OBJECTIVES:Gestational trophoblastic disease (GTD) is a rare condition that affects reproductive-age women with excellent clinical outcomes if treated appropriately. The study aims to describe patterns of care of GTD in Ontario, Canada between 2005-2022. METHODS:Using province-wide administrative databases, individuals with molar pregnancies and gestational trophoblastic neoplasia (GTN) were identified between 2005-2022. Patient characteristics included age, socioeconomic status, comorbidities, type of treatment, type of provider and type of chemotherapy. Descriptive statistics were used to analyze baseline characteristics. Characteristics of low-risk GTN were compared to those of high-risk GTN to determine differences. Overall survival is reported with Kaplan-Meier curves. RESULTS:Between 2005-2022, there were 2,334,219 hospital births recorded in Ontario, among which 1,660 molar pregnancies were identified (0.7 per 1,000 births). Suction evacuation was the most common management (91.0%), while 9.0% underwent hysterectomy. Patients treated with hysterectomy were significantly older (mean 36 vs. 31 years, p<0.01). Procedures were performed by general gynecologists (83.0%) and gynecologic oncologists (16.0%, p<0.01). Among 385 patients treated with GTN-chemotherapy, 87.3% had low-risk and 12.7% high-risk GTN. High-risk patients were older (mean 37 vs. 33 years, p=0.01) and more likely to have undergone hysterectomy (24.5% vs. 10.1%, p<0.01). Low-risk and high-risk GTN were mostly treated with a single line of chemotherapy (77.7%). Gynecologic oncologists provided most first-line chemotherapy (77.4%) compared to medical oncologists (19.5%). At least 1 subsequent hospital birth was noted in 28.0% of GTN patients and 17.4% had 2 or more. Eight deaths occurred (2.1%), primarily within the first 2 years of diagnosis, yielding a 5-year overall survival of 97.9%. CONCLUSIONS:While survival for GTN in Ontario appears excellent for a cohort including mostly low-risk GTN, under-ascertainment may mask variability in treatment and outcomes. Our findings support mandatory reporting, centralized referral, and a provincial registry to reliably define care and drive improvements.

OBJECTIVE:To assess the management and outcomes of patients diagnosed with an isolated serous tubal intraepithelial carcinoma lesion across Canada. METHODS:This retrospective study included consecutive patients with an isolated serous tubal intraepithelial carcinoma lesion diagnosed between 2006 and 2020 at 15 Canadian centers. Cases underwent multicenter panel pathology review. RESULTS:Of 107 patients, 41 serous tubal intraepithelial carcinoma cases (38.3%) were identified at prophylactic surgery for germline pathogenic variants, 36 (33.6%) at surgery for suspicion of malignancy, and 30 (28.0%) at surgery for benign conditions. Treatment groups included observation (n=62, 57.9%), staging surgery (n=35, 32.7%), and adjuvant chemotherapy (n=10, 9.3%). Median follow-up was 55.5 months (interquartile range 30.26-82.07 months). Overall, nine patients developed high-grade serous carcinoma. The cumulative incidence of high-grade serous carcinoma was not significantly different between treatment groups ( P =.181); however, no patient treated with chemotherapy developed high-grade serous carcinoma. The cumulative incidence of high-grade serous carcinoma was 1.1% (95% CI, 0.1-5.3%) at 2 years and 5.7% (95% CI, 1.8-13.1%) at 5 years. No significant predictive factors were found on univariate analysis. After multicenter pathology review of 59 cases (55.1%), consensus diagnosis was reached: 45 (76.3%) with serous tubal intraepithelial carcinoma, three (5.1%) with serous tubal intraepithelial lesion, seven (11.9%) with high-grade serous carcinoma, and two (3.4%) with normal tissue. Of the cases reviewed, only 1 of 45 patients (2.2%) with confirmed serous tubal intraepithelial carcinoma developed high-grade serous carcinoma at 73 months, indicating a 5-year cumulative incidence of cancer of 2.6% (95% CI, 0.2-11.7). CONCLUSION:Management of serous tubal intraepithelial carcinoma varied across centers. The 5-year cumulative incidence of high-grade serous carcinoma after isolated serous tubal intraepithelial carcinoma was 5.7%, consistent with recent literature. However, multicenter pathology review revealed initial underdiagnosed high-grade serous carcinoma, and 5-year cumulative incidence of high-grade serous carcinoma after confirmed serous tubal intraepithelial carcinoma decreased to 2.6%, underscoring the importance of diagnostic confirmation by expert pathologists to guide accurate management.

