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Mao SPH, Desravines N, Zarei S, Viswanathan AN, Fader AN. Combined trastuzumab and radiation therapy for HER2-positive uterine serous carcinoma: A case report. Gynecol Oncol Rep 2023; 49:101250. [PMID: 37575611 PMCID: PMC10415829 DOI: 10.1016/j.gore.2023.101250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/15/2023] Open
Abstract
Overexpression of HER2 in endometrial cancer is associated with poor prognosis, aggressive disease, and resistance to standard therapies. Recent studies have shown that HER2-targeted therapies, such as trastuzumab, can be effective in treating HER2-positive endometrial cancer in combination with chemotherapy. Currently, the management of advanced-stage HER2-positive uterine serous carcinoma (USC) consists of adjuvant platinum-based chemotherapy with concurrent trastuzumab followed by trastuzumab maintenance therapy until disease recurrence or prohibitive toxicity. In the setting of persistent pelvic disease following systemic therapy, consolidation with tumor-directed radiation therapy also offers an opportunity to eradicate residual disease. With the emergence of molecular tumor classifications and systemic therapies (chemotherapy, immunotherapy, and target therapies), the landscape of adjuvant multi-modality therapy is ever changing and increasingly individualized. Currently, there is no prospective evidence to guide pelvic radiotherapy with concurrent trastuzumab in endometrial cancer, and as a result, no reported toxicity in endometrial cancer patients. In this case report, we present two patients with HER2-positive USC who received multi-agent chemotherapy with trastuzumab followed by pelvic radiation therapy and concurrent trastuzumab. Both patients tolerated this multimodal treatment without significant or persistent moderate or severe adverse events. These two cases provide insight into the safety and feasibility of administering radiation therapy with trastuzumab in endometrial cancer in the maintenance phase. Our report suggests that trastuzumab-based therapy may be a promising treatment option for HER2-positive endometrial cancer patients who receive concurrent or adjuvant chemotherapy and radiation therapy.
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Affiliation(s)
- SPH Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N Desravines
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - S Zarei
- Gynecologic Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - AN Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - AN Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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2
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Yamada SD, Adams S, Fader AN. Foreword. Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01218-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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3
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Dugan K, Yu R, Xing D, Ronnett B, Ferriss J, Wethington S, Fader AN, Baras A, Stone R. Programmed Death Ligand 1 (PD-L1) as a Therapeutic Target in Gestational Trophoblastic Neoplasia (GTN) (098). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01324-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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4
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Gaillard S, Deery A, Fader AN, Huh W, Liang M, Straughn M, Arend R, Wu T, Leath C, Roden R. Safety and feasibility of an HPV therapeutic vaccine (TA-CIN) in patients with HPV16 associated cervical cancer (458). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01680-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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5
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Acosta-Torres S, Murdock T, Beavis A, Gough E, Fader AN, Shih IM. Identifying biomarkers of response to progestin therapy in conservatively managed endometrial cancer and atypical hyperplasia/endometrioid intraepithelial neoplasia (266). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Schneiter MK, Levinson K, Rositch AF, Stone RL, Nickles Fader A, Stuart Ferriss J, Wethington SL, Beavis AL. Gynecologic Oncology HPV Vaccination Practice Patterns: Investigating Practice Barriers, Knowledge Gaps and Opportunities for Maximizing Cervical Cancer Prevention. Gynecol Oncol Rep 2022; 40:100952. [PMID: 35284612 PMCID: PMC8907676 DOI: 10.1016/j.gore.2022.100952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
Novel survey of gynecologic oncologists’ perspectives and practices regarding HPV vaccination. Higher levels of vaccine knowledge were associated with recommending the vaccine. Knowledge about prescribing policies and clinic factors were common barriers to HPV vaccination. There are modifiable patient, provider, and systemic level barriers to HPV vaccination.
Objective HPV vaccination is an important form of cancer prevention. Gynecologic oncologists have an opportunity to improve adult vaccination rates. We aimed to describe current HPV vaccination practices and barriers to vaccination reported by gynecologic oncologists. Methods An online survey was developed, pilot tested and sent to U.S. members of the Society of Gynecologic Oncology. Results Of the 226 respondents, most were female (73%), < 45 years old (64%) and practiced in urban (60%) and academic settings (69%). Ninety percent had recommended the HPV vaccine in the past year. Nearly half (47%) had facilitated vaccination by: administering the HPV vaccine in clinic (40%), stocking the vaccine (35%), or prescribing the vaccine (30%). Recommending the vaccine was associated with higher outpatient volume, practicing in the South vs. Northeast, and having higher levels of vaccine knowledge. Of the 90% who recommended the vaccine, 60% did not prescribe or know if they could prescribe the vaccine in their state. Prioritization of cancer treatment was the most commonly reported barrier to HPV vaccination (88%). Approximately half of providers reported other systems-level hinderances such as high cost of stocking the vaccine, clinic flow disruption, or uncertainty surrounding insurance coverage. Almost all recommenders offered the vaccine at HPV-related dysplasia (92%) or cancer (80%) visits, while only 24–50% offered it at non-HPV-related visits. Conclusions These survey results identify patient, provider, and systems-level barriers that could be targeted to help increase adult HPV vaccination in gynecologic oncology clinics.
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7
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Xun H, Fadavi D, Darrach H, Fischer N, Yesantharao P, Kraenzlin F, Nickles Fader A, Segars JH, Sacks JM. Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation. Cureus 2021; 13:e18891. [PMID: 34804735 PMCID: PMC8599396 DOI: 10.7759/cureus.18891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx. METHODS Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018. RESULTS Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance. CONCLUSIONS We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.
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Affiliation(s)
- Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Nicole Fischer
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Amanda Nickles Fader
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - James H Segars
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, USA
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8
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Wethington SL, Wahner-Hendrickson AE, Swisher EM, Kaufmann SH, Karlan BY, Fader AN, Dowdy SC. PARP inhibitor maintenance for primary ovarian cancer - A missed opportunity for precision medicine. Gynecol Oncol 2021; 163:11-13. [PMID: 34391577 DOI: 10.1016/j.ygyno.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Stephanie L Wethington
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Elizabeth M Swisher
- Division of Gynecologic Oncology, University of Washington, Seattle, WA, USA
| | | | - Beth Y Karlan
- Women's Cancer Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amanda Nickles Fader
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA.
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Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Fisher CM, Frederick P, Gaffney DK, Giuntoli R, Han E, Huh WK, Lurain Iii JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Urban R, Wyse E, McMillian NR, Motter AD. NCCN Guidelines Insights: Cervical Cancer, Version 1.2020. J Natl Compr Canc Netw 2021; 18:660-666. [PMID: 32502976 DOI: 10.6004/jnccn.2020.0027] [Citation(s) in RCA: 167] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Cervical Cancer provide recommendations for diagnostic workup, staging, and treatment of patients with the disease. These NCCN Guidelines Insights focus on recent updates to the guidelines, including changes to first- and second-line systemic therapy recommendations for patients with recurrent or metastatic disease, and emerging evidence on a new histopathologic classification system for HPV-related endocervical adenocarcinoma.
