Perceptions of preparedness, timing of cancer diagnosis, and objective emergency preparedness among gynecological cancer patients in Puerto Rico before and after Hurricane Maria

OBJECTIVES

This study investigated the impact of cancer diagnosis status, individual feelings of preparedness, and other covariates on objective emergency preparedness among women diagnosed with gynecological cancers before or after the 2017 Hurricanes Irma and Maria in Puerto Rico.

METHODS

This study included 240 women who were interviewed by telephone from 9/2019-11/2020. Objective emergency preparedness was assessed using a list of six items. Subjective emergency preparedness was assessed by asking the women how prepared they felt (well, somewhat, or not at all) to face an emergency. Crude and multivariable logistic regression analyses were conducted to assess the associations (odds ratios [ORs] and 95% confidence intervals [CIs]) between variables of interest and objective preparedness.

RESULTS

Before and after the hurricanes, 60% and 66% of women, respectively, were objectively prepared. Before the hurricanes, women reporting feeling well-prepared (vs. not prepared) (OR=9.31, 95%CI:3.96-21.91) and those who were diagnosed before (vs. after) the hurricanes (OR=1.71, 95%CI:0.95-3.09) were more likely to be objectively prepared. After the hurricanes, self-perceived well-preparedness (OR=2.46, 95% CI: 1.10-5.51) was positively associated with emergency preparedness when compared to feeling unprepared.

CONCLUSIONS

Perceptions of emergency preparedness and having a cancer diagnosis increased the likelihood of being objectively prepared for an emergency.

POLICY SUMMARY

This study demonstrates the need for state, territorial, and federal governments to include emergency preparedness plans for cancer patients in the Comprehensive Cancer Control plans. The study also indicates a need for cancer specific emergency preparedness information to be readily available for patients.

Effect of chronic comorbidities on quality of life of gynecologic cancer patients in Puerto Rico

Objective.

To describe prevalence of chronic diseases and evaluate associations between comorbidities and quality of life in gynecologic cancer patients in Puerto Rico.

Methods.

A cross-sectional study among 233 women aged ≥21 years with a gynecologic cancer diagnosis. Through telephone interviews, information on comorbidities, quality of life, and other covariates were assessed. Quality of life included six items, assessing physical and mental health. Multivariate logistic regression models were used to estimate magnitude of association between the comorbidities under study (diabetes, cardiovascular and autoimmune diseases) and quality-of-life items, through adjusted prevalence odds ratio (aPOR; 95% confidence interval [CI]).

Results.

Most women (90.1%) reported one or more comorbidities in addition to their cancer diagnosis; cardiovascular diseases (63.1%) were more common than autoimmune diseases (37.3%) and diabetes (33.9%). Between 30% and 40% of the sample indicated dysfunctions in their general health (39.5%) and frequent physical (33.9%) and mental distress (31.8%). Adjusting for age and gross family income, women with autoimmune diseases presented higher prevalence of frequent limitations for daily activities (aPOR 2.00; 95% CI 1.05–3.81), poor general health (aPOR 3.52; 95% CI 1.90–6.49), frequent mental distress (aPOR 2.19; 95% CI 1.19–4.03), and dissatisfaction with life (aPOR 4.86; 95% CI 1.82–12.95) compared to those who did not report autoimmune diseases. No associations with cardiovascular diseases and diabetes were observed.

Conclusions.

Quality-of-life dysfunctions were highly prevalent in this population of gynecologic cancer patients. Suffering from autoimmune comorbidities significantly exacerbated those dysfunctions.

Abstract LB-154: Disruption of essential services after Hurricanes Irma and Maria and quality of life among women with gynecological cancer receiving care in Puerto Rico

