Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, or epithelial ovarian cancer: a Program in Evidence-Based Care guideline adaptation

From Treatment to Recovery: Gynecological Survivors' and Caregivers' Perspectives About the Usability of an Educational Resource

The objective of this study was to understand gynecological cancer (GC) survivors' and their informal caregivers' perceptions about the usability of an educational resource to support their transition from primary cancer treatment into surveillance and/or recovery. After developing an empirical- and experiential-informed educational resource, we used a semi-structured questioning process to understand GC survivors and their caregivers' perceptions about its usability. Data were collected via online focus groups or 1:1 interviews that were audio recorded and transcribed. We used thematic analysis to analyze the data. Ten participants who were survivors or informal caregivers of cervical, ovarian, or uterine/endometrial cancer participated in two rounds of data collection. We grouped qualitative data into two themes: (1) reputable, relevant, and accessible education reduces uncertainty and promotes connection, and (2) individualized delivery of education provided by trusted cancer clinicians. The transition from treatment to surveillance is a challenging time for which reputable, relevant, and accessible educational resources are useful to facilitate an understanding about and self-management of survivorship-related concerns. Survivors and caregivers look to clinicians to provide reputable education to address their needs. This education should be diverse in content and referred to repeatedly throughout the cancer trajectory.

Prognostic Factors After the First Recurrence of Ovarian Cancer

Objective: Ovarian cancer is the fifth most frequent tumor in women and the second most common gynecological cancer. Recurrence of ovarian cancer develops in up to 50-90% of patients within the first five years after diagnosis. Approximately 70% of patients with advanced disease will experience a relapse. The aim of this study was to assess prognostic factors that may predict a higher probability of additional recurrences, as well as their treatment and impact on disease-free and overall survival. Method: A retrospective observational study was conducted on patients diagnosed with recurrent ovarian cancer at the Gynecologic Oncology Unit of Hospital Universitario La Paz (Madrid, Spain) from January 2000 to December 2020. All variables related to the initial treatment, diagnosis, and management of the recurrence were collected and analyzed. Results: Data from 144 patients with recurrent ovarian cancer were analyzed. Statistically significant differences were found in disease-free survival between patients depending on initial tumor staging and primary treatment. Better outcomes were observed in patients with FIGO (International Federation of Gynecology and Obstetrics) stages I-II compared to those with FIGO stages III-IV at diagnosis (p = 0.021), as well as in patients who underwent primary cytoreduction compared to those who received neoadjuvant chemotherapy followed by interval surgery (p < 0.001). The disease-free interval was categorized into three periods, <6 months, 6-12 months, and ≥12 months, with greater survival observed in those with a longer disease-free interval (p < 0.001). After the first recurrence, two factors significantly influenced patient survival: the type of treatment received after the first recurrence (p < 0.001) and the type of chemotherapy regimen (p = 0.001). Complete cytoreduction during primary treatment was an independent prognostic factor and was related to better overall survival in patients where it was achieved (p = 0.004), regardless of the number of recurrences. Conclusions: The prognostic factors with impact on the survival of patients with a first recurrence of ovarian cancer are the following: treatment modality of the primary tumor, treatment modality of the recurrence, type of chemotherapy regimen, and disease-free interval from initial diagnosis to the first recurrence.

Evaluation of follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

This is an update of a previous Cochrane Review, last updated in 2014. Ovarian cancer is the eighth most common cancer and seventh most common cause of death due to cancer in women worldwide. Traditionally, most women who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, or health-related quality of life (HRQOL), or relieving anxiety. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential effects of different strategies of follow-up in women with epithelial ovarian cancer, following completion of primary treatment.

SEARCH METHODS

For this update, we searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL 2022, Issue 11, MEDLINE, and Embase from August 2013 to November 2022. We also searched review articles and contacted experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias. They compared results, and resolved disagreements by discussion. We assessed the certainty of evidence, using the GRADE approach, for the outcomes of interest: overall survival (OS), health-related quality of life (HRQOL), psychological effects, and cost analysis.