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Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- 8The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | - John R Lurain Iii
- 17Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- 19Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- 20Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- 25St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- 26UCSF Helen Diller Family Comprehensive Cancer Center
| | - Renata Urban
- 27Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
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10
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Nickles Fader A, Gien LT, Miller A, Covens A, Gershenson DM. A randomized phase III, two-arm trial of paclitaxel, carboplatin, and maintenance letrozole versus letrozole monotherapy in patients with stage II-IV, primary low-grade serous carcinoma of the ovary or peritoneum. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps5601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5601 Background: Low-grade serous carcinoma of the ovary or peritoneum (LGSOC) is a rare subtype of epithelial carcinoma. Differences in epidemiology, pathogenesis, disease presentation, and clinical outcomes have been characterized between women diagnosed with LGSOC and those with the p53-driven high-grade serous carcinoma (HGSOC). Ultimately, patients with LGSOC should be treated differently than those with HGSOC. Several studies suggest that LGSOC is relatively chemoresistant and that most tumors robustly express estrogen and progesterone receptors. Recently, retrospective reports suggest that utilization of the aromatase inhibitor, letrozole, as monotherapy or in addition to platinum/taxane-based chemotherapy in those with primary advanced-stage LGSOC results in preliminarily promising survival outcomes. Methods: This study is a two-arm, randomized, open-label, Phase III clinical trial. The primary objective is to assess whether letrozole monotherapy (2.5 mg po daily) is non-inferior to carboplatin (AUC 5-6) and paclitaxel (175 mg/m2) followed by letrozole maintenance therapy with respect to progression free survival in women with primary, Stage II-IV LGSOC who have undergone an attempt at maximal surgical cytoreduction. Secondary endpoints include incidence of adverse events, objective response rate in those with measurable disease after surgery, response duration, overall survival, and adherence to letrozole maintenance therapy. Study subjects must have undergone a bilateral salpingo-oophorectomy, and p53 IHC testing of tumors is required to rule out those with aberrant p53 expression commonly observed in HGSOC tumors. Study strata include residual disease status and country of enrollment. Four hundred and fifty patients will be enrolled in the United States, Canada and South Korea through the NRG Oncology trials network. Correlative aims include analyzing the association of ER/PR tumoral expression with aromatase inhibitor therapy response and determining ESR1 mutational status in those who develop letrozole resistance. The study includes two interim analyses; at 20% information time, a futility analysis will be conducted, and at 40% information time, both efficacy and futility will be assessed. This is one of the first randomized trials performed in women with primary, advanced LGSOC, and the study is open with 71 patients enrolled at the time of abstract submission. Clinical trial information: NCT04095364.
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Affiliation(s)
| | | | - Austin Miller
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Al Covens
- Sunnybrook Research Institute Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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11
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Smith AJ, Applebaum J, Nickles Fader A. The association of the affordable care's Medicaid expansion on survival in gynecologic cancer: A National Cancer Database study. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1501 Background: Under the Affordable Care Act’s 2014 Medicaid expansion, more than 12 million Americans gained health insurance. Whether such gains in insurance improve survival in gynecologic cancer is unknown. This study aims to determine whether Medicaid expansion is associated with improved survival among women with gynecologic cancers. Methods: We conducted a retrospective cohort study using a difference-in-differences study design comparing insurance status, stage at diagnosis, delays in treatment, and one-year survival before and after the ACA’s Medicaid expansion in Medicaid expansion states (intervention group) compared to women in non-expansion states (control group). Using hospital-reported data from the 2010-2016 National Cancer Database, we compared outcomes overall for women ages 40-64 years old with endometrial, cervical, ovarian, or vulva/vaginal cancer and then stratified by cancer type, stage, race, and rural/urban status. We adjusted for patient (area-level income, area-level education, distance traveled for care, comorbidities), clinical (co-morbidities, grade) and hospital (academic facility) characteristics. Results: Our sample included 241,713 women with gynecologic cancer, 119,392 in expansion states and 122,321 in non-expansion states. Post-Medicaid expansion, there was a statistically significant 0.8 % increase in 1-year survival among patients in expansion states compared to non-expansion states (95% CI 0.1-1.5). There was also a significant reduction in uninsurance (-1.1%, 95%CI, --1.5, -0.7) and delays of 30+ days from diagnosis to treatment (-2.4%, 95%CI -3.4, -1.2). There was no significant change in early-stage diagnosis (0%; 95%CI -0.7-0.7). Improvements in one-year survival after Medicaid expansion were driven by ovarian cancer (difference-in-differences 2.2%, 95%CI 0.6-3.8) and in white women (difference-in-differences 0.8%, 95%CI 0.1-1.5), while there was no significant difference in one-year survival for non-white or rural women. Conclusions: The Affordable Care Act’s Medicaid expansion was significantly associated with 1-year survival and insurance access among patients with gynecologic cancer. Insurance expansion efforts in non-Medicaid expansion states may improve survival for women with gynecologic cancer.
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Affiliation(s)
- Anna Jo Smith
- Johns Hopkins Department of Gynecology and Obstetrics, Baltimore, MD
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Chau DB, Beavis AL, Ronnett BM, Jenson E, Gocke CD, Anderson J, Nickles Fader A, Stone R. Genetically Related Choriocarcinoma Developing 5 Yr After a Complete Hydatidiform Mole and Simulating a Cornual Ectopic Pregnancy. Int J Gynecol Pathol 2021; 39:367-372. [PMID: 31033803 DOI: 10.1097/pgp.0000000000000607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Persistent gestational trophoblastic disease can arise from any type of antecedent pregnancy, including molar and tubal pregnancies. While most cases of persistent gestational trophoblastic disease present within the first year following initial diagnosis, recurrence has rarely been reported many years after initial diagnosis. Distinguishing recurrence from a new independent lesion is clinically important. A 25-yr-old woman presented with a mass in the right uterine cornu that was discontiguous with the endometrial cavity and was associated with an elevated serum human chorionic gonadotropin level. She had a history of an invasive complete hydatidiform mole with lung involvement treated with chemotherapy 5 yr prior. Wedge resection of the right cornu was performed due to concern for a cornual ectopic pregnancy. Pathologic evaluation demonstrated a choriocarcinoma. Molecular genotyping confirmed the tumor as recurrent disease genetically related to the prior complete hydatidiform mole. She completed 4 cycles of EMA-CO therapy, and has been disease-free with undetectable serum human chorionic gonadotropin level for 2 yr.
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Affiliation(s)
- Danielle B Chau
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service (D.B.C., A.L.B., A.N.F., R.S.) Department of Pathology (B.M.R., E.J., C.D.G.) Department of Gynecology and Obstetrics (B.M.R., J.A.) Department of Oncology (C.D.G.), Johns Hopkins Hospital, Baltimore, Maryland
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13
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Smith AJB, Jones TN, Miao D, Fader AN. Minimally Invasive Radical Hysterectomy for Cervical Cancer: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 28:544-555.e7. [PMID: 33359291 DOI: 10.1016/j.jmig.2020.12.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare recurrence rate, progression-free survival (PFS), and overall survival for early-stage cervical cancer after minimally invasive (MIS) vs abdominal radical hysterectomy. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. METHODS OF STUDY SELECTION We identified studies from 1990 to 2020 that included women with stage I or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or PFS and overall survival with MIS vs abdominal radical hysterectomy. (The review protocol was registered with the International Prospective Register of Systematic Reviews: CRD4202173600). TABULATION, INTEGRATION, AND RESULTS We performed random-effects meta-analyses overall and by length of follow-up. Fifty articles on 40 cohort studies and 1 randomized controlled trial that included 22 593 women with cervical cancer met the inclusion criteria. Twenty percent of the studies had <36 months of follow-up, and 24% had more than 60 months of follow-up. The odds of PFS were worse for women undergoing MIS radical hysterectomy (odds ratio 1.54; 95% CI [confidence interval], 1.24-1.94; 14 studies). When limited to studies with longer follow-up, the odds of PFS were progressively worse with MIS radical hysterectomy (HR [hazard ratio] 1.48 for >36 months; 95% CI, 1.21-1.82; 10 studies; HR 1.69 for >48 months; 95% CI, 1.26-2.27; 5 studies; and HR 2.020 for >60 months; 95% CI, 1.36-3.001; 3 studies). For overall survival, the odds were not significantly different for MIS vs abdominal hysterectomy (odds ratio 0.94; 95% CI, 0.66-1.35; 14 studies) (HR 0.99 for >36 months; 95% CI, 0.66-1.48; 9 studies; HR 1.05 for >48 months; 95% CI, 0.57-1.94; 4 studies; and HR 1.35 for >60 months; 95% CI, 0.73-2.51; 3 studies). CONCLUSION In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse PFS than open radical hysterectomy for early-stage cervical cancer. The emergence of this finding with longer follow-up highlights the importance of long-term, high-quality studies to guide cancer and surgical treatments.
