Barriers to urogynecological care in a population of gynecological oncology patients

Short-Term Outcomes After Hysterectomy for Endometrial Cancer/EIN With Concomitant Pelvic Floor Disorder Surgery

IMPORTANCE

Endometrial cancer and precancer are common gynecologic problems for many women. A majority of these patients require surgery as the mainstay of treatment. Many of these patients often have concurrent pelvic floor disorders. Despite the prevalence and shared risk, fewer than 3% of women undergo concomitant surgery for PFDs at the time of surgery for endometrial cancer or endometrial intraepithelial neoplasia/hyperplasia.

OBJECTIVE

This study aimed to evaluate postoperative morbidity of concomitant pelvic organ prolapse (POP) and/or urinary incontinence (UI) procedures at the time of hysterectomy for endometrial cancer (EC) or endometrial intraepithelial neoplasia/endometrial hyperplasia (EIN/EH).

METHODS

This retrospective analysis of women undergoing hysterectomy for EC or EIN/EH between 2017 and 2022 used the American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome was any major complication within 30 days of surgery. Comparisons were made between 2 cohorts: hysterectomy with concomitant pelvic organ prolapse/urinary incontinence procedures (POPUI) versus hysterectomy without concomitant POP or UI procedures (HYSTAlone). A subgroup analysis was performed in patients with EC. A propensity score matching cohort was also created.

RESULTS

A total of 23,144 patients underwent hysterectomy for EC or EIN/EH: 1.9% (n = 432) had POP and/or UI procedures. Patients with POPUI were older, were predominantly White, had higher parity, and had lower body mass index with lower American Society of Anesthesiologists class. Patients with POPUI were less likely to have EC (65.7% vs 78.3%, P < 0.0001) and more likely to have their hysterectomy performed by a general obstetrician- gynecologists or urogynecologists. Major complications were low and not significantly different between POPUI and HYSTAlone (3.7% vs 3.6%, P = 0.094). A subgroup analysis of EC alone found that the HYSTAlone subset did not have more advanced cancers, yet the surgeon was more likely a gynecologic oncologist (87.1% vs 68.0%, P < 0.0001). There were no statistically significant differences between the 2 cohorts for the primary and secondary outcomes using propensity score matching analysis.

CONCLUSIONS

Concomitant prolapse and/or incontinence procedures were uncommon and did not increase the rate of 30-day major complications for women undergoing hysterectomy for EC/EH.

Pelvic floor dysfunction survivorship needs and referrals in the gynecologic oncology population: a narrative review

The population of survivors of gynecologic malignancies continues to grow. The population of gynecologic oncology survivors has a high prevalence of pelvic floor disorders. Gynecologic oncology patients identify several survivorship needs, including a need for more focused pelvic floor disorder sequelae care. The increasing focus on patient needs following cancer treatment has led to the development of survivorship care plans and other strategies for addressing post-treatment transitions and sequelae. Common themes in patient survivorship care are patient needs for flexible and integrated care, and it is unclear if survivorship care plans in their current state improve patient outcomes. Patient referrals, specifically to urogynecologists, may help address the gaps in survivorship care of pelvic floor dysfunction.The objective of this review is to discuss the burden of pelvic floor disorders in the gynecologic population and to contextualize these needs within broader survivorship needs. The review will then discuss current strategies of survivorship care, including a discussion of whether these methods meet survivorship pelvic floor disorder needs. This review addresses several gaps in the literature by contextualizing pelvic floor disorder needs within other survivorship needs and providing a critical discussion of current survivorship care strategies with a focus on pelvic floor disorders.

Concurrent Surgery for Locoregional Gynecologic Cancers and Pelvic Floor Disorders in a Population of Patients With Medicare Insurance

OBJECTIVE

To estimate the rate of concurrent surgery for locoregional gynecologic cancer and pelvic organ prolapse-urinary incontinence (POP-UI) and to assess the rate of surgery for POP-UI within 5 years for those who did not undergo concurrent surgery.

METHODS

This is a retrospective cohort study. The SEER-Medicare data set was used to identify cases of local or regional endometrial, cervical, and ovarian cancer diagnosed from 2000 to 2017. Patients were followed up for 5 years from diagnosis. We used χ 2 tests to identify categorical variables associated with having a concurrent POP-UI procedure with hysterectomy or within 5 years of hysterectomy. Logistic regression was used to calculate odds ratios and 95% CIs adjusted for variables statistically significant (α=.05) in the univariate analyses.