MAIN RESULTS

For this update, we included one new RCT, including 112 women with ovarian, fallopian tube, or peritoneal cancer, who had completed primary treatment by surgery, with or without chemotherapy. This study reported the effect of individualised, i.e. individually tailored, nurse-led follow-up versus conventional medical follow-up on HRQOL, psychological outcomes, and cost-analysis. Individualised follow-up improved HRQOL in one of the two scales, with a decrease in mean difference (MD) in the QLQ-C30 discomfort scale following 12 months of individualised treatment compared to 12 months of conventional treatment (MD -5.76 points, 95% confidence interval (CI) -10.92 to -0.60; 1 study, 112 participants; low-certainty evidence; minimal important difference 4 to 10 points). There may be little or no difference in the other HRQOL scale (QLQ-Ov28, MD -0.97 points, 95% CI -2.57 to 0.63; 1 study, 112 participants: low-certainty evidence); psychological outcome, measured with the hospital anxiety and depression scale (HADS; MD 0.10 point, 95% CI -0.81 to 1.02; 1 study, 112 participants: low-certainty evidence), or cost analysis (MD -GBP 695.00, 95% CI -1467.23 to 77.23; 1 study, 112 participants: moderate-certainty evidence). Our previous review included one RCT, with 529 women in a confirmed remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer. This study evaluated immediate treatment of ovarian cancer relapse following a rise of serum CA125 levels versus delaying treatment until symptoms developed for OS, and HRQOL. There was little or no difference in OS between the immediate and delayed arms after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% CI 0.80 to 1.20; 1 study, 529 participants; moderate-certainty evidence). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88).

AUTHORS' CONCLUSIONS

Limited evidence from one trial suggests that routine surveillance with CA125 in asymptomatic women and treatment at CA125-defined relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. However, this study pre-dates the use of PARPi maintenance treatment and the increased use of secondary cytoreductive surgery, so the results may be limited in their applicability to current practice. Limited evidence from one trial suggests that individualised nurse-led follow-up may improve HRQOL in women with ovarian cancer following completion of primary treatment. Large RCTs are needed to compare different types of follow-up, looking at survival, HRQOL, psychological effects, and cost as outcomes.

The needs of gynecological cancer survivors at the end of primary treatment: A scoping review and proposed model to guide clinical discussions

OBJECTIVE

Gynecological cancer (GC) survivors have unmet needs when they complete primary cancer treatment. Despite this, no known research has summarized these needs and survivors' suggestions to address them. We conducted a scoping review to fill these gaps and develop a model useful to guide clinical discussions and/or interventions.

METHODS

English, full length, and accessible primary studies describing the needs of GC survivors were included. No restrictions on date nor country of publication were applied. Two reviewers screened and extracted data, which was verified by a third reviewer.

RESULTS

Seventy-one studies met the inclusion criteria for data extraction. Results were thematically grouped into seven dimensions: physical needs, sexuality-related concerns, altered self-image, psychological wellbeing, social support needs, supporting the return to work, and healthcare challenges and preferences. After consulting with a stakeholder group (a GC survivor, clinicians, and researchers), the dimensions were summarized into a proposed model to guide clinical assessments and/or interventions.

CONCLUSION

Results illuminate the diverse needs of GC survivors as they complete primary cancer treatment and their recommendations for care to meet these needs.

PRACTICE IMPLICATIONS

The resulting model can be used to guide assessments, discussions and/or interventions to optimally prepare GC survivors for transition out of primary cancer treatment.

Gynecologic cancer surveillance in the era of SARS-CoV-2 (COVID-19)

The SARS-CoV-2 (COVID-19) pandemic has significantly impacted the management of patients with gynecologic cancers. Many centers have reduced access to routine visits to avoid crowded waiting areas and specially to reduce the infection risk for oncologic patients. The goal of this review is to propose a surveillance algorithm for patients with gynecologic cancers during the COVID-19 pandemic based on existing evidence and established guidelines. It is time to consider strategies based on telemedicine and to adapt protocols in this new era. We hereby propose a strategy for routine surveillance both during and beyond the pandemic.

Therapeutic options following second-line platinum-based chemotherapy in patients with recurrent ovarian cancer: Comparison of active surveillance and maintenance treatment