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Affiliation(s)
- Anna Jo Bodurtha Smith
- Department of Gynecology and Obstetrics (Drs. Smith, Jones, Miao, and Fader), Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Tiffany Nicole Jones
- Department of Gynecology and Obstetrics (Drs. Smith, Jones, Miao, and Fader), Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Diana Miao
- Department of Gynecology and Obstetrics (Drs. Smith, Jones, Miao, and Fader), Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amanda Nickles Fader
- Department of Gynecology and Obstetrics (Drs. Smith, Jones, Miao, and Fader), Johns Hopkins School of Medicine, Baltimore, Maryland; The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics (Dr. Fader), Johns Hopkins School of Medicine, Baltimore, Maryland
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14
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Beavis AL, Sanneh A, Stone RL, Vitale M, Levinson K, Rositch AF, Fader AN, Topel K, Abing A, Wethington SL. Basic social resource needs screening in the gynecologic oncology clinic: a quality improvement initiative. Am J Obstet Gynecol 2020; 223:735.e1-735.e14. [PMID: 32433998 PMCID: PMC8340269 DOI: 10.1016/j.ajog.2020.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/28/2020] [Accepted: 05/12/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Social determinants of health are known to contribute to disparities in health outcomes. Routine screening for basic social needs is not a part of standard care; however, the association of those needs with increased healthcare utilization and poor compliance with guideline-directed care is well established. OBJECTIVE In this study, we aimed to assess the prevalence of basic social resource needs identified through a quality improvement initiative in a gynecologic oncology outpatient clinic. In addition, we aimed to identify clinical and demographic factors associated with having basic social resource needs. STUDY DESIGN We performed a prospective cohort study of women presenting to a gynecologic oncology clinic at an urban academic institution who were screened for basic social resource needs as part of a quality improvement initiative from July 2017 to May 2018. The following 8 domains of resource needs were assessed: food insecurity, housing insecurity, utility needs, financial strain, transportation, childcare, household items, and difficulty reading hospital materials. Women with needs were referred to resources to address those needs. Demographic and clinical information were collected for each patient. The prevalence of needs and successful follow-up interventions were calculated. Patient factors independently associated with having at least 1 basic social resource need were identified using multivariable Poisson regression. RESULTS A total of 752 women were screened in the study period, of whom 274 (36%) reported 1 or more basic social resource need, with a median of 1 (range, 1-7) need. Financial strain was the most commonly reported need (171 of 752, 23%), followed by transportation (119 of 752, 16%), difficulty reading hospital materials (54 of 752, 7%), housing insecurity (31 of 752, 4%), food insecurity (28 of 752, 4%), household items (22 of 752, 3%), childcare (15 of 752, 2%), and utility needs (13 of 752, 2%). On multivariable analysis, independent factors associated with having at least 1 basic social resource need were being single, divorced or widowed, nonwhite race, current smoker, nonprivate insurance, and a history of anxiety or depression. A total of 36 of 274 (13%) women who screened positive requested assistance and were referred to resources to address those needs. Of the 36 women, 25 (69%) successfully accessed a resource or felt equipped to address their needs, 9 (25%) could not be reached despite repeated attempts, and 2 (6%) declined assistance. CONCLUSION Basic social resource needs are prevalent in women presenting to an urban academic gynecologic oncology clinic and can be identified and addressed through routine screening. To help mitigate ongoing disparities in this population, screening for and addressing basic social resource needs should be incorporated into routine comprehensive care in gynecologic oncology clinics.
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Affiliation(s)
- Anna Louise Beavis
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Awa Sanneh
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca L Stone
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Kimberly Levinson
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anne F Rositch
- Department of Cancer Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Amanda Nickles Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kristin Topel
- Department of General Pediatrics and Adolescent Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Stephanie L Wethington
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD.
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Morris SN, Fader AN, Milad MP, Dionisi HJ. Authors’ Reply. J Minim Invasive Gynecol 2020; 27:1423-1424. [PMID: 32344029 PMCID: PMC7182744 DOI: 10.1016/j.jmig.2020.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 11/02/2022]
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Morris SN, Fader AN, Milad MP, Dionisi HJ. Authors’ Reply. J Minim Invasive Gynecol 2020; 27:1424-1425. [DOI: 10.1016/j.jmig.2020.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 11/28/2022]
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Koh WJ, Abu-Rustum NR, Bean S, Bradley K, Campos SM, Cho KR, Chon HS, Chu C, Clark R, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Tillmanns T, Ueda S, Wyse E, Yashar CM, McMillian NR, Scavone JL. Cervical Cancer, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 17:64-84. [PMID: 30659131 DOI: 10.6004/jnccn.2019.0001] [Citation(s) in RCA: 587] [Impact Index Per Article: 146.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.
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Erickson BK, Najjar O, Klein M, Shahi M, Dolan M, Cimino-Mathews A, Grandelis A, Buza N, Delaney P, Tymon-Rosario J, Santin A, Ferriss JS, Stone RL, Nickles Fader A. Human epidermal growth factor 2 (HER2) in early stage uterine serous carcinoma: A multi-institutional cohort. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.6084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6084 Background: Uterine serous carcinoma (USC) is a rare and aggressive malignancy, accounting for 40% of all endometrial cancer deaths. Human Epidermal Growth Factor Receptor 2 (HER2) has emerged as an important prognostic and therapeutic target in USC. Given recent randomized trial results, HER2-directed therapy is now recommended in advanced-stage or recurrent, HER2-positive disease. The significance of tumoral HER2 expression in early-stage disease has not yet been established. Methods: In this IRB-approved, retrospective, multi-institutional cohort, women diagnosed with stage I USC from 2000-2018 were identified. Patient demographic, treatment, and survival data were collected. Immunohistochemistry (IHC) was performed for HER2 and scored 0-3+. Equivocal IHC results (2+) were further tested with in-situ hybridization (ISH) per the 2007 ASCO-CAP HER2 breast cancer guidelines. HER2 overexpression (“positive”) was defined as 3+ IHC or ISH positive. Kaplan-Meier analyses and Cox-proportional hazards were used to compare survival between the cohorts. Results: In total, 173 patients with stage I USC were tested for HER2; 25% were HER2-positive, 77.4% had stage IA and 22.6% had stage IB disease. Adequate clinical follow up was available for 168 patients. There were no significant differences in age, race/ethnicity, body mass index, surgical management, sub-stage, tumor size, adjuvant therapy, or follow-up duration between the HER2-positive and negative cohorts. On univarite analysis, presence of lymph-vascular space invasion was correlated with HER2-positive tumors (p=0.003). After a median follow-up of 50 months, there were 41 (24.4%) recurrences. Significantly more recurrences were observed in the HER2-positive cohort (47.6% vs. 16.7%, p<0.001). HER2 overexpression was also associated with poorer progression-free (PFS) and overall survival (OS) (p<0.001 and p=0.012). After adjusting for prognostic factors including sub-stage and adjuvant treatment, those with HER2-positive tumors experienced inferior PFS (aHR 3.67, 95%CI 1.92-6.98; p<0.001) and OS (aHR 2.03, 95%CI 1.03-4.01; p=0.042) compared to HER2-negative tumors. Conclusions: Uterine serous carcinoma is a poor prognostic tumor, even in patients with early-stage disease. Given its significant association with worse survival outcomes, tumoral HER2 overexpression appears to be a prognostic biomarker in women with stage I disease. These data provide rationale for clinical trials with HER2-directed therapy in early-stage uterine serous carcinoma.