Objectives: Cancer patients have increased risk of poor outcomes after disasters. On September 2017 Hurricanes Irma and María affected Puerto Rico (PR), causing the population to experience major stressors. We describe the disruption of essential services among women with gynecologic cancer in PR after hurricanes Irma and Maria and its impact on quality of life (QoL). We also compare QoL of these women before and after the hurricanes. Methods: This ongoing cross-sectional study is recruiting women aged ≥21 years diagnosed between September 2016-September 2018 and receiving care in PR; we have conducted 110 phone interviews from September 2019-December 2019. Patients' interviews address stressors (including disruptions and time in essential services such as power, electricity and telecommunications) and multilevel responses experienced by the women in the aftermath of the hurricanes. QoL was measured by using a scale from the BRFSS, which includes six items within two domains: physical and mental health; these items were assessed at two time periods (30 days and 3 months) before and after the hurricanes. The association between disruption of essential services and QoL was evaluated with the Chi-square test. Paired McNemar's test was used to compare women's QoL before and after the hurricanes. Results: Mean age of study participants is 63.7±12.1 years; 64.5% of women had a diagnosis of endometrial cancer, 15.5% cervical, 15.5% ovarian, 3.6% vulvar, and 1.0% vaginal. 100% of patients reported disruptions in electric power, 84.5% in potable water, and 75.2% in telecommunications. On average, patients endured 114 days (±88.8) without electric power, 63 days (±62.8) without potable water, and 62 days (±56.3) without telecommunications. We did not find significant differences between the disruption of essential services and QoL indicators (p>0.05). Nonetheless, QoL indicators were worst after the hurricanes than before. Frequent activity limitations (before=22.3% vs. after=39.1%), frequent mental distress (before=26.4% vs. after= 59.1%) and feeling dissatisfied/very dissatisfied with life (before=6.2% vs. after= 21.7%) increased (p<0.001). Frequent physical distress (33.6% vs. 40.9%) and fair/poor general health status (33.9% vs. 50.9%) also increased after the hurricanes, these results were marginally significant (p<0.10). Conclusion: Most of the patients experienced long interruptions in essential services, after hurricanes. The fact that all patients experienced some kind of disruption may explain the lack of association of these variables with QoL. Nonetheless, this study shows that participant's QoL worsened after the hurricanes. Study results should guide the development of a disaster management plan for cancer patients that focuses on minimizing the adverse effects on QoL in the aftermath of a catastrophic event. Acknowledgement: NCI Grant #R21CA239457

Citation Format: Ana P. Ortiz, Sandra García-Camacho, Andrea Pacheco-Díaz, William Calo, Sharee A. Umpierre, Pablo Méndez-Lazaro, Istoni DaLuz-Santana, Lianeris Estremera-Rodriguez, Mirza Rivera, Guillermo Tortolero-Luna. Disruption of essential services after Hurricanes Irma and Maria and quality of life among women with gynecological cancer receiving care in Puerto Rico [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-154.

Knowledge among Puerto Rican Women about Risk of Infertility Associated with Overweight and Obesity

OBJECTIVE

Our study sought to evaluate how aware the women attending gynecology clinics at the University of Puerto Rico Medical Sciences Campus (UPRMSC) were of the association between infertility and excess body weight (i.e., overweight and obesity).

METHODS

Women 21 years old and older attending gynecology clinics at UPR-MSC were invited to participate in this study (n = 234). A self-administered survey was provided to all the women. Logistic regression models were performed to determine associations.

RESULTS

About 56.8% of the women were found to be aware of the effects of obesity on fertility; their main source of medical information was their primary doctor. The odds (adjusted for age and annual income) of being aware of the association between obesity and infertility were about 2.41 (95% CI: 1.07-5.42) times higher in women with a BMI greater than or equal to 25 kg/m2 than they were in those with a BMI of less than 25 kg/m2. An interaction by age group (adjusted for BMI) was found for the association between annual income and knowledge of the obesity-infertility association (OR≥40 years old: 3.51, 95% CI: 1.41-8.72; OR<40 years old: 0.57, 95% CI: 0.15-2.13).

CONCLUSION

Our study revealed that there is a lack of knowledge regarding the effects of obesity on fertility and identifies characteristics associated with this knowledge. The contents of health-care-provider counseling and the barriers affecting communication between patients and health care providers could be assessed in further studies.

Ovarian cancer clinical trial endpoints: Society of Gynecologic Oncology white paper

OBJECTIVE

To explore the value of multiple clinical endpoints in the unique setting of ovarian cancer.

METHODS

A clinical trial workgroup was established by the Society of Gynecologic Oncology to develop a consensus statement via multiple conference calls, meetings and white paper drafts.

RESULTS

Clinical trial endpoints have profound effects on late phase clinical trial design, result interpretation, drug development, and regulatory approval of therapeutics. Selection of the optimal clinical trial endpoint is particularly provocative in ovarian cancer where long overall survival (OS) is observed. The lack of new regulatory approvals and the lack of harmony between regulatory bodies globally for ovarian cancer therapeutics are of concern. The advantages and disadvantages of the numerous endpoints available are herein discussed within the unique context of ovarian cancer where both crossover and post-progression therapies potentially uncouple surrogacy between progression-free survival (PFS) and OS, the two most widely supported and utilized endpoints. The roles of patient reported outcomes (PRO) and health related quality of life (HRQoL) are discussed, but even these widely supported parameters are affected by the unique characteristics of ovarian cancer where a significant percentage of patients may be asymptomatic. Original data regarding the endpoint preferences of ovarian cancer advocates is presented.