Background Risk-reducing gynecological surgery (RRGS) is a prophylactic procedure that may be offered to BRCA1, BRCA2, and Lynch syndrome (LS) mutation carriers to reduce the risk of developing gynecological cancer. This study was conducted to better understand patients' information needs and evaluate how patients weigh different sources of information in their decision-making process surrounding RRGS.Methods This study used a qualitative approach to understanding women's perspectives towards RRGS. Semi-structured interviews were conducted virtually with 8 women. Women offered RRGS between 35 and 70 years of age who are English-speaking and have an identifiable BRCA or LS mutation were included. Data from interviews was coded with constant comparative analysis to develop themes.Results Of the eight women, six had selected to undergo either prophylactic hysterectomy or oophorectomy: 5 decided yes to RRGS; 1 decided no; 2 were undecided. Thematic analysis found that the key factors affecting women's decisions around prophylactic surgery were cancer risk, surgical menopause, and psychological readiness. To make an informed decision, women relied most heavily on information provided by healthcare professionals (e.g. doctors, genetic counselors) and family members with prior cancer experience. However, some women reported that they did not feel adequately informed enough to make a decision and identified COVID-19 as a significant barrier affecting access to information.Conclusion This qualitative study revealed the key sources of information influencing attitudes regarding RRGS and how women consulted different sources of information to reach a decision. Results underscore the need for greater attention to women's information needs in the context of psychological readiness, particularly amidst the pandemic. Research involving a larger sample size may help to better inform how support can be provided to individuals with BRCA and LS mutations considering RRGS.

ImportanceDespite research supporting the benefits of early palliative care, timely initiation by gynecologic oncology patients is reportedly low, which may limit the effectiveness of palliative care.ObjectiveTo investigate the association of the timing of palliative care initiation with the aggressiveness of end-of-life care using established quality indicators among patients with ovarian cancer.Design, Setting, and ParticipantsThis population-based retrospective cohort study of ovarian cancer decedents used linked administrative health care data to identify palliative care provision across all health care sectors and health care professionals (specialist and nonspecialist) and end-of-life quality indicators in Ontario, Canada, from 2006 to 2018. Data analyses were performed July 12, 2024.Main Outcomes and MeasuresThe primary outcome was the associations between the timing of palliative care and end-of-life quality indicators, including emergency department use, hospital or intensive care unit admission in the last 30 days of life, chemotherapy in last 14 days of life, death in the hospital, and a composite measure of aggressive care. Late palliative care was defined as 3 months or less prior to death.ResultsThere were 8297 ovarian cancer decedents. Their mean (SD) age at death was 69.6 (13.1) years, and their mean (SD) oncologic survival was 2.8 (3.9) years. Among 3958 patients with known cancer stage, 3495 (88.3%) presented with stage III or IV disease. One-third of patients (2667 [32.1%]) received late palliative care in the final 3 months of life. Results of multivariable regression analysis indicated that any palliative care initiated earlier than 3 months before death was associated with lower rates of aggressive end-of-life care (odds ratio [OR], 0.47 [95% CI, 0.37-0.60]), death in hospital (OR, 0.54 [95% CI, 0.45-0.65]), and intensive care unit admission (OR, 0.46 [95% CI, 0.27-0.76]). Specialist palliative consultation from 3 months up to 6 monts before death was associated with decreased likelihood of late chemotherapy (OR, 0.46 [95% CI, 0.24-0.88]).ConclusionsFindings from this cohort study suggested that early palliative care may be associated with less-aggressive end-of-life care than late palliative care. Implementation strategies for early palliative care initiation are needed to optimize care quality and health resource utilization at the end of life.