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Levinson K, Beavis A, Purdy C, Rositch A, Viswanathan A, Wolfson AH, Kelly MG, Tewari K, McNally L, Guntupalli SR, Ragab O, Lee YC, Miller DS, Huh WK, Wilkinson KJ, Spirtos NM, Van Le L, Casablanca Y, Holman LL, Nickles Fader A. Beyond Sedlis: A novel, histology-based nomogram for predicting recurrence risk and need for adjuvant radiation in cervical cancer—A NRG/GOG ancillary analysis. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.6019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6019 Background: In GOG 49, factors associated with a 3-year, 30% recurrence risk in squamous cell carcinoma of the cervix (SCC) after surgery alone were defined. These "intermediate" risk factors [tumor size (TS), depth of tumor invasion (DOI), and lymphvascular space invasion (LVSI)] were then studied in GOG 92, which demonstrated the utility of treating patients (pts) with ≥2 intermediate risk factors with adjuvant radiation (RT), Sedlis Criteria. However, pts with < 30% recurrence risk were not eligible and few pts with adenocarcinoma (AC) were included. Our study purpose was 1) to evaluate recurrence risk factors for AC vs SCC, and 2) to define contemporary nomograms for adjuvant treatment in pts with both histologies. Methods: We performed an ancillary analysis of GOG 49, 92, and 141, and included Stage I pts who received no neoadjuvant/adjuvant therapy. Multivariable Cox proportional hazards models were created separately for AC and SCC to evaluate independent risk factors for recurrence. Model accuracy was tested with ROC curves. Prognostic nomograms were generated for 2-year recurrence risk for AC and SCC. Results: We identified 715 with SCC and 105 pts with AC; 142 with SCC (19.9%) and 18 with AC 17.1%) recurred. For SCC, factors associated independently with recurrence were: LVSI [HR 1.58 (CI 1.12-2.22)], DOI [middle 1/3, HR 4.31 (CI 1.81-10.26); deep 1/3, HR 7.05 (CI 2.99-16.64)] and TS [≥4cm HR 2.67 (CI 1.67-4.29)]. In contrast, for AC, only TS ≥4cm was independently associated with recurrence [HR 4.69 (CI 1.25-17.63)]. At 3 years, ROC curves for these models predicted recurrence with 76% and 75% accuracy for SCC and AC, respectively. Utilizing a nomogram generated from these models, for SCC, DOI had the greatest impact on recurrence, with mid 1/3 conferring an 18% risk and deep 1/3 a 32% risk, while LVSI and TS increased risk by 4-10%, respectively. In contrast, for AC, TS alone had the greatest impact on recurrence risk with TS 2-4cm conferring a 20% risk over 3 years and TS ≥4cm, a 28% risk. Conclusions: Our nomogram differs from the Sedlis Criteria in demonstrating that single, as well as a combination of risk factors predict substantial 3-year recurrence rates in Stage I cervical cancer. Furthermore, these factors differ by AC and SCC subtypes, suggesting that distinct, histology-specific nomograms may have greater utility in identifying pts who will most benefit from adjuvant therapy.
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Affiliation(s)
| | - Anna Beavis
- Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Anne Rositch
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | - Aaron Howard Wolfson
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miami, FL
| | | | | | | | | | - Omar Ragab
- Keck School of Medicine of USC, Los Angeles, CA
| | - Yi-Chun Lee
- SUNY Health Science Center at Brooklyn, Brooklyn, NY
| | - David S. Miller
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | | | - Linda Van Le
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Laura L. Holman
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Morris SN, Fader AN, Milad MP, Dionisi HJ. Understanding the "Scope" of the Problem: Why Laparoscopy Is Considered Safe during the COVID-19 Pandemic. J Minim Invasive Gynecol 2020; 27:789-791. [PMID: 32247882 PMCID: PMC7129473 DOI: 10.1016/j.jmig.2020.04.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Stephanie N Morris
- Department of Obstetrics and Gynecology, Minimally Invasive Gynecologic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts.
| | - Amanda Nickles Fader
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Magdy P Milad
- Division of Minimally Invasive Gynecologic Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Humberto J Dionisi
- Women's Surgery Center, National University of Córdoba, CEDEM, Cordoba, Argentina
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21
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Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Wyse E, McMillian NR, Scavone J. Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1374-1391. [PMID: 31693991 DOI: 10.6004/jnccn.2019.0053] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.
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Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | | | - John R Lurain
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
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22
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Koh WJ, Abu-Rustum NR, Bean S, Bradley K, Campos SM, Cho KR, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, George S, Han E, Higgins S, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Tillmanns T, Ueda S, Wyse E, Yashar CM, McMillian NR, Scavone JL. Uterine Neoplasms, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 16:170-199. [PMID: 29439178 DOI: 10.6004/jnccn.2018.0006] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.
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Whelan S, Ophir E, Kotturi MF, Levy O, Ganguly S, Leung L, Vaknin I, Kumar S, Dassa L, Hansen K, Bernados D, Murter B, Soni A, Taube JM, Fader AN, Wang TL, Shih IM, White M, Pardoll DM, Liang SC. PVRIG and PVRL2 Are Induced in Cancer and Inhibit CD8 + T-cell Function. Cancer Immunol Res 2019; 7:257-268. [PMID: 30659054 DOI: 10.1158/2326-6066.cir-18-0442] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/30/2018] [Accepted: 12/05/2018] [Indexed: 01/05/2023]
Abstract
Although checkpoint inhibitors that block CTLA-4 and PD-1 have improved cancer immunotherapies, targeting additional checkpoint receptors may be required to broaden patient response to immunotherapy. PVRIG is a coinhibitory receptor of the DNAM/TIGIT/CD96 nectin family that binds to PVRL2. We report that antagonism of PVRIG and TIGIT, but not CD96, increased CD8+ T-cell cytokine production and cytotoxic activity. The inhibitory effect of PVRL2 was mediated by PVRIG and not TIGIT, demonstrating that the PVRIG-PVRL2 pathway is a nonredundant signaling node. A combination of PVRIG blockade with TIGIT or PD-1 blockade further increased T-cell activation. In human tumors, PVRIG expression on T cells was increased relative to normal tissue and trended with TIGIT and PD-1 expression. Tumor cells coexpressing PVR and PVRL2 were observed in multiple tumor types, with highest coexpression in endometrial cancers. Tumor cells expressing either PVR or PVRL2 were also present in numbers that varied with the cancer type, with ovarian cancers having the highest percentage of PVR-PVRL2+ tumor cells and colorectal cancers having the highest percentage of PVR+PVRL2- cells. To demonstrate a role of PVRIG and TIGIT on tumor-derived T cells, we examined the effect of PVRIG and TIGIT blockade on human tumor-infiltrating lymphocytes. For some donors, blockade of PVRIG increased T-cell function, an effect enhanced by combination with TIGIT or PD-1 blockade. In summary, we demonstrate that PVRIG and PVRL2 are expressed in human cancers and the PVRIG-PVRL2 and TIGIT-PVR pathways are nonredundant inhibitory signaling pathways.See related article on p. 244.