RESULTS

Of 30,862 patients with locoregional gynecologic cancer, only 5.5% underwent concurrent POP-UI surgery. Of those with a preexisting diagnosis related to POP-UI, however, 21.1% had concurrent surgery. Of the patients who had a diagnosis of POP-UI at the time of initial surgery for cancer and who did not undergo concurrent surgery, an additional 5.5% had a second surgery for POP-UI within 5 years. The rate of concurrent surgery remained constant over the time period (5.7% in 2000 and 2017) despite an increase in the frequency of POP-UI diagnosis in the same time frame.

CONCLUSION

The rate of concurrent surgery for patients with an early-stage gynecologic cancer and POP-UI-associated diagnosis in women older than age 65 years was 21.1%. Of women who did not undergo concurrent surgery but had a diagnosis of POP-UI, 1 in 18 underwent surgery for POP-UI within 5 years of their index cancer surgery. Dedicated efforts must be made to identify patients who would most benefit from concurrent cancer and POP-UI surgery in those with locoregional gynecologic cancers and pelvic floor disorders.

Surgeon Attitudes Toward Concurrent Urogynecologic and Gynecologic Oncology Procedures: A Cross-sectional Survey

IMPORTANCE

There is increasing overlap in the urogynecologic and gynecologic oncologic patient populations. To improve patient advocacy and access to care, a collaborative surgical approach may benefit this cohort.

OBJECTIVE

The aim of the study was to evaluate surgeon attitudes toward performing concurrent urogynecologic and gynecologic oncology procedures. We hypothesized that most surgeons are amenable to collaboration.

STUDY DESIGN

We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Oncology and the American Urogynecologic Society from August to November 2020. A 23-item online survey was created to assess surgeon demographics, practice and screening patterns, and attitudes toward surgical collaboration. We also evaluated obstacles to performing joint procedures and assessed whether attitudes could be influenced by new information.

RESULTS

A total of 338 surveys were included in the analysis, including 158 urogynecologists and 226 gynecologic oncologists (GOs). Most surgeons (77.8%) will recommend concurrent procedures with another specialty, and 97.8% of urogynecologists and 95.7% of oncologists currently perform joint surgical procedures. Male surgeons, regardless of specialty, were more likely to recommend staged procedures (44% vs 31%, P < 0.001), as were GOs (28% vs 10.1%, P < 0.001). However, oncologists were more likely than urogynecologists to initiate referrals for surgical collaboration (33.3% vs 14.4%, P < 0.001).

CONCLUSIONS

A total of 22.2% of urogynecologists and oncologists prefer staging surgical procedures. The most common barrier to a combined procedure was logistics. Urogynecologists were more concerned about the effects of cancer treatments on healing, the use of mesh implants, and financial reimbursements as compared with GOs. Treatment delay was a significantly greater concern for the oncologists.

Patient and clinician perspectives of pelvic floor dysfunction after gynaecological cancer

Purpose

To explore and compare patient and clinician experiences, knowledge and preferences in relation to screening and management of pelvic floor (PF) dysfunction in the gynaecology-oncology setting.

Methods

Semi-structured interviews were conducted with women reporting PF symptoms after gynaecological cancer treatment, and gynaecology-oncology clinicians. Interviews were transcribed and thematically analysed and were conducted until data saturation was reached.

Results

We interviewed 12 patients and 13 clinicians. We identified two main themes: (1) Experience with PF symptoms, screening, disclosure and management and (2) Future hope of what should happen to screen and manage PF symptoms. Differences between what participants had experienced and what they felt should happen highlighted a perceived need for improving PF screening and management. A sub-theme that reflected relevant barriers and enablers was also identified. Barriers included time pressure, being focussed on cancer treatment and not side-effects, and patients feeling unwell, emotional, and overwhelmed with the logistics of oncology appointments. Enablers included the patient-clinician relationship, and opportunities for improving management included integrating nursing and PF physiotherapy with oncology appointments.

Conclusions

Gynaecological cancer survivors and clinicians perceive a need to improve screening and management for PF symptoms. While barriers and differences in perception exist, there are opportunities to improve how PF symptoms can be screened and managed in this population. Further studies exploring the feasibility of providing integrated multidisciplinary PF therapy services may be warranted.

Barriers to Care Affecting Presentation to Urogynecologists in a Community Setting

OBJECTIVE

To evaluate barriers to care for patients presenting to urogynecologists and determine how these barriers differ in private and public/county health care settings.

