Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update

BACKGROUND

Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges.

METHODS

Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.

Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South

As persistent inequities in health gained increased attention nationally due to COVID-19 and racial justice protests in 2020, it has become increasingly important to evaluate both the process and outcomes associated with coalition-based efforts to address health inequities. The Two Georgias Initiative supports coalitions in 11 rural counties to (1) achieve greater health equity, (2) improve health and health care, (3) build healthier rural communities and improve social conditions that impact the health of rural populations, and (4) build community, organizational, and individual leadership capacity for health equity. Rural communities suffer significant health disparities relative to urban areas, and also experience internal inequities by race and poverty level. The evaluation framework for The Two Georgias Initiative provides a comprehensive mixed methods approach to evaluating both processes and outcomes. Early results related to community readiness and capacity to address health inequities, measured through a coalition member survey (n = 236) conducted at the end of the planning phase, suggest coalitions were in the preparation stage, with higher levels of readiness among coalition members and organizations/groups similar to the coalition members' own, lower levels among public officials and other leaders, and the lowest levels among county residents. In addition, coalition members reported more experience with downstream drivers (e.g., access to care) of health than upstream drivers (e.g., affordable housing, environmental or racial justice). By providing a logic model, evaluation questions and associated indicators, as well as a range of data collection methods, this evaluation approach may prove practical to others aiming to evaluate their efforts to address health equity.

Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AIMS

Risk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume 'mini-pelvis' radiotherapy fields, were evaluated in a population-based study.

MATERIALS AND METHODS

All patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed.

RESULTS

In total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy.

CONCLUSION

Risk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.

Somatic yolk sac differentiation in tumors of the gynecologic tract: A report of two cases and review of the literature

•Somatic yolk sac tumor differentiation associated with malignant neoplasms is uncommon and associated with poor outcome.•In the gynecologic tract, somatic yolk sac differentiation most often arises in postmenopausal patients.•Somatic yolk sac differentiation shares driver mutations with and likely differentiates from the corresponding carcinoma.•This is the first report of somatic yolk sac differentiation in the gynecologic tract from a non-epithelial malignancy.

Abstract 419: The development of BRPF1 degraders as a potential treatment for acute myeloid leukemia

Acetylation of histones and additional nuclear proteins is a key mechanism in the regulation of gene expression. Aberrant acetylation has been linked to a wide range of diseases including cancer, inflammation, and neurodevelopmental disorders. Histone acetylation is introduced by histone acetyltransferases complexes (HATs), where substrate specificity is dramatically enhanced by scaffolding proteins that activate and target them to specific chromatin sites. A protein of interest with both epigenetic acetyl reader and scaffolding function is the protein Bromodomain and PHD finger-containing protein 1 (BRPF1). The Protein contains domains of two plant homeodomain (PHD) fingers separated by a zinc knuckle (PZP domain), a bromodomain, and a proline-tryptophan-tryptophan-proline (PWWP) Tudor domain. Native BRPF1 complexes can contain either MOZ/MORF or HBO1 as the catalytic MYST-family acetyltransferase subunit and the stable complex with Moz-Tif2 is known to lead to the development of human acute myeloid leukemia (AML). Given this, we chose to pursue the development of BRPF1 degraders to probe cancer disease biology especially in AML, where new therapies are required to overcome several unmet needs such as less-toxic treatments and relapsed/refractory disease paradigms. Here we present the design and synthesis of a range of BRPF1 degraders in highly desirable physicochemical space utilizing in-silico modeling. The prepared degraders which utilize multiple E3 ligases were then screened against cell lines harboring Mixed-lineage leukemia (MLL) translocations specifically the THP-1 cell line. In addition to this, we investigated the ability of the compounds to effectively degrade the target and suitability of our degraders for potential in-vivo exposure through a panel of routine ADMET assays.

Citation Format: Daniel Joseph Glynn, Rosie Crampton, Thomas Pesnot, Andrew Scott, Anne-Chloe Nassoy, Ralph Kirk, Daniele Narducci, Gary Nelson, Lynette Ongiri, Habiba Begum, Vincent Rao, Matilda Bingham, Rhoanne McPherson, Darryl Turner. The development of BRPF1 degraders as a potential treatment for acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 419.

Validation in Alberta of an administrative data algorithm to identify cancer recurrence

Background

Readily available population-based data about cancer recurrence would improve surveillance and research for women of reproductive age.