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Affiliation(s)
- Sarah Whelan
- Compugen, USA, Inc., South San Francisco, California
| | | | | | | | - Sudipto Ganguly
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland
| | - Ling Leung
- Compugen, USA, Inc., South San Francisco, California
| | | | - Sandeep Kumar
- Compugen, USA, Inc., South San Francisco, California
| | | | - Kyle Hansen
- Compugen, USA, Inc., South San Francisco, California
| | | | - Benjamin Murter
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland
| | - Abha Soni
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland
| | - Janis M Taube
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland
| | - Amanda Nickles Fader
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tian-Li Wang
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ie-Ming Shih
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark White
- Compugen, USA, Inc., South San Francisco, California
| | - Drew M Pardoll
- Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland
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Affiliation(s)
- Elizabeth C Wick
- *Department of Surgery, Johns Hopkins University, Baltimore, MD †Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, MD ‡Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD §Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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25
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Koh WJ, Greer BE, Abu-Rustum NR, Campos SM, Cho KR, Chon HS, Chu C, Cohn D, Crispens MA, Dizon DS, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Higgins S, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Tillmanns T, Ueda S, Valea FA, Wyse E, Yashar CM, McMillian N, Scavone J. Vulvar Cancer, Version 1.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15:92-120. [PMID: 28040721 DOI: 10.6004/jnccn.2017.0008] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vulvar cancer is a rare gynecologic malignancy. Ninety percent of vulvar cancers are predominantly squamous cell carcinomas (SCCs), which can arise through human papilloma virus (HPV)-dependent and HPV-independent pathways. The NCCN Vulvar Cancer panel is an interdisciplinary group of representatives from NCCN Member Institutions consisting of specialists in gynecological oncology, medical oncology, radiation oncology, and pathology. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Vulvar Cancer provide an evidence- and consensus-based approach for the management of patients with vulvar SCC. This manuscript discusses the recommendations outlined in the NCCN Guidelines for diagnosis, staging, treatment, and follow-up.
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Bodurtha Smith AJ, Fader AN, Tanner EJ. Sentinel lymph node assessment in endometrial cancer: a systematic review and meta-analysis. Am J Obstet Gynecol 2017; 216:459-476.e10. [PMID: 27871836 DOI: 10.1016/j.ajog.2016.11.1033] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/05/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND In the staging of endometrial cancer, controversy remains regarding the role of sentinel lymph node mapping compared with other nodal assessment strategies. OBJECTIVE We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of sentinel lymph node mapping in the management of endometrial cancer. DATA SOURCES We searched Medline, Embase, and the Cochrane Central Registry of Controlled trials for studies published in English before March 25, 2016 (PROSPERO CRD42016036503). STUDY ELIGIBILITY CRITERIA Studies were included if they contained 10 or more women with endometrial cancer and reported on the detection rate, sensitivity, and/or impact on treatment or survival of sentinel lymph node mapping. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently reviewed abstracts and full-text articles for inclusion and assessed study quality. The detection rate, sensitivity, and factors associated with successful mapping (study size, body mass index, tumor histology and grade, injection site, dye type) were synthesized through random-effects meta-analyses and meta-regression. RESULTS We identified 55 eligible studies, which included 4915 women. The overall detection rate of sentinel lymph node mapping was 81% (95% confidence interval, 77-84) with a 50% (95% confidence interval, 44-56) bilateral pelvic node detection rate and 17% (95% confidence interval, 11-23) paraaortic detection rate. There was no difference in detection rates by patient body mass index or tumor histology and grade. Use of indocyanine green increased the bilateral detection rate compared with blue dye. Additionally, cervical injection increased the bilateral sentinel lymph node detection rate but decreased the paraaortic detection rate compared with alternative injection techniques. Intraoperative sentinel lymph node frozen section increased the overall and bilateral detection rates. The sensitivity of sentinel node mapping to detect metastases was 96% (95% confidence interval, 91-98); ultrastaging did not improve sensitivity. Compared with women staged with complete lymphadenectomy, women staged with sentinel lymph node mapping were more likely to receive adjuvant treatment. CONCLUSION Sentinel lymph node mapping is feasible and accurately predicts nodal status in women with endometrial cancer. The current data favors the use of cervical injection techniques with indocyanine green. Sentinel lymph mapping may be considered an alternative standard of care in the staging of women with endometrial cancer.
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Affiliation(s)
- Anna Jo Bodurtha Smith
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Amanda Nickles Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD
| | - Edward J Tanner
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD.
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27
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Desale MG, Tanner EJ, Sinno AK, Angarita AA, Fader AN, Stone RL, Levinson KL, Bristow RE, Roche KL. Perioperative fluid status and surgical outcomes in patients undergoing cytoreductive surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2016; 144:S0090-8258(16)31501-3. [PMID: 28029449 DOI: 10.1016/j.ygyno.2016.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/10/2016] [Accepted: 10/17/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this study is to investigate the impact of fluid status on perioperative outcomes of patients undergoing cytoreductive surgery (CRS) for advanced epithelial ovarian cancer (EOC). METHODS Patients undergoing CRS for stage III or IV EOC at a comprehensive cancer center from 12/2010 to 05/2015 were identified. Those who underwent upper abdominal procedures or colon resections were included. Demographic, perioperative, and 30-day complication data were collected. Perioperative weight change was utilized as a surrogate for fluid status. The time to diuresis (tD) was defined as the postoperative day the patient's weight began to downtrend. RESULTS One hundred ten patients were included. Median age was 62years and median BMI 25.8kg/m2. The majority (74.5%) were stage IIIC. At least 1 bowel resection was performed in 60 cases (54.5%). A median of 5381mL of crystalloid (range 1000-17,550mL) and 500mL of colloids (range 0-2783mL) was given intraoperatively. The median perioperative weight change was +7.3kg (range-0.9kg to +35.7kg). The median tD was 3days (range 1-17days). On univariate analysis, net positive fluid status was associated with unscheduled reoperation, anastomotic leak, surgical site infections (SSI), and length of stay >5days. On multivariate analysis, fluid status was independently associated with SSI (p=0.01). CONCLUSIONS Perioperative fluid excess is common in patients undergoing CRS for EOC and is independently associated with SSI.