METHODS

Standardized anonymous questionnaires were distributed from May 2018 to July 2018 to new patients presenting to a urogynecologist at three institutions: two private health care clinics (sites A and B) and one public/county hospital clinic (site C). Patients identified symptom duration, symptom severity, and factors inhibiting presentation to care from a list of barriers. Patients then identified the primary barrier to care.

RESULTS

One hundred nine questionnaires were distributed, and 88 were submitted, resulting in an 81% response rate (31 from site A, 30 from site B, 27 from site C). In analysis of the private versus public setting, there was no statistical difference between age (58 years vs 57 years, P = 0.69), body mass index (28 vs 30, P = 0.301), symptom duration (24 months vs 16 months, P = 0.28), or severity respectively. When asked to identify the primary barrier to presentation, patients in the private setting stated they did not know to see a specialist (26.2%, P = 0.002), while patients in the public setting could not obtain a closer appointment time (22.2% vs 13.1%, P = 0.35. Additionally, patients in the public setting were more likely to cite lack of health care coverage as a barrier to care (18.5% vs 1.6%, P = 0.01).

CONCLUSION

This study highlights barriers that can contribute to the disparity of care seen in our patient population. Efforts should be made to acknowledge and mitigate hindrances impacting access to care.

Pelvic floor disorders and sexuality in women with ovarian cancer: A systematic review

INTRODUCTION

Pelvic floor disorders (PFD) are common conditions impacting quality of life and sexuality may worsen after ovarian cancer therapies. Our objective was to describe the prevalence of PFD and sexuality in women with ovarian cancer (OC).

METHODS

We reviewed articles indexed in the MEDLINE database until June 2020 and selected articles assessing UI, POP, FI and sexual dysfunction in a population of women with OC.

RESULTS

Of 360 articles, 18 were included: four assessed UI, two assessed POP, three FI, and 13 sexual dysfunction. PFD findings were highly heterogeneous due to the definitions used and the populations studied. The prevalence of any type of UI in patients with OC before treatment is around 50%, and about 17% report feeling a bulge in their vagina. These rates are similar to those reported in women without cancer. Similarly, the main post-treatment UI scores were not significantly different from women without cancer. Fecal incontinence has been less studied in women with OC but reported as affecting 4% of patients preoperatively and 16% postoperatively. About half of the women are sexually active after surgical treatment with high reported rates of dyspareunia (40-80%) and vaginal dryness (60-80%). Compared with healthy women, some authors found that OC patients had greater problems with loss of desire and poorer sexual function scores; other authors did not find a significant difference.

CONCLUSIONS

While PFD seem to be common in women after treatment for OC, the rates are not higher than in the general population. Overall, there is a higher prevalence of UI and sexual dysfunction compared with bowel dysfunction. More prospective studies are needed to explore the impact of gynecologic cancers and their treatments on pelvic floor function and pelvic health-related quality of life.

Pelvic floor myofascial pain in gynecology oncology patients: A pilot study

Objective:

Here we present a pilot study investigating the prevalence of pelvic floor myofascial pain in patients presenting to an academic tertiary care gynecologic oncology clinic. We describe patients’ responses to a pain survey including the pain disability index.

Methods:

An IRB approved prospective survey and chart review was conducted. Patients underwent standard physical exam maneuvers for detection of pelvic floor myofascial pain. Consented patients completed a pain survey and pain disability index on presentation to clinic. Statistical analysis included Chi square test and Mann Whitney test.

Results:

Twenty-nine percent (45/155) of patients exhibited pelvic floor myofascial pain, while 71% (110/155) did not. Of those with malignancy, 28% (16/57) had pelvic floor myofascial pain and 72% (41/57) did not. Patients with pelvic floor myofascial pain had a significantly higher rating of “pain right now” ( p = 0.001) and “usual level of pain during the past week” ( p = 0.003) than those without such pain. Patients with pelvic floor myofascial pain had significantly greater disability in family/home responsibilities ( p = 0.01), recreation ( p = 0.001), social activity ( p = 0.008), occupation ( p = 0.015), sexual behavior ( p = 0.025), and life support activities ( p = 0.007) compared to those without pelvic floor myofascial pain.

Conclusion:

Pelvic floor myofascial pain affects 28% of patients with malignancy. Routine incorporation of a myofascial exam can identity those with such pain, which can lead to improved quality of life in gynecologic oncology patients with pelvic floor disorders.