no significant differences in DNMT1/3a/3b expression between Type I and II EC samples. Analysis of 540 EC patient tumor samples from the TCGA database revealed no significant difference between the expression of TET1/2/3 in EC subtypes. However, analysis by stage revealed a significantly higher expression of TET1 and TET3 in Stage III Type II EC samples when compared to Stage III Type I EC samples and DNMT3b in Stage I samples. Conclusions: TET and DNMT enzymes are expressed in both immortalized EC cells and patient-derived tumor samples. They are variably deregulated among EC subtypes. Subgroup analysis of the TCGA TET and DNMT RNA-Seq data by stage revealed significantly increased expression of TET enzymes in higher stages. This suggests that while TET enzymes may not contribute to endometrial carcinogenesis, they may play a role in tumor metastasis. Further analysis is needed to better define the role of TET enzymes in the epigenetic modulation of EC.

Background: Incidental identification of peritoneal nodules during laparoscopy may present a diagnostic dilemma. The differential diagnosis includes a variety of benign and malignant entities such as peritoneal carcinomatosis. Case: A 44-year-old G2P2 woman presented with recurrent menorrhagia and pelvic pain was found to have large uterine fibroids on imaging studies. Bilateral uterine artery embolization was performed with complete devascularization of the fibroid. Seven years later, she presented with similar symptoms. Imaging studies demonstrated a vascular uterine lesion. A total laparoscopic hysterectomy with bilateral salpingectomy was performed with no complications. During surgery, vesicular peritoneal implants were incidentally identified posterior to the uterus between the uterosacral ligaments. Biopsy and pathologic analysis of these nodules confirmed that they contained foreign material consistent with embolization beads. Pathologic analysis of the uterus demonstrated an intramural uterine fibroid, and presence of embolization beads in cervix, myometrium and bilateral peritubal regions. Conclusion: Non-target peritoneal implantation of embolic beads after uterine artery embolization is a rare entity that can result in vesicular appearing nodules.

BACKGROUND: Operative vaginal delivery is used to expedite a safe vaginal delivery in the second stage of labor and is considered an essential part of residency training in obstetrics and gynecology. OBJECTIVE: To assess the self-reported readiness of obstetrics and gynecology residents in the United States to perform vacuum-assisted vaginal delivery and forceps-assisted vaginal delivery compared with the perceptions of program directors. STUDY DESIGN: The Council on Resident Education in Obstetrics and Gynecology surveyed the residents in all US training programs about their readiness to perform forceps-assisted and vacuum-assisted deliveries. The program directors were simultaneously surveyed about the readiness of their cohort to perform operative deliveries with and without attending oversight. The primary outcome of the survey was the residents' self reported confidence in their ability to autonomously and independently perform operative deliveries. RESULTS: A total of 5084 out of 5514 (92.9%) resident physicians and 241 out of the 292 (83%) residency program directors completed the survey. Eighty-seven percent (95% confidence interval, 84.9-88.9) of the graduating residents reported feeling that they could autonomously perform a vacuum-assisted vaginal delivery, compared with 49.5% (95% confidence interval, 46.6-52.4) for forceps-assisted vaginal delivery (P<.01). Similarly, whereas 95.9% (95% confidence interval, 94.6-97.0) of the residents felt that they could confidently perform an emergency vacuum-assisted vaginal delivery, only 42.3% (95% confidence interval, 39.4-45.2) felt confident performing an emergency forceps assisted vaginal delivery (P<.01). The residency program directors significantly overestimated their residents' confidence in independently performing an emergency forceps-assisted vaginal delivery or vacuum-assisted vaginal delivery than the residents themselves (54% [95% confidence interval, 47.1-60.5] vs 24% [95% confidence interval, 22.5-24.9] and 98.6% [95% confidence interval, 97.0-100] vs 71.9 [95% confidence interval, 70.6-73.2] respectively P<.01). Trainees in military-based residency programs and those interested in pursuing a career as generalists or maternal-fetal medicine specialists reported significantly higher preparedness to perform a forceps-assisted vaginal delivery. CONCLUSION: Graduating obstetrics and gynecology residents report feeling less prepared to independently perform a forceps-assisted vaginal delivery than a vacuum-assisted vaginal delivery. The program directors had more confidence in the ability of their residents to perform an operative vaginal delivery than the residents themselves.