Most women with advanced ovarian cancer respond to initial treatment, consisting of surgical resection and ≈6 cycles of platinum-based chemotherapy. However, disease recurrence occurs in most patients, and subsequent therapies become necessary. Historically, close monitoring following treatment (active surveillance) was the only available option, as continued maintenance chemotherapy treatment led to increased toxicity without providing any meaningful clinical benefit. Recently, targeted therapy with the angiogenesis inhibitor bevacizumab and the poly(ADP-ribose) polymerase (PARP) inhibitors olaparib, niraparib, and rucaparib have demonstrated significant clinical benefits as maintenance treatment for recurrent disease. Despite consensus guidelines recommending their use, maintenance treatments are currently underutilized. Here, we review evidence from pivotal clinical trials of approved second-line maintenance treatments demonstrating efficacy in terms of progression-free survival and postprogression efficacy outcomes for patients with recurrent ovarian cancer. Adverse events frequently associated with bevacizumab include hypertension, proteinuria, and non-central nervous system bleeding, whereas PARP inhibitors are associated with nausea, vomiting, fatigue, and anemia. Patient-centered outcomes analyses show that PARP inhibitors provide significant benefits to patient health status, even when accounting for the toxicities associated with treatment. Many factors influence the selection of second-line maintenance treatment for patients with recurrent ovarian cancer, including the maintenance treatment received in the first-line setting. Overall, targeted maintenance treatment represents a new standard of care for patients with ovarian cancer, and we recommend that maintenance treatment should be offered to all eligible patients with recurrent ovarian cancer.

Use of PROM during follow-up of patients with ovarian cancer: the PROMova study protocol

BACKGROUND

There is a paucity of high-level evidence on the optimal follow-up of patients with ovarian cancer after primary treatment. A debate is ongoing on the extent to which follow-up should consider patient preferences and patient-reported outcome measures. Incorporation of patient-reported outcome measures supports the dialog between patient and clinician and may be instrumental in symptom monitoring and detection of underlying issues, especially when used actively during the clinical consultation.

PRIMARY OBJECTIVE AND ENDPOINT

The PROMova study aims to assess whether proactive use of patient-reported outcome measures during follow-up care increases patient involvement as perceived by the patient compared with standard care. Another objective is to measure satisfaction with the care provided.

STUDY HYPOTHESIS

It is hypothesized that proactive use of patient-reported outcome measures during the clinical encounter will improve patients' experience of involvement in follow-up care.

TRIAL DESIGN

PROMova is a multi-center, observational cohort study collecting data from eight departments in Denmark. Five departments use the patient-reported outcome measures proactively during the consultation and three provide standard care. Participants are followed up with patient-reported outcome measures for up to 3 years. The patient-reported outcome measures package comprises EORTC QLQ-C30, EORTC QLQ-OV28, a questionnaire screening tool for recurrence, CollaboRATE, and selected questions from the Patient Experience Questionnaire.

MAJOR INCLUSION/EXCLUSION CRITERIA

Patients older than 18 years diagnosed with ovarian, fallopian tube, or primary peritoneal cancer are eligible when entering the follow-up program after primary treatment. Participants must be able to speak and read Danish.

SAMPLE SIZE

223 patients with ovarian cancer.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The protocol closed for enrollment in 2019. Publication of final results is expected in spring 2022.

TRIAL REGISTRATION

PROMova was registered with ClinicalTrials.gov November 2016 Identifier: NCT02916875.

Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Assessing Suspected Deep Pelvic or Abdominal Recurrence in Gynecologic Cancer: A Feasibility Study

OBJECTIVES

To assess the feasibility of gastrointestinal endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for histologic confirmation of cancer recurrence in women with gynecologic cancer.

METHODS

This work was a retrospective cohort study comprising 46 consecutive women treated for gynecologic cancer and suspected of having a deep pelvic or abdominal recurrence on ultrasound imaging, computed tomography, positron emission tomography-computed tomography, or magnetic resonance imaging, evaluated at our institution from January 2010 to December 2017. Primary cancer was ovarian (n = 22), cervical (n = 13), endometrial (n = 4), sarcoma (n = 4), and other (n = 3). All women underwent EUS examinations for locating the lesion and guiding FNA. The results of FNA (benign/malignant) were assessed. Procedure-related complications were recorded.

RESULTS

The patients' mean age was 57.8 years. A total of 66 procedures were performed. Eleven women underwent 2 procedures; 2 women underwent 3 procedures; and 1 woman underwent 6 procedures at different times during the study period. In 1 case, no lesion was detected on the EUS assessment, and in 2 cases, FNA was not successful. Most lesions were located in the retroperitoneum or involved the intestine. Fine-needle aspiration could be performed in 63 cases (94.5%). Cytologic samples were adequate in 62 of 63 (98.4%). Recurrence was confirmed in 56 cases (90.3%) and ruled out in 6 (9.7%). No patient had any complication related to the procedure.

CONCLUSIONS

Endoscopic ultrasound-guided FNA is a minimally invasive, feasible, and safe technique for confirming pelvic/abdominal recurrence of gynecologic cancer.