ObjectiveTo evaluate intraoperative factors predicting appendiceal pathology during gynecologic oncology surgery for suspected mucinous ovarian neoplasms. MethodsWe conducted a retrospective study on 225 patients with mucinous ovarian neoplasms who underwent surgery for an adnexal mass with concurrent appendectomy between 2000 and 2018. Regression analyses were used to evaluate intraoperative factors, such as frozen section of the ovarian mass and surgeon's impression of the appendix in predicting appendiceal pathology. ResultsMost patients (77.8%) had a normal appendix on final pathology. Abnormal appendix cases (n = 26) included: metastasis from high-grade adenocarcinoma of the ovary (n = 1), neuroendocrine tumor of the appendix (n = 4), and low-grade appendiceal mucinous neoplasms (n = 26; 23 associated with a mucinous ovarian adenocarcinoma, 2 with a benign mucinous ovarian cystadenoma, and 1 with a borderline mucinous ovarian tumor). Combining normal intraoperative appearance of the appendix with benign or borderline frozen section yielded a negative predictive value of 85.1%, with 14.9% of patients being misclassified, and 6.0% having a neuroendocrine tumor or low-grade appendiceal neoplasm. ConclusionBenign or borderline frozen section of an ovarian mucinous neoplasm and normal appearing appendix have limited predictive value for appendiceal pathology. Appendectomy with removal of the mesoappendix should be considered in all cases of mucinous ovarian neoplasm, regardless of intraoperative findings.

IntroductionAll patients with high grade epithelial ovarian cancer(HGEOC) do not benefit equally from PARP inhibitors, but all are exposed to PARP-associated toxicities. This study aims to assess the correlation between the pathology-based Chemotherapy Response Score(CRS) at the time of interval debulking surgery(IDS) and progression free survival(PFS) in patients who received PARP maintenance, to determine this score’s potential as a marker of expected benefit from PARP.MethodsThis is a retrospective cohort study of patients with HGEOC who underwent IDS between January 2016 and September 2022. Demographic and clinical parameters were collected. χ2 test and Student t-test were used to compare descriptive variables and Kaplan-Meier survival analysis with log rank test comparison for PFS.ResultsOn 169 patients, 47 received PARP maintenance and the majority needed dose reduction due to toxicity(53.2%). Patients with CRS 1(No/Minimal response) or CRS 2–3(Moderate/Complete response) were comparable in terms of baseline characteristics. Patients CRS 1 compared to CRS 2–3 had lower PFS regardless of maintenance(p=0.017). Patients with CRS 2–3 who received PARP showed significantly improved PFS(20 vs 15 months, p=0.029) compared to those who did not, while in those with CRS 1 maintenance was not associated with improved PFS(p=0.27). Results were similar on multivariate analysis, adjusting for BRCA status and surgical outcomes.Conclusion/ImplicationsIn HGEOC patients demonstrating response(CRS 2–3) to NACT, PARP maintenance was associated with a significant improvement in PFS. CRS can be a helpful tool in counseling prior to PARP inhibitor initiation, in patients BRCA-intact, and in settings where homologous recombination deficiency testing is not easily available.

The purpose of this paper is to provide evidence-based guidance on the management of a positive human papilloma virus (HPV) test and to provide guidance around screening and HPV testing for specific patient populations. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC), and the Canadian Partnership Against Cancer. The literature informing these guidelines was obtained through a systematic review of relevant literature by a multi-step search process led by an information specialist. The literature was reviewed up to July 2021 with manual searches of relevant national guidelines and more recent publications. The quality of the evidence and strength of recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include primary care providers, gynecologists, colposcopists, screening programs, and healthcare facilities. The implementation of the recommendations will ensure an optimum implementation of HPV testing with a focus on the management of positive results. Recommendations for appropriate care for underserved and marginalized groups are made.

(Abstracted from Am J Obstet Gynecol 2023;228:553.e1–553.e8) The transversus abdominis plane (TAP) block is an anesthetic technique wherein a local anesthetic solution is into the fascial plane between the transversus abdominis and the internal oblique muscles. The TAP block has been shown to reduce requirements of opioids after surgery; however, it can be time-consuming for use in the operating room setting.

Despite previous research supporting the benefits of palliative care (PC) for improving quality of life and improving the quality of end of life (EOL) care, palliative care (PC) utilization by gynecologic oncology patients has been reported to be low, and the optimal timing of PC initiation is unknown. The primary objective was to investigate the impact of the timing of palliative care initiation on the aggressiveness of EOL care in patients dying of gynecologic cancers, using metrics defined by the National Quality forum.