Currently, the application of peritoneal washings as a diagnostic tool for endometrial cancer staging is not well defined. The case described aims to highlight the current ambiguity surrounding the use of peritoneal washings in clinical practice. A 69-year-old G3P3003 presented to her gynecologist with complaints of new-onset heavy vaginal bleeding. The patient sought an endometrial biopsy, which suggested serous endometrial intraepithelial carcinoma (EIC) focally suspicious for invasive carcinoma, with the involvement of polyps. Based on these results, a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral sentinel lymph node dissection, and omentectomy were performed. Results from her final pathology exhibited a stage IA uterine serous carcinoma (USC) involving a polyp (4.2 cm in greatest dimension) with no myometrial or lymphovascular invasion, but washings were positive for adenocarcinoma. Based on her family history of malignancy, the patient underwent germline panel testing. The patient's somatic tumor testing demonstrated proficient DNA mismatch repair status, microsatellite stability, low tumor mutational burden (4 mut/Mb), low loss of heterozygosity (9%), amplification of the ERBB2 (HER2/neu) gene by both immunohistochemistry (3+, 20% positive) and fluorescence in-situ hybridization. Her tumor also had weakly positive estrogen receptor expression (1+, 10% positive); furthermore, some pathogenic variants in KRAS (c.37G>T), PIK3CA (c.263G>A), and TP53 (c.743G>A) were identified. Given the incongruent findings found with the positive peritoneal washing and negative lymph node involvement in addition to molecular testing, management for this patient was unclear. Ultimately, this case highlights a number of advances within the field of gynecological oncology but also emphasizes the persistent ambiguity and incongruency in the management of patients with early-stage high-risk histologies. Moving forward it will become increasingly important to be able to develop a more standardized process to assess how these diagnostic tools should inform prognosis and treatment plans.

Objectives: Loss of estrogen and progesterone receptor expression has historically been associated with poor survival outcomes in women with uterine cancer, but the role of the remaining 46 nuclear hormone receptors remains unclear. Recently, data from The Cancer Genome Atlas demonstrated a novel association between loss of thyroid hormone receptor beta expression and increased survival in uterine cancer patients.1 The purpose of this study was to explore the association between clinical indices of thyroid function and survival outcomes in women diagnosed with uterine cancer. 1. Pique, D.G., Greally, J.M. & Mar, J.C. Identification of a novel subgroup of endometrial cancer patients with loss of thyroid hormone receptor beta expression and improved survival. BMC Cancer 20:857 (2020). Methods: A single-institution retrospective cohort study was performed examining all women diagnosed with uterine cancer from 2006-2016. Data regarding patient demographics, medical co-morbidities, histology, stage and treatment course were abstracted from the medical record. Historical records and thyroid function studies (TSH, T3, free T4) were used to identify patients who were euthyroid, hypothyroid, or hyperthyroid within 1 year prior to their cancer diagnosis until the end of the follow-up period. The primary outcome was time to death from cancer diagnosis. A Cox proportional hazards model was used to identify the association between thyroid dysfunction and survival by using thyroid status as a time-dependent covariate and adjusting for age, grade and stage of disease. Results: A total of 1201 patients were included for analysis. One thousand thirty (86%) patients had no thyroid dysfunction at time of cancer diagnosis, 145 patients (12%) carried the baseline diagnosis of hypothyroidism and 26 patients (2%) had hyperthyroidism. Twenty three women with normal thyroid function at baseline developed thyroid dysfunction during follow-up (91% hypothyroid, 9% hyperthyroid). A total of 218 deaths were observed. There were