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Affiliation(s)
- M G Desale
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - E J Tanner
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - A K Sinno
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - A Africano Angarita
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - A N Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - R L Stone
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - K L Levinson
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - R E Bristow
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, University of California-Irvine, Orange, CA, USA.
| | - K Long Roche
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD, USA; Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Koh WJ, Greer BE, Abu-Rustum NR, Apte SM, Campos SM, Cho KR, Chu C, Cohn D, Crispens MA, Dizon DS, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, George S, Han E, Higgins S, Huh WK, Lurain JR, Mariani A, Mutch D, Fader AN, Remmenga SW, Reynolds RK, Tillmanns T, Valea FA, Yashar CM, McMillian NR, Scavone JL. Uterine Sarcoma, Version 1.2016: Featured Updates to the NCCN Guidelines. J Natl Compr Canc Netw 2016; 13:1321-31. [PMID: 26553763 DOI: 10.6004/jnccn.2015.0162] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The NCCN Guidelines for Uterine Neoplasms provide interdisciplinary recommendations for treating endometrial carcinoma and uterine sarcomas. These NCCN Guidelines Insights summarize the NCCN Uterine Neoplasms Panel's 2016 discussions and major guideline updates for treating uterine sarcomas. During this most recent update, the panel updated the mesenchymal tumor classification to correspond with recent updates to the WHO tumor classification system. Additionally, the panel revised its systemic therapy recommendations to reflect new data and collective clinical experience. These NCCN Guidelines Insights elaborate on the rationale behind these recent changes.
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Affiliation(s)
- Wui-Jin Koh
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Benjamin E Greer
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Nadeem R Abu-Rustum
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Sachin M Apte
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Susana M Campos
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Kathleen R Cho
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Christina Chu
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - David Cohn
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Marta Ann Crispens
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Don S Dizon
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Oliver Dorigo
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Patricia J Eifel
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Christine M Fisher
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Peter Frederick
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - David K Gaffney
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Suzanne George
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Ernest Han
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Susan Higgins
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Warner K Huh
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - John R Lurain
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Andrea Mariani
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - David Mutch
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Amanda Nickles Fader
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Steven W Remmenga
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - R Kevin Reynolds
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Todd Tillmanns
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Fidel A Valea
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Catheryn M Yashar
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Nicole R McMillian
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
| | - Jillian L Scavone
- From Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; University of Washington/Seattle Cancer Care Alliance; Memorial Sloan Kettering Cancer Center; Moffitt Cancer Center; Dana-Farber/Brigham and Women's Cancer Center; University of Michigan Comprehensive Cancer Center; Fox Chase Cancer Center; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute; Vanderbilt-Ingram Cancer Center; Massachusetts General Hospital Cancer Center; Stanford Cancer Institute; The University of Texas MD Anderson Cancer Center; University of Colorado Cancer Center; Roswell Park Cancer Institute; Huntsman Cancer Institute at the University of Utah; City of Hope Comprehensive Cancer Center; Yale Cancer Center/Smilow Cancer Hospital; University of Alabama at Birmingham Comprehensive Cancer Center; Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Mayo Clinic Cancer Center; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; Fred & Pamela Buffet Cancer Center at The Nebraska Medical Center; St. Jude Children's Research Hospital/The University of Tennessee Health Science Center; Duke Cancer Institute; UC San Diego Moores Cancer Center; and National Comprehensive Cancer Network
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Beavis AL, Smith AJB, Fader AN. Lifestyle changes and the risk of developing endometrial and ovarian cancers: opportunities for prevention and management. Int J Womens Health 2016; 8:151-67. [PMID: 27284267 PMCID: PMC4883806 DOI: 10.2147/ijwh.s88367] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Modifiable lifestyle factors, such as obesity, lack of physical activity, and smoking, contribute greatly to cancer and chronic disease morbidity and mortality worldwide. This review appraises recent evidence on modifiable lifestyle factors in the prevention of endometrial cancer (EC) and ovarian cancer (OC) as well as new evidence for lifestyle management of EC and OC survivors. For EC, obesity continues to be the strongest risk factor, while new evidence suggests that physical activity, oral contraceptive pills, and bariatric surgery may be protective against EC. Other medications, such as metformin and nonsteroidal anti-inflammatory drugs, may be protective, and interventional research is ongoing. For OC, we find increasing evidence to support the hypothesis that obesity and hormone replacement therapy increase the risk of developing OC. Oral contraceptive pills are protective against OC but are underutilized. Dietary factors such as the Mediterranean diet and alcohol consumption do not seem to affect the risk of either OC or EC. For EC and OC survivors, physical activity and weight loss are associated with improved quality of life. Small interventional trials show promise in increasing physical activity and weight maintenance for EC and OC survivors, although the impact on long-term health, including cancer recurrence and overall mortality, is unknown. Women's health providers should integrate counseling about these modifiable lifestyle factors into both the discussion of prevention for all women and the management of survivors of gynecologic cancers.
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Affiliation(s)
- Anna L Beavis
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | - Amanda Nickles Fader
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins Medicine, Baltimore, MD, USA
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Diaz LA, Uram JN, Wang H, Bartlett B, Kemberling H, Eyring A, Azad NS, Dauses T, Laheru D, Lee JJ, Crocenzi TS, Goldberg RM, Fisher GA, Greten TF, Meyer CF, Nickles Fader A, Armstrong DK, Koshiji M, Vogelstein B, Le DT. Programmed death-1 blockade in mismatch repair deficient cancer independent of tumor histology. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.3003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Jennifer N. Uram
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Hao Wang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Bjarne Bartlett
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Holly Kemberling
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Aleksandra Eyring
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Nilofer Saba Azad
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Tianna Dauses
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dan Laheru
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | | | - Richard M. Goldberg
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital, Columbus, OH
| | | | - Tim F. Greten
- National Cancer Institute at the National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Bert Vogelstein
- Ludwig Center for Cancer Genetics and Therapeutics at Johns Hopkins, Baltimore, MD
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Levinson K, Ojalvo L, Riedel D, Angarita A, Nickles Fader A, Rositch A. Treatment of gynecologic cancers in HIV+ women. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e17064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - David Riedel
- University of Maryland Medical Center, Institute of Human Virology, Baltimore, MD
| | | | | | - Anne Rositch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Angarita AM, Johnson CA, Fader AN, Christianson MS. Fertility Preservation: A Key Survivorship Issue for Young Women with Cancer. Front Oncol 2016; 6:102. [PMID: 27200291 PMCID: PMC4843761 DOI: 10.3389/fonc.2016.00102] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/11/2016] [Indexed: 12/14/2022] Open
Abstract
Fertility preservation in the young cancer survivor is recognized as a key survivorship issue by the American Society of Clinical Oncology and the American Society of Reproductive Medicine. Thus, health-care providers should inform women about the effects of cancer therapy on fertility and should discuss the different fertility preservation options available. It is also recommended to refer women expeditiously to a fertility specialist in order to improve counseling. Women’s age, diagnosis, presence of male partner, time available, and preferences regarding use of donor sperm influence the selection of the appropriate fertility preservation option. Embryo and oocyte cryopreservation are the standard techniques used while ovarian tissue cryopreservation is new, yet promising. Despite the importance of fertility preservation for cancer survivors’ quality of life, there are still communication and financial barriers faced by women who wish to pursue fertility preservation.