OBJECTIVE:Early palliative care (PC) is associated with improved patient quality of life, less aggressive end-of-life care, and prolonged survival. We evaluated patterns of PC delivery in gynecologic oncology. METHODS:We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care data. RESULTS:The cohort included 16,237 decedents; 51.1% died of ovarian cancer, 30.3% uterine cancer, 12.1% cervical cancer, and 6.5% vulvar/vaginal cancers. Palliative care was most often delivered in the hospital inpatient setting in 81%, and 53% received specialist PC. PC was first received during hospital admission in 53%, and by outpatient physician care in only 23%. Palliative care was initiated a median 193 days prior to death, with the lowest two quintiles initiating care ≤70 days before death. The average user of PC resources (third quintile) received 68 days of PC. While cumulative use of community PC gradually increased over the final year of life, institutional palliative care use exponentially rose from 12 weeks until death. On multivariable analyses, predictors of initiating palliative care during a hospital admission included age ≥70 years at death, ≤3 month cancer survival, having cervical or uterine cancer, not having a primary care provider, or being in the lowest 3 income quintiles. CONCLUSION:Most palliative care is initiated and delivered during hospital admission, and is initiated late in a significant proportion. Strategies to increase access to anticipatory and integrated palliative care may improve the quality of the disease course and the end of life.

Objectives Early palliative care (PC) (≥6–12mo from death) has been associated with improved patient quality-of-life, less aggressive end-of-life care, and prolonged survival, and is understudied in gynecology. We characterized patterns of PC utilization and predictive factors in gynecologic cancer patients. Methods We conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006–2018 using ICES-linked administrative healthcare data. Multivariable logistic regression was used to determine factors associated with PC utilization. Results In this cohort of 16,237 women, 93.4% of decedents accessed palliative care, initially in the outpatient setting for 68.8% and institutionally for 31.2%. Palliative care was initiated a median 127 days before death (IQR 38–361d), and PC users accessed a median 8 institutional days (IQR 0–21d) and 41 community days (IRQ 3–174d). While use of community PC gradually increased toward the end of life, use of institutional palliative care exponentially increased from 12 weeks until death. On multivariable analyses, factors significantly associated with an increased likelihood of receiving palliative care were longer cancer-related survival and Deyo-Charlson comorbidity score ≥1. Factors significantly associated with decreased likelihood of palliative care were age ≥80 years, diagnosis of uterine or vulvar-vaginal cancers, initial diagnosis of stage I-III malignancy (vs. stage IV), living rurally or in the third income quintile, or death after 2007. Conclusions While >90% of gynecologic cancer decedents accessed palliative care, median initiation was within the last 4 months of life (late PC), which may result in suboptimal quality of disease and end-of-life care. Access to PC may be inequitable.

Objectives Background: GOG-240 demonstrated improved oncologic outcomes with addition of bevacizumab to standard chemotherapy for metastatic or recurrent cervical carcinoma. Previously, JCOG0505 revealed non-inferior oncologic outcomes of carboplatin/paclitaxel(TC) compared to cisplatin/paclitaxel(TP). However, there is no recent data comparing adverse events and chemotherapy response rates between TC and TP since addition of bevacizumab. Objective: To compare adverse events and response to chemotherapy of patients with metastatic or recurrent non-resectable cervical carcinoma who initiated chemotherapy between 01/2015 and 09/2021 with carboplatin/paclitaxel/bevacizumab(TCB) or cisplatin/paclitaxel/bevacizumab(TPB). Methods A retrospective study was conducted. Adverse events were classified using the National Cancer Institute Common Terminology Criteria for Adverse Events. Results Forty-seven patients were included; 29 with squamous cell histology and 18 with adenocarcinoma or adenosquamous histology. Median follow-up was 19 months. Thirty-eight patients received TCB, 9 received TPB; 19 were treated for metastatic disease, 3 for persistent disease, and 26 for recurrent disease. Median number of chemotherapy cycles was 6. While response to chemotherapy was similar in both groups (stable disease 13.2% vs 33.3%, p=0.15, partial or complete response, 36.8% vs 33.3%, p=0.84), patients receiving TCB experienced significantly less grade 3–5 (26.3% vs 66.7%, p=0.02) and grade 1–2 adverse events (13.2% vs 55.6%, p=0.005). Bevaziumab was discontinued in 12 patients (25.5%) due to severe toxicity, with significantly greater rate of fistula and perforation compared to rates in GOG 240 (12.8% vs 3%, p=0.004). Conclusions In this cohort, patients receiving TCB had similar response to chemotherapy, but significantly less adverse events, than those receiving TPB. Bevacizumab confers a high risk of severe adverse events.