no differences in survival among patients with hypothyroidism or hyperthyroidism compared to euthyroid patients [HR 0.72 (95% CI 0.47-1.12, p=0.15); HR 0.51 (95% CI 0.16-1.58, p=0.24) respectively]. Women diagnosed with thyroid dysfunction prior to cancer diagnosis were observed to have a 30% lower hazard of death compared to euthyroid women, although this did not achieve statistical significance [HR 0.70 (95% CI 0.46-1.07, p=0.10)]. Patients who developed thyroid dysfunction after cancer diagnosis were observed to have a 3.7 fold higher hazard of death compared to patients who remained euthyroid during followup [HR 3.70 (95% CI 1.60-8.30), p=0.01], but this did not maintain significance in models adjusting for age, grade and stage of disease. Conclusions: Thyroid dysfunction was not associated with a difference in survival in women with uterine cancer in our cohort. Timing of thyroid dysfunction relative to uterine cancer diagnosis may affect clinical outcomes. Additional studies are needed to explore the relationship of thyroid dysfunction and uterine cancer. Loss of estrogen and progesterone receptor expression has historically been associated with poor survival outcomes in women with uterine cancer, but the role of the remaining 46 nuclear hormone receptors remains unclear. Recently, data from The Cancer Genome Atlas demonstrated a novel association between loss of thyroid hormone receptor beta expression and increased survival in uterine cancer patients.1 The purpose of this study was to explore the association between clinical indices of thyroid function and survival outcomes in women diagnosed with uterine cancer. 1. Pique, D.G., Greally, J.M. & Mar, J.C. Identification of a novel subgroup of endometrial cancer patients with loss of thyroid hormone receptor beta expression and improved survival. BMC Cancer 20:857 (2020). A single-institution retrospective cohort study was performed examining all women diagnosed with uterine cancer from 2006-2016. Data regarding patient demographics, medical co-morbidities, histology, stage and treatment course were abstracted from the medical record. Historical records and thyroid function studies (TSH, T3, free T4) were used to identify patients who were euthyroid, hypothyroid, or hyperthyroid within 1 year prior to their cancer diagnosis until the end of the follow-up period. The primary outcome was time to death from cancer diagnosis. A Cox proportional hazards model was used to identify the association between thyroid dysfunction and survival by using thyroid status as a time-dependent covariate and adjusting for age, grade and stage of disease. A total of 1201 patients were included for analysis. One thousand thirty (86%) patients had no thyroid dysfunction at time of cancer diagnosis, 145 patients (12%) carried the baseline diagnosis of hypothyroidism and 26 patients (2%) had hyperthyroidism. Twenty three women with normal thyroid function at baseline developed thyroid dysfunction during follow-up (91% hypothyroid, 9% hyperthyroid). A total of 218 deaths were observed. There were no differences in survival among patients with hypothyroidism or hyperthyroidism compared to euthyroid patients [HR 0.72 (95% CI 0.47-1.12, p=0.15); HR 0.51 (95% CI 0.16-1.58, p=0.24) respectively]. Women diagnosed with thyroid dysfunction prior to cancer diagnosis were observed to have a 30% lower hazard of death compared to euthyroid women, although this did not achieve statistical significance [HR 0.70 (95% CI 0.46-1.07, p=0.10)]. Patients who developed thyroid dysfunction after cancer diagnosis were observed to have a 3.7 fold higher hazard of death compared to patients who remained euthyroid during followup [HR 3.70 (95% CI 1.60-8.30), p=0.01], but this did not maintain significance in models adjusting for age, grade and stage of disease. Thyroid dysfunction was not associated with a difference in survival in women with uterine cancer in our cohort. Timing of thyroid dysfunction relative to uterine cancer diagnosis may affect clinical outcomes. Additional studies are needed to explore the relationship of thyroid dysfunction and uterine cancer.

BACKGROUND:Residency applications have increased in the last decade, creating growing challenges for applicants and programs.OBJECTIVE:We evaluated factors associated with application and match into obstetrics and gynecology residency.METHODS:During the annual in-training examination administered to all obstetrics and gynecology residents in the United States, residents were surveyed on the residency application process.RESULTS:Ninety-five percent (5094 of 5347) residents responded to the survey. Thirty-six percent reported applying to 30 or fewer programs, 26.7% applied to more than 31 programs, and 37.1% opted not to answer this question. Forty-nine percent of residents received honors in their obstetrics and gynecology clerkship and 37.1% did not. The majority of residents (88.6%) reported scoring between 200 and 250 on USMLE Step 1. Eighty-six percent matched into one of their top 5 programs. The only factor associated with matching in residents' top 5 programs was receiving honors in their clerkship (OR 1.29; 95% CI 1.08-1.54; P < .005). The only factor associated with matching below the top 5 programs was a couples match (OR 0.56; 95% CI 0.43-0.72; P < .001). In choosing where to apply, residents identified program location and reputation as the most important factors, while for ranking, location and residency culture were the most important.CONCLUSIONS:Most obstetrics and gynecology residents reported matching into their top 5 choices. Receiving an honors grade in the clerkship was the only factor associated with matching in applicants' top 5 programs. Location was the most important factor for applying to and ranking of programs.

Objectives: COVID-19 is characterized by rapid human-to-human transmission via contaminated respiratory droplets and therefore presents unique challenges in all aspects of healthcare delivery. This is especially true for patients with conditions, such as gynecologic cancer, which require frequent interface with healthcare centers. To further decrease the risk of exposure to these patients, alternate models of care delivery have been implemented and quickly adopted by medical centers. We sought to report the impact of modifications to traditional gynecologic cancer care at our institution. Methods: We identified women with suspected or confirmed gynecologic malignancy, age 18 or older, who received care at Montefiore Medical Center between March 16, 2020 and June 7, 2020; these dates reflect a series of executive orders issued by the governor of New York allowing the State Commissioner of Health to cancel elective procedures at hospitals, ambulatory surgery centers, and in the outpatient setting. Clinical data was abstracted from each patient's chart. Patients with incomplete treatment records were excluded. Results: A total of 111 women were identified to be undergoing active treatment and were included in our analysis, representing a total of 703 virtual or in-person patient encounters. More televisit encounters were performed compared to in-person encounters (209 vs 153). The average number of televisits per patient was significantly greater than the average number of in-person outpatient visits per patient (1.88±0.28 vs 1.38±0.42, p=0.047). Other encounters included 173 outpatient laboratory encounters, 112 outpatient radiology encounters, 30 emergency department encounters, 23 hospitalizations, and 3 ambulatory surgeries. Per patient, the median number of interactions was 5 (interquartile range 3-10). Patients with endometrial cancer (n=38) were more likely to be seen in person at least once in an outpatient visit than those with ovarian cancer (n=57) (OR 3.56, 95% CI 1.50-8.43). No significant difference between endometrial and ovarian cancer was seen in other types of encounters, including televisits (OR 0.94, 95% CI 0.32-2.74), inpatient admissions (OR 0.60, 95% CI 0.22-1.70), emergency room encounters (OR 0.77, 95% CI 0.28-2.09), ambulatory radiology encounters (OR 0.67, 95% CI 0.30-1.55), or ambulatory laboratory encounters (OR 0.96, 95% CI 0.42-2.24). Conclusions: The majority of patient encounters for gynecologic cancer at our institution during the SARS-COV-2 pandemic surge were conducted by telemedicine. Prior to the pandemic, telemedicine was not an active method of cancer care delivery within our institution. We predict that gynecologic oncology practice patterns will shift to include telemedicine as an integral part of patient care, even after SARS-COV-2 is no longer prevalent in the community.

Objectives: For over a decade palliative medicine in conjunction with disease modifying therapy has been recommended for women with metastatic, recurrent and symptomatic malignancies. The objective of this study was to compare the prevalence of palliative care consultations as well as aggressive care at the end of life (ACE) scores between women who died from gynecologic malignancies from 2005-2010 verse 2015-2020 as stratified by timely verses no/untimely consultation. We hypothesize that in the past fifteen years there has been an increase in palliative medicine consultation. Methods: After IRB approval data including patient demographics, histopathology, treatment and metrics of quality palliative care were abstracted from patients who died from gynecologic malignancies between 2005-2010 and 2015-2020 at a tertiary care medical center. Timely palliative consultation was defined as ≥to 30 days before death. Metrics contributing one point each to the ACE scores were 1) admission to ICU within 30 days of death, 2) hospital admission more than 14 days in the last 30 days of life, 3) more than one hospital admission during the past 30 days of life,4) more than one emergency room visit during the last 30 days of life,5) death in an acute care setting, 6) initiation of a new chemotherapy during the last 30 days of life, 7)last chemotherapy within 14 days of death, and 8) hospice admission less than 3 days before death. Data were reported in a descriptive fashion and analyzed using Student's T test, Wilcoxon Scores, and chi-square analysis with Stata 14.2. Results: Of 147 women in 2015-2020 cohort, 59(40%) had timely referral to palliative medicine compared to 18(18%) of the 2005-2010 cohort (p<0.01). Palliative referral increased from 49% to 73% (p<0.01). The median number of days from palliative referral to death was 16 days (range 0-159) in the historical and 35 days (range 0-667) in the modern cohort (p=0.02). Median ACE scores were 2 (range 0-5) for late/no referral verses 0 (range 0-4) for timely consultation (p<0.01) in 2015-2020 and 2 (range 0-6) for late/no referral verses 0 (range 0-3) for timely consultation (p=0.02) in 2005-2010. In the 2015-2020 cohort there was a significant decrease in incident metrics of new chemotherapy in the last month of life, chemotherapy in last 14 days of life, death in an ICU, and death in an acute care setting (p<0.05) (Table 1). There was also a nonsignificant trend of decrease in women who received cardiopulmonary resuscitation at the end of life for women who had timely palliative medicine consultation in the 2015-2020 cohort, 5% verses 16% (p=0.06). The median time from hospice to death in the historical group was 29 days (0-149) and 59 days (0-610) in the modern group (p=0.02). There were significant differences in age, race, insurer, disease site, stage and marital status between patients with timely verses untimely/no consultation (p<0.05). Conclusions: There has been an increased consultation frequency and proportion of timely referrals to palliative medicine comparing contemporary to historical deaths from gynecologic malignancies. In both time periods overall ACE scores and some component scores were improved for women who received timely referral to palliative medicine. These data should be interpreted with caution secondary to baseline differences in cohorts who received timely palliative consultation verses untimely/no consultation For over a decade palliative medicine in conjunction with disease modifying therapy has been recommended for women with metastatic, recurrent and symptomatic malignancies. The objective of this study was to compare the prevalence of palliative care consultations as well as aggressive care at the end of life (ACE) scores between women who died from gynecologic malignancies from 2005-2010 verse 2015-2020 as stratified by timely verses no/untimely consultation. We hypothesize that in the past fifteen years there has been an increase in palliative medicine consultation. After IRB approval data including patient demographics, histopathology, treatment and metrics of quality palliative care were abstracted from patients who died from gynecologic malignancies between 2005-2010 and 2015-2020 at a tertiary care medical center. Timely palliative consultation was defined as ≥to 30 days before death. Metrics contributing one point each to the ACE scores were 1) admission to ICU within 30 days of death, 2) hospital admission more than 14 days in the last 30 days of life, 3) more than one hospital admission during the past 30 days of life,4) more than one emergency room visit during the last 30 days of life,5) death in an acute care setting, 6) initiation of a new chemotherapy during the last 30 days of life, 7)last chemotherapy within 14 days of death, and 8) hospice admission less than 3 days before death. Data were reported in a descriptive fashion and analyzed using Student's T test, Wilcoxon Scores, and chi-square analysis with Stata 14.2. Of 147 women in 2015-2020 cohort, 59(40%) had timely referral to palliative medicine compared to 18(18%) of the 2005-2010 cohort (p<0.01). Palliative referral increased from 49% to 73% (p<0.01). The median number of days from palliative referral to death was 16 days (range 0-159) in the historical and 35 days (range 0-667) in the modern cohort (p=0.02). Median ACE scores were 2 (range 0-5) for late/no referral verses 0 (range 0-4) for timely consultation (p<0.01) in 2015-2020 and 2 (range 0-6) for late/no referral verses 0 (range 0-3) for timely consultation (p=0.02) in 2005-2010. In the 2015-2020 cohort there was a significant decrease in incident metrics of new chemotherapy in the last month of life, chemotherapy in last 14 days of life, death in an ICU, and death in an acute care setting (p<0.05) (Table 1). There was also a nonsignificant trend of decrease in women who received cardiopulmonary resuscitation at the end of life for women who had timely palliative medicine consultation in the 2015-2020 cohort, 5% verses 16% (p=0.06). The median time from hospice to death in the historical group was 29 days (0-149) and 59 days (0-610) in the modern group (p=0.02). There were significant differences in age, race, insurer, disease site, stage and marital status between patients with timely verses untimely/no consultation (p<0.05). There has been an increased consultation frequency and proportion of timely referrals to palliative medicine comparing contemporary to historical deaths from gynecologic malignancies. In both time periods overall ACE scores and some component scores were improved for women who received timely referral to palliative medicine. These data should be interpreted with caution secondary to baseline differences in cohorts who received timely palliative consultation verses untimely/no consultation

5555 Background: The Khorana score is a previously validated method to identify patients at high risk of VTE during chemotherapy who would potentially benefit from thromboprophylaxis. The objectives of our study were to evaluate risk factors and timing associated with VTE in a large cohort of ovarian cancer patients and to assess the predictive ability of the Khorana score in this population. Methods: After IRB approval, a retrospective analysis was performed of all patients with ovarian cancer in the Albert Einstein Tumor Registry who received treatment between 2000 and 2020. Demographic, clinical, surgical and histologic data and information regarding timing of VTE were abstracted from the medical record. Khorana scores were retrospectively calculated for all patients who received chemotherapy based on their pre-chemotherapy laboratory indices. Bivariate analysis and multivariable logistic regression were used to examine the association between Khorana score and VTE. Results: A total of 472 patients were included over a median follow-up time of 33.7 (13.3, 61.1) months of whom 142 (31%) underwent diagnostic imaging to rule out VTE. A total of 62 patients (15%) were diagnosed with VTE with a median time from presentation to VTE of 8.7 (2.7, 30.3) months. Individual covariates which were significantly associated with VTE included stage III-IV disease, epithelial histology, open surgery, radical tumor debulking, and presence of residual disease after surgery. Of the 254 patients who received chemotherapy for their disease, 36 (14%) developed VTE within 3 weeks of receiving chemotherapy. Patients with Khorana scores of 2 (OR 1.73 95% CI 0.88-3.42) or 3 (OR 0.89 95% CI 0.33-2.44) were not significantly more likely to develop VTE during chemotherapy compared to patients with a score of 1. However, patients with a score of 4 were 6.74 times more likely to develop a VTE during chemotherapy (95% CI 1.39 - 32.73). Overall, a Khorana score of 2 or higher conferred no significant increased risk of developing VTE during chemotherapy than a score of 1 (OR 1.61 95% CI 0.85- 3.02). In a multivariable model, the Khorana score was not significantly associated with risk of VTE and a Khorana score of 2 or higher could explain only 0.86% of the variability in predicting VTE. The only variables significantly associated with VTE after adjustment were stage III-IV disease and hyperlipidemia. Conclusions: Patients with ovarian cancer are at high risk of developing VTE many months after diagnosis and initiation of chemotherapy. Current ASCO and SGO guidelines recommend thromboprophylaxis for those initiating chemotherapy with a Khorana score of 2 or higher, however our study found that these patients are not at increased risk compared to those with a score of 1. Future models should be developed and validated in large population-based cohorts to determine if there is a more accurate strategy to identify women with ovarian cancer who are at risk for VTE.

Objective To characterize the microbiota of postmenopausal women undergoing hysterectomy for endometrioid (EAC) or uterine serous cancers (USC) compared to controls with non-malignant conditions. Methods Endometrial, cervicovaginal and anorectal microbial swabs were obtained from 35 postmenopausal women (10 controls, 14 EAC and 11 USC) undergoing hysterectomy. Extracted DNA was PCR amplified using barcoded 16S rRNA gene V4 primers. Sequenced libraries were processed using QIIME2. Phyloseq was used to calculate α- and β- diversity measures. Biomarkers associated with case status were identified using ANCOM after adjustment for patient age, race and BMI. PICRUSt was used to identify microbial pathways associated with case status. Results Beta-diversity of microbial communities across each niche was significantly different (R2 = 0.25, p < 0.001). Alpha-diversity of the uterine microbiome was reduced in USC (Chao1, p = 0.004 and Fisher, p = 0.007) compared to EAC. Biomarkers from the three anatomical sites allowed samples to be clustered into two distinct clades that distinguished controls from USC cases (p = 0.042). The USC group was defined by 13 bacterial taxa across the three sites (W-stat>10, FDR<0.05) including depletion of cervicovaginal Lactobacillus and elevation of uterine Pseudomonas . PICRUSTt analysis revealed highly significant differences between the USC-associated clades within the cervicovaginal and uterine microbiota. Conclusions The microbial diversity of anatomic niches in postmenopausal women with EAC and USC is different compared to controls. Multiple bacteria are associated with USC case status including elevated levels of cervicovaginal Lactobacillus , depletion of uterine Pseudomonas , and substantially different functional potentials identified within cervicovaginal and uterine niches.

5571 Background: Racial disparities in uterine cancer outcomes are present, as Black patients with uterine cancer have markedly higher mortality when compared with White patients. Potential etiologies of this discrepancy have been investigated, including implicit bias, histopathologic factors and stage at presentation, molecular and genetic factors, and socioeconomic factors. The purpose of this study is to explore if non-White patients with uterine cancer are more likely to experience distant cancer recurrence compared to White patients. Methods: A single-institution retrospective cohort study was performed examining all patients diagnosed with uterine cancer from 2006-2016. Data regarding patient demographics, medical co-morbidities, histology, stage, treatment course, and disease recurrence were abstracted from the medical record. Race was categorized based on how a patient was registered in the medical record. The primary outcome was location of recurrence, with local recurrence defined as vaginal/cuff recurrence and distant recurrence representing nodal, intraperitoneal, or distant recurrence. A multivariable regression model was built in a backwards stepwise fashion to examine the association of individual covariates with distant recurrence as opposed to vaginal recurrence. Results: A total of 1205 patients with uterine cancer were included for analysis. Three hundred eighteen (26.5%) patients were White, 472 (39.2%) Black, 319 (26.5%) Hispanic, 91 (7.6%) Asian, and 4 (0.3%) other. A total of 223 (18.5%) patients experienced disease recurrence. Black women experienced a statistically significant increased risk of recurrence compared with non-Black women [OR 1.99 (95% CI 1.37-2.88), p < 0.01]. Additionally, Black patients were significantly more likely to experience nodal, intra-peritoneal and distant recurrences relative to White patients (p < 0.01). When adjusting for covariates including race, histology, grade, stage and adjuvant treatment, non-White race [OR 3.87 (95% CI (1.42-10.54), p < 0.01] was associated with significant increase in risk of distal recurrence. Conclusions: The findings of this study suggest that non-White race is potentially contributory to distant recurrence of uterine cancer, even when accounting for histopathologic differences, stage at presentation, and other traditional covariates. These findings suggest that the disparate outcomes experienced by non-White patients are likely multi-factorial in nature and highlight the need for efforts focused on optimizing treatment and improving outcomes of non-White women with uterine cancer.[Table: see text]