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Affiliation(s)
- Ana Milena Angarita
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Cynae A Johnson
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins Hospital , Baltimore, MD , USA
| | - Amanda Nickles Fader
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Mindy S Christianson
- Division of Reproductive Endocrinology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Abstract
BACKGROUND AND OBJECTIVES To compare our initial experience in laparoscopic surgery for ovarian endometriomas performed through an umbilical incision using a single 3-channel port and flexible laparoscopic instrumentation versus traditional laparoscopy. METHODS This study was conducted in 3 tertiary care referral centers. Since September 2009, we have performed laparoendoscopic single-site surgery in 24 patients diagnosed with ovarian endometriomas. A control group of patients with similar diagnoses who underwent traditional operative laparoscopy during the same period was included (n = 28). In the laparoendoscopic single-site surgery group, a multichannel port was inserted into the peritoneum through a 1.5- to 2.0-cm umbilical incision. RESULTS Patients in the laparoendoscopic single-site surgery group were significantly older (P = .04) and had a higher body mass index (P = .005). Both groups were comparable regarding history of abdominal surgery, lateral pelvic side wall involvement, and cul-de-sac involvement. After we controlled for age and body mass index, the size of the resected endometriomas, duration of surgery, and amount of operative blood loss were comparable in both groups. When required, an additional 5-mm port was inserted in the right or left lower quadrant in the laparoendoscopic single-site surgery group to allow the use of a third instrument for additional tissue retraction or manipulation (10 of 24 patients, 41.6%). However, adhesiolysis was performed more frequently in the conventional laparoscopy group. The duration of hospital stay was <24 hours in both groups. No intraoperative complications were encountered. All incisions healed and were cosmetically satisfactory. CONCLUSION The laparoendoscopic single-site surgery technique is a reasonable initial approach for the treatment of endometriomas. In our experience, an additional side port is usually needed to treat pelvic side wall and cul-de-sac endometriosis that often accompanies endometriomas.
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Affiliation(s)
- Mohamed A Bedaiwy
- University Hospitals Case Medical Center, Case Western Reserve University, OH, USA; Department of Obstetrics and Gynecology, Faculty of Medicine, The University of British Columbia D415A4500 Oak Street Vancouver, BC V6H 3N1, Canada.
| | - Tarek Farghaly
- University Hospitals Case Medical Center, Case Western Reserve University, OH, USA
| | - William Hurd
- University Hospitals Case Medical Center, Case Western Reserve University, OH, USA
| | - James Liu
- University Hospitals Case Medical Center, Case Western Reserve University, OH, USA
| | - Gihan Mansour
- University Hospitals Case Medical Center, Case Western Reserve University, OH, USA
| | - Amanda Nickles Fader
- Department of Gynecology, Greater Baltimore Medical Center and Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pedro Escobar
- Department of OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Parker W, Berek JS, Pritts E, Olive D, Kaunitz AM, Chalas E, Clarke-Pearson D, Goff B, Bristow R, Taylor HS, Farias-Eisner R, Fader AN, Maxwell GL, Goodwin SC, Love S, Gibbons WE, Foshag LJ, Leppert PC, Norsigian J, Nager CW, Johnson T, Guzick DS, As-Sanie S, Paulson RJ, Farquhar C, Bradley L, Scheib SA, Bilchik AJ, Rice LW, Dionne C, Jacoby A, Ascher-Walsh C, Kilpatrick SJ, Adamson GD, Siedhoff M, Israel R, Paraiso MF, Frumovitz MM, Lurain JR, Al-Hendy A, Benrubi GI, Raman SS, Kho RM, Anderson TL, Reynolds RK, DeLancey J. An Open Letter to the Food and Drug Administration Regarding the Use of Morcellation Procedures in Women Having Surgery for Presumed Uterine Myomas. J Minim Invasive Gynecol 2016; 23:303-8. [DOI: 10.1016/j.jmig.2015.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 12/27/2022]
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Tergas AI, Angarita A, Cristello A, Lippitt M, Nickles Fader A, Long K. The “little big things”: A qualitative study of ovarian cancer survivors and their experiences with the health care system. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.3_suppl.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
252 Background: Navigating a complex and ever-changing health care system can be stressful and detrimental to psychosocial well-being for patients with serious illness. This study explored women’s experiences navigating the health care system during treatment of ovarian cancer. Methods: Focus groups moderated by trained investigators were conducted with ovarian cancer survivors at an academic cancer center. Personal experiences with cancer treatment, provider relationships, barriers to care, and the health care system were explored. Sessions were audiotaped, transcribed, and coded using grounded theory. Subsequent one-on-one interviews were conducted to further evaluate common themes. Results: Sixteen ovarian cancer survivors with a median age of 59 years participated in the focus group study.Provider consistency, personal touch, and patient advocacy positively impacted care experience.Treatment with a known provider, who was well acquainted with the individual’s medical history, was deemed an invaluable aspect of care. Negative experiences that burdened patients, referred to as the “Little Big Things”, included systems-based challenges: scheduling, wait times, pharmacy, transportation, parking, financial, insurance and discharge. Consistency, a “care-team” approach, effective communication, and efficient connection to resources were suggested as ways to improve patients’ experiences. Conclusions: Systems-based challenges were perceived as burdens to ovarian cancer survivors. The role of a consistent, accessible care team and efficient delivery of resources in the care of women with ovarian cancer should be explored further.
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Affiliation(s)
- Ana Isabel Tergas
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY
| | | | | | | | | | - Kara Long
- Memorial Sloan Kettering Cancer Center, New York, NY
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Tseng JH, Long Roche K, Jernigan AM, Salani R, Bristow RE, Fader AN. Lifestyle and Weight Management Counseling in Uterine Cancer Survivors: A Study of the Uterine Cancer Action Network. Int J Gynecol Cancer 2015; 25:1285-91. [PMID: 25966932 DOI: 10.1097/igc.0000000000000475] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE The purpose of this study was to examine the experiences, attitudes, and preferences of uterine cancer survivors with regard to weight and lifestyle counseling. MATERIALS AND METHODS Members of the US Uterine Cancer Action Network of the Foundation for Women's Cancer were invited to complete a 45-item, Web-based survey. Standard descriptive statistical methods and χ tests were used to analyze responses. RESULTS One hundred eighty (28.3%) uterine cancer survivors completed the survey. Median age was 58 years, 85% were white, and median survivorship period was 4.4 years. Most had stage I-II disease (69%) and were overweight or obese (65%). Eighty-nine percent of respondents received care by a gynecologic oncologist. Increased respondent body mass index was associated with decreased exercise frequency (P = 0.016). Only 50% of respondents underwent any weight/lifestyle counseling, with those living in the West and Southwest reporting the highest rates (70.8% and 69.2%, P = 0.011). Most who received counseling felt that discussions were motivating, performed in a sensitive manner, and did not undermine the patient-physician relationship. Specific recommendations were rarely offered; there were no reported referrals to weight loss programs or bariatric specialists, and few (6%) reported referrals to nutritionists. Respondents (85%) preferred their gynecologic oncologist address weight using direct, face-to-face counseling with specific recommendations regarding interventions and referral to specialists. Finally, self-reported overweight respondents experienced greater success with weight loss compared to those reporting obesity or morbid obesity (30.8% vs 15.8% vs 12.5%, P = 0.011). CONCLUSIONS Uterine cancer survivors reported high obesity, low activity rates, and a desire for substantive weight loss counseling from their gynecologic oncologists. Respondents suggested that current counseling practices are inadequate and incongruent with their needs. Further research to define optimal timing, interventional strategies, and specific recommendations for successful lifestyle changes in this population is warranted.