Methods

We randomly selected 200 women from the Alberta Cancer Registry who had received a cancer diagnosis and who ever had a pregnancy between 2003 and 2012. Administrative data were obtained and linked. Several definitions of recurrence were assessed using various minimum lengths of time between the initial diagnosis date and subsequent diagnoses or treatments, or both. Chart review was used as a "gold standard" definition of recurrence.

Results

Chart review identified recurrences in 26 women. The definition that best captured "recurrence" was 2 or more cancer diagnosis codes 10 or more months from the diagnosis date [sensitivity: 80.8%; 95% confidence interval (ci): 60.7% to 93.5%; specificity: 81.0%; 95% ci: 74.4% to 86.6%; positive predictive value: 38.9%; 95% ci: 25.9% to 53.1%; negative predictive value: 96.6%; 95% ci: 92.2% to 98.9%; kappa = 0.42; 95% ci: 0.28 to 0.57].

Conclusions

Recurrence in reproductive-aged women can be captured with moderate validity using administrative data, but should be interpreted with caution.

Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines

BACKGROUND

ERAS® Society guidelines are holistic, multidisciplinary tools designed to improve outcomes after surgery. The enhanced recovery after surgery (ERAS) approach was initially developed for colorectal surgery and has been implemented successfully across a large number of settings, resulting in improved patient outcomes. As the ERAS approach is increasingly being adopted worldwide and new guidelines are being generated for new populations, there is a need to define an ERAS® Society guideline and the methodology that should be followed in its development.

METHODS

The ERAS® Society recommended approach for developing new guidelines is based on the creation of multidisciplinary guideline development groups responsible for defining topics, planning the literature search, and assessing the quality of the evidence.

RESULTS

Clear definitions for the elements of an ERAS guideline involve multimodal and multidisciplinary approaches impacting on multiple patient outcomes. Recommended methodology for guideline development follows a rigorous approach with systematic identification and evaluation of evidence, and consensus-based development of recommendations. Guidelines should then be evaluated and reviewed regularly to ensure that the best and most up-to-date evidence is used consistently to support surgical patients.

CONCLUSION

There is a need for a standardized, evidence-informed approach to both the development of new ERAS® Society guidelines, and the adaptation and revision of existing guidelines.

Abstract 2751: Development of a specific Wee-1 inhibitor

Somatic mutations in the TP53 gene are one of the most frequent alterations in human cancers. The resulting TP53-deficient cancer cells rely on WEE1 to trigger a G2/M arrest, which allows for DNA repair and survival. Inhibition of WEE1 has therefore emerged as an attractive therapeutic strategy to selectively sensitise TP53-deficient tumours to DNA damaging agents. The WEE1 kinase inhibitor adavosertib is the only agent undergoing evaluation in a range of clinical trials to validate this hypothesis. It has also been the tool compound of choice to interrogate WEE1 biology for over a decade.

However, recent reports show adavosertib has antiproliferative single agent activity, which is counter intuitive considering its postulated mode of action. Other studies suggest adavosertib exerts poor kinase selectivity, and inhibits PLK1 with similar potency as WEE1. Since PLK1 is a well-established mitotic regulator with biological functions throughout the cell cycle, its inhibition may contribute to the clinical efficacy and toxicity observed for adavosertib. Other reported WEE1 inhibitors also suffer from low selectivity and single agent toxicity, making then unsuitable tool compounds. There is a clear need to identify a selective Wee1 tool compound.

Using a structure-based drug design approach, we exploited subtle active site differences to identify novel, potent WEE1 inhibitors that display high selectivity over PLK1. These compounds allowed us to demonstrate the distinct effects of WEE1 and PLK1 inhibition on cellular toxicity, and confirm that adavosertib’s single agent efficacy is unlikely to be mediated solely through the inhibition of WEE1. Our ongoing studies aim to provide a WEE1 selective tool compound that more rigorously probes WEE1 biology, and eventually leads to the development of less toxic therapeutic agents.

Citation Format: Mandy Watson, Tom Pesnot, Andrew Scott, Anthony Huxley, Gary Nelson, Montserrat Shelbourne, Jen Morton, Tilly Bingham. Development of a specific Wee-1 inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2751.

Cells respond to deletion of CAV1 by increasing synthesis of extracellular matrix

A range of cellular functions have been attributed to caveolae, flask-like invaginations of the plasma membrane. Here, we have used RNA-seq to achieve quantitative transcriptional profiling of primary embryonic fibroblasts from caveolin 1 knockout mice (CAV1-/- MEFs), and thereby to gain hypothesis-free insight into how these cells respond to the absence of caveolae. Components of the extracellular matrix were decisively over-represented within the set of genes displaying altered expression in CAV1-/- MEFs when compared to congenic wild-type controls. This was confirmed biochemically and by imaging for selected examples. Up-regulation of components of the extracellular matrix was also observed in a second cell line, NIH-3T3 cells genome edited to delete CAV1. Up-regulation of components of the extracellular matrix was detected in vivo by assessing collagen deposition and compliance of CAV1-/- lungs. We discuss the implications of these findings in terms of the cellular function of caveolae.

No incidence of glenohumeral joint dislocation in a review of 220 paediatric proximal humerus fractures

PURPOSE

Proximal humerus fractures in adults are approached with a high suspicion for potential associated glenohumeral dislocation. Axillary views of the shoulder can be painful and possibly even lead to dynamic angulation of the proximal humerus fracture. The incidence of associated glenohumeral dislocation in the paediatric population is unclear and it would be useful to determine whether children with proximal humerus fracture require specific axillary view imaging to rule out dislocation.

METHODS

We retrospectively reviewed 220 proximal humerus fractures in 218 total children. Imaging and follow-up clinic notes were reviewed for potential glenohumeral dislocation.

RESULTS

Average patient age was 9.8 years SD 3.8 with 55% of the patients male and a wide variety of mechanisms of injury. None of the 220 fractures evaluated showed radiographic evidence of a shoulder dislocation, and all 218 children had a follow-up appointment at least 21 days after the injury without any clinical concern of a missed shoulder dislocation.

CONCLUSION

No paediatric patients presenting with proximal humerus fractures had a corresponding glenohumeral joint dislocation in our relatively large series. We recommend obtaining this additional imaging only in cases with higher energy mechanisms, if there is suspicion of subluxation or dislocation on anteroposterior and scapular-Y views or if there is clinical concern.

LEVEL OF EVIDENCE

Level III Diagnostic.

F.L. de Castelnau's Norman River fishes housed in the Macleay Museum, University of Sydney

Type specimens were located in the Macleay Museum for five species described by F.L. de Castelnau: Kurtus gulliveri (syntype), Pseudoambassis macleayi (lectotype and two paralectotypes), Pseudoambassis elongatus (lectotype and paralectotype), Acanthoperca gulliveri (syntype) and Engraulis nasutus (syntypes). The last-named is shown to be a senior subjective synonym of Anchovia aestuaria Ogibly 1910, and is referred to the genus Thryssa Cuvier 1829.

First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies

OBJECTIVE

In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities.

METHODS

Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design.

RESULTS

Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities.

CONCLUSIONS AND FUTURE DIRECTION

Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients

BACKGROUND

The Enhanced Recovery After Surgery (eras) colorectal guideline has been implemented widely across Alberta. Our study examined the clinical and cost impacts of eras on colon cancer patients across the province.

METHODS

We first used both summary statistics and multivariate regression methods to compare, before and after guideline implementation, clinical outcomes (length of stay, complications, readmissions) in consecutive elective colorectal patients 18 or more years of age and in colon cancer and non-cancer patients treated at the Peter Lougheed Centre and the Grey Nuns Hospital between February 2013 and December 2014. We then used the differences in clinical outcomes for colon cancer patients, together with the average cost per hospital day, to estimate cost impacts.

RESULTS

The analysis considered 790 patients (398 cancer and 392 non-cancer patients). Mean guideline compliance increased to 60% in cancer patients and 57% in non-cancer patients after eras implementation from 37% overall before eras implementation. From pre- to post-eras, mean length of stay declined to 8.4 ± 5 days from 9.5 ± 7 days in cancer patients, and to 6.4 ± 4 days from 8.8 ± 5.5 days in non-cancer patients (p = 0.0012 and p = 0.0041 respectively). Complications declined significantly in the renal, hepatic, pancreatic, and gastrointestinal groups (difference in proportions: 13% in cancer patients; p < 0.05). No significant change in the risk of readmission was observed. The net cost savings attributable to eras implementation ranged from $1,096 to $2,771 per cancer patient and from $3,388 to $7,103 per non-cancer patient.

CONCLUSIONS

Implementation of eras not only resulted in clinical outcome improvements, but also had a significant beneficial impact on scarce health system resources. The effect for cancer patients was different from that for non-cancer patients, representing an opportunity for further refinement and study.