CONCLUSIONS

Endpoint selection in ovarian cancer clinical trials should reflect the impact on disease burden and unique characteristics of the treatment cohort while reflecting true patient benefit. Both OS and PFS have led to regulatory approvals and are clinically important. OS remains the most objective and accepted endpoint because it is least vulnerable to bias; however, the feasibility of OS in ovarian cancer is compromised by the requirement for large trial size, prolonged time-line for final analysis, and potential for unintended loss of treatment effect from active post-progression therapies. A large magnitude of effect in PFS improvement should establish benefit, and further communication with regulatory authorities to clarify acceptable endpoints should be undertaken.

Risk factors for abnormal cervical cytology in pregnant women attending the high-risk obstetrics clinic at the University Hospital in San Juan, Puerto Rico

OBJECTIVE

Approximately 30% of women diagnosed with cervical cancer are in their childbearing years, and 5-8% of pregnant women seeking prenatal care are found to have an abnormal Papanicolaou smear. Prenatal visits are an excellent opportunity for cervical cytology testing and patient education because of close follow-up. The objective of this study is to examine the overall prevalence of cervical dysplasia and associated risk factors in pregnant women aged 15 to 30 years attending the high-risk obstetrics clinics at the University Hospital in San Juan, Puerto Rico between December 2005 and May 2007.

METHODS

We performed a systematic review of 237 prenatal charts from patients attending the high-risk obstetrics clinics at the University Hospital in San Juan. The variables studied were age, place of birth, gestational age at first visit, gravidity, age at first coitus, number of sexual partners, tobacco use, Papanicolaou smear results, and cervical gonorrhea and Chlamydia test results. The relationship between cervical cytology results and the aforementioned variables was statistically assessed.

RESULTS

Abnormal cervical cytology was found in 16 (6.8%) of the patients. Of these, 75% were atypical squamous cells of unknown significance (ASCUS), 19% low-grade squamous intraepithelial lesion (LGSIL), and 6% high-grade squamous intraepithelial lesion (HGSIL). Gravidity > 3 was observed in 16.5% of the patients, and 48.7% were in their second trimester of gestation. Their first coitus was at age 17 or earlier (66.5%), and 78% had between 1 and 3 sexual partners. Having a positive Chlamydia test was significantly (p < 0.05) associated with the risk of having an abnormal cervical cytology. Other variables such as gravidity, age at first coitus, number of sexual partners, and tobacco use were not statistically associated with an abnormal cervical cytology test.

CONCLUSION

The overall prevalence of cervical dysplasia among pregnant women who attend the high-risk obstetrics clinic at the University Hospital in San Juan, Puerto Rico is similar to what has been reported elsewhere. Among all variables studied, only a positive Chlamydia test was found to be associated with an abnormal cervical cytology test. Given the high number of women seeking prenatal care and the close follow-up provided during this period, prenatal care is an excellent opportunity for cervical cytology testing and patient education.

Comparison of the endocervical brush and the endocervical curettage for the evaluation of the endocervical canal

OBJECTIVE

To evaluate and compare the efficacy in obtaining an adequate endocervical sampling using the endocervical brush and the endocervical curettage.

METHODS

Analysis of the cytology and histology of samples obtained from patients referred to the University of Puerto Rico School of Medicine Tertiary Care Center Anaplasia Clinics for colposcopy due to an abnormal Pap smear having atypical cells or higher as classified according to the Bethesda System. All patients underwent evaluation of the endocervical canal with an endocervical brush and an endocervical curettage.

RESULTS

Fifty three of fifty-eight patients had correlating endocervical brush Papanicolaou smear and endocervical curettage. Only five patients presented discrepancies. All endocervical brush samples had sufficient tissue for diagnosis.

CONCLUSION

The endocervical curettage is operator dependent, is difficult to perform in patients with a stenotic cervical os or in menopausal patients. The endocervical brush is easier to use, malleable and has a lower processing cost. In view of these findings evaluation of the endocervix can be safely performed with the use of an endocervical brush. When used properly, the endocervical brush has a sensitivity of 90%, a specificity of 92.1% and a positive predictive value of 87.5%.

Immunocytochemical analysis of uterine papillary serous carcinomas for estrogen and progesterone receptors

Uterine papillary serous carcinoma (UPSC), an aggressive histologic variant of endometrial cancer, is particularly resistant to cytotoxic chemotherapy. In reviewing a group of patients treated with cisplatin, doxorubicin, and cyclophosphamide, we were surprised to find that 90% of specimens tested by biochemical analysis were positive for estrogen receptor (ER), progesterone receptor (PR), or both. To further study receptor content and localization, we performed immunocytochemical analysis (ICA) on 29 archival UPSC specimens. In ER studies, three specimens were unevaluable because of inadequate internal controls; of the remaining 26, only two were ER positive, showing weak, focal staining. In PR studies, 18 samples had adequate controls, and all tumor specimens were receptor negative. Corresponding biochemical ER data were available for 11 cases, of which 10 were ER positive. ICA, however, showed all 10 to be negative. Biochemical PR data were available for seven samples: Six were positive. All six biochemically positive PR specimens were PR negative when analyzed by ICA. Biochemical assays for ER and PR may overestimate positivity as a result of contamination with normal tissue or the presence of receptor-positive typical endometrial adenocarcinoma in tumors of mixed histology. ICA may eliminate this problem, but it has technical limitations, especially when used for archival tissue analysis. Because urinary papillary serous carcinoma appears to be a receptor-negative tumor, further evaluation of hormonal therapy is not likely to be beneficial.

Human papillomavirus DNA in tissue biopsy specimens of vulvar vestibulitis patients treated with interferon

Thirteen women with the diagnosis of vulvar vestibulitis based on clinical symptoms, presence of vestibular tenderness on physical examination, and acetowhite changes of the vulvar vestibule were treated with intradermal injection of alpha-interferon. Biopsies of the acetowhite areas were analyzed for human papillomavirus (HPV) DNA using polymerase chain reaction amplification and dot blot hybridization. Eleven of 13 subjects harbored one of the HPV DNA types; six of these were type 16 and/or 18 and the others were unidentified. Five subjects (all HPV DNA-positive) reported resolution of symptoms with interferon therapy. Our results indicate the presence of HPV DNA in a subset of patients with vulvar vestibulitis, but its presence is not predictive of response to interferon therapy.

Cross-reactivity of monoclonal antibodies directed against lymphocyte markers with trophoblast cells of normal placenta, hydatidiform mole, and gestational choriocarcinoma

The current study was undertaken to characterize the expression of trophoblast-lymphocyte cross-reactive antigens on normal, molar, and malignant trophoblast. A panel of monoclonal antibodies directed against lymphoid cell markers were tested in immunofluorescence assay on cryostat sections of placenta and mole and on monolayers of choriocarcinoma cells. NKH-1, a monoclonal antibody to natural killer cells, reacted with both molar and placental villous trophoblast and with two choriocarcinoma cell lines. NKH-2, a monoclonal antibody reactive with a subset of natural killer cells, did not react with placental villous trophoblast but reacted with molar villous trophoblast in three of five moles tested and with both choriocarcinoma cell lines. B5, a monoclonal antibody which reacts with activated B cells, reacted with both choriocarcinoma cell lines but did not react with normal placental or molar trophoblast. MY7, a monoclonal antibody to myeloid colony-forming cells, reacted with only one of the choriocarcinoma cell lines. Trophoblast-lymphocyte cross-reactive antigens may be important in the immunobiology of gestational trophoblastic disease by modulating interactions between the trophoblast and the maternal immune system.

Expression of trophoblast-leukocyte common antigens and placental-type alkaline phosphatase in complete molar pregnancy

The current study was undertaken to determine the localization of trophoblast-leukocyte common antigens and placental-type alkaline phosphatase in complete molar pregnancy with the use of rabbit antiserum and murine monoclonal antibodies in immunofluorescence assays. Trophoblast-leukocyte common antigens were expressed on all normal villous trophoblast (8 to 38 weeks' gestation) and on all complete moles studied. Placental-type alkaline phosphatase was not expressed on villous trophoblast before 20 weeks' gestation in either normal placentas or complete moles. In contrast, there was strong expression of placental-type alkaline phosphatase on villous trophoblast of normal placentas of more than 20 weeks' gestational age. The expression of polymorphic antigens such as trophoblast-leukocyte common antigens and placental-type alkaline phosphatase on molar trophoblast may be important in the immunobiologic features of gestational trophoblastic disease.

Immunobiology of complete molar pregnancy and gestational trophoblastic tumor

The unique curability of gestational trophoblastic tumors may in part be attributable to a host immunologic response. The occurrence of rapidly progressive and fatal choriocarcinoma may be favored by histocompatibility between patients and their partners. However, histocompatibility is not a prerequisite for the development and persistence of gestational choriocarcinoma. The expression of HLA by choriocarcinoma cells in culture is enhanced following incubation with gamma-interferon and this may be of both biologic and clinical significance. Complete molar pregnancy is a complete allograft because all molar chromosomes are of paternal origin. Patients with complete mole are sensitized to paternal HLA antigen which is expressed in molar tissue. Other polymorphic antigen systems including trophoblast-leukocyte common antigens and placental-type alkaline phosphatase are also expressed in molar tissue. We have studied the immunopathology of the molar implantation site to investigate possible humoral and cellular immune responses. The relationships among normal placenta, complete mole and choriocarcinoma are not clearly understood. The pattern of expression of oncofetal antigens in these three gestational tissues may be used to assess trophoblastic differentiation. In studies to date, molar trophoblast has the same pattern of expression of oncofetal antigens as normal placental trophoblast. We will review recent advances in our understanding of the immunobiology of gestational trophoblastic disease and suggest new directions for further research.