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Affiliation(s)
- Jill H Tseng
- *The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD; †Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH; and ‡Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California-Irvine, Orange, CA
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Koh WJ, Greer BE, Abu-Rustum NR, Apte SM, Campos SM, Cho KR, Chu C, Cohn D, Crispens MA, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mutch D, Fader AN, Remmenga SW, Reynolds RK, Teng N, Tillmanns T, Valea FA, Yashar CM, McMillian NR, Scavone JL. Cervical Cancer, Version 2.2015. J Natl Compr Canc Netw 2015; 13:395-404; quiz 404. [DOI: 10.6004/jnccn.2015.0055] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kushnir CL, Angarita AM, Havrilesky LJ, Thompson S, Spahlinger D, Sinno AK, Tanner EJ, Secord AA, Roche KL, Stone RL, Fader AN. Selective cardiac surveillance in patients with gynecologic cancer undergoing treatment with pegylated liposomal doxorubicin (PLD). Gynecol Oncol 2015; 137:503-7. [PMID: 25735254 DOI: 10.1016/j.ygyno.2015.02.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/22/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The study objective was to examine the safety and cost savings of selective cardiac surveillance (CS) during treatment with pegylated liposomal doxorubicin (PLD). METHODS A retrospective, dual institution study of women receiving PLD for the treatment of a gynecologic malignancy was performed. The study period was 2002-2014. At both institutions, a selective strategy for CS was implemented in which only high-risk women with a cardiac history or with symptoms suggestive of cardiac toxicity during PLD treatment underwent a cardiac evaluation. Patient demographics, clinical and treatment history were evaluated. Cost analyses were performed utilizing professional/technical fee rates for echocardiogram and multi-gated acquisition scan for each state. RESULTS PLD was administered in 184 women. The mean patient age was 62.7years, and 79% were treated for recurrent ovarian or peritoneal carcinoma. The median cumulative administered dose of PLD was 300mg/m(2); 24 received >550mg/m(2). The median follow-up time was 20months. Of the 184 patients, the majority (n=157, 85.3%) did not undergo either an initial cardiac evaluation or surveillance during or post-PLD treatment. Fifty-three patients considered high risk for anthracycline-induced cardiotoxicity underwent CS. Only three patients (1.6%) in the entire cohort developed CHF that was possibly related to PLD treatment; all had significant pre-existing cardiac risk factors. Selective instead of routine use of CS in the study population resulted in a cost savings of $182,552.28. CONCLUSION Utilizing cardiac surveillance in select women undergoing PLD treatment for gynecologic malignancies resulted in significant health care cost savings without adversely impacting clinical outcomes.
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Affiliation(s)
- C L Kushnir
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - A M Angarita
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - L J Havrilesky
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Duke University Medical Center, Durham, NC, United States
| | - S Thompson
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - D Spahlinger
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Duke University Medical Center, Durham, NC, United States
| | - A K Sinno
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - E J Tanner
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - A A Secord
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - K L Roche
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - R L Stone
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States
| | - A N Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, United States.
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Groen RS, Gershenson DM, Fader AN. Updates and emerging therapies for rare epithelial ovarian cancers: one size no longer fits all. Gynecol Oncol 2015; 136:373-83. [PMID: 25481800 DOI: 10.1016/j.ygyno.2014.11.078] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 02/03/2023]
Abstract
Epithelial ovarian carcinoma consists of not one, but several, entities. A number of subtypes exist, including high-grade and low-grade serous carcinomas, clear cell, endometrioid carcinoma and mucinous carcinoma. Historically, women with epithelial ovarian cancer have been treated similarly and "lumped" in the same cooperative group treatment trials, irrespective of their tumor subtype. Recently, however, differences in epidemiology, tumor biology, tumor marker expression and treatment responses have been elucidated among the histologic subtypes, with a clear distinction emerging between the Type I, lower grade tumors and Type 2, higher grade epithelial malignancies. A mounting body of research demonstrates that a "one-size-fits-all" treatment approach to epithelial ovarian tumors is no longer relevant, especially for the Type I subtypes. Indeed, with the exception of high-grade serous carcinoma, most other epithelial subtypes exhibit some degree of chemotherapy resistance, rendering treatment problematic, especially in the setting of advanced disease. This review summarizes the genetic, molecular, and clinical differences of the more rare, but clinically important, Type I epithelial ovarian tumors. Additionally, a critical appraisal of both historical and contemporary treatment approaches and the rationale for targeted therapies are emphasized.
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Affiliation(s)
- Reinou S Groen
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Amanda Nickles Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA.
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Cripe J, Tseng J, Eskander R, Fader AN, Tanner E, Bristow R. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Recurrent Ovarian Carcinoma: Analysis of 30-Day Morbidity and Mortality. Ann Surg Oncol 2014; 22:655-61. [DOI: 10.1245/s10434-014-4026-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 12/26/2022]
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Sinno AK, Fader AN, Roche KL, Giuntoli RL, Tanner EJ. A comparison of colorimetric versus fluorometric sentinel lymph node mapping during robotic surgery for endometrial cancer. Gynecol Oncol 2014; 134:281-6. [PMID: 24882555 DOI: 10.1016/j.ygyno.2014.05.022] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 05/19/2014] [Accepted: 05/22/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The study objective was to compare the ability to detect sentinel lymph nodes (SLNs) in women with endometrial cancer (EC) or complex atypical hyperplasia (CAH) using fluorometric imaging with indocyanine green (ICG) versus colorimetric imaging with isosulfan blue (ISB). METHODS Women underwent SLN mapping, with either ISB or ICG, during robotic-assisted total laparoscopic hysterectomy (RA-TLH) from September 2012 to March 2014. SLNs were submitted for permanent pathologic analysis. Completion lymphadenectomy and ultrastaging were performed according to institutional protocols. RESULTS RA-TLH and SLN mapping was performed in 71 women; 64 had EC (64) and 7 had CAH. Age, body mass index (BMI), stage and tumor characteristics were similar in the ICG versus the ISB cohorts. Overall, SLNs were identified bilaterally (62.0%), unilaterally (21.1%), or neither (16.9%), and in 103 of 142 hemi-pelvises (72.5%). The mean number of SLNs retrieved per hemipelvis was 2.23(SD 1.7). SLNs were identified in the hypogastric (76.8%), external iliac (14.2%), common iliac (4.5%) and paraaortic (4.5%) regions. ICG mapped bilaterally in 78.9% of women compared with 42.4% of those injected with ISB (p=0.02). Five women (7%) had positive lymph nodes, all identified by the SLN protocol (false negative rate: 0%). On multivariate analysis, BMI was negatively correlated with bilateral mapping success (p=0.02). When stratified by dye type, the association with BMI was only significant for ISB (p=0.03). CONCLUSIONS Fluorescence imaging with ICG may be superior to colorimetric imaging with ISB in women undergoing SLN mapping for endometrial cancer. SLN mapping success is negatively associated with increasing patient BMI only when ISB is used.
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Affiliation(s)
- Abdulrahman K Sinno
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amanda Nickles Fader
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kara Long Roche
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert L Giuntoli
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Edward J Tanner
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA.
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Eskander RN, Osann K, Dickson E, Holman LL, Rauh-Hain JA, Spoozak L, Wu E, Krill L, Fader AN, Tewari KS. Assessment of palliative care training in gynecologic oncology: a gynecologic oncology fellow research network study. Gynecol Oncol 2014; 134:379-84. [PMID: 24887355 DOI: 10.1016/j.ygyno.2014.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/18/2014] [Accepted: 05/22/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Palliative care is recognized as an important component of oncologic care. We sought to assess the quality/quantity of palliative care education in gynecologic oncology fellowship. METHODS A self-administered on-line questionnaire was distributed to current gynecologic oncology fellow and candidate members during the 2013 academic year. Descriptive statistics, bivariate and multivariate analyses were performed. RESULTS Of 201 fellow and candidate members, 74.1% (n=149) responded. Respondents were primarily women (75%) and white (76%). Only 11% of respondents participated in a palliative care rotation. Respondents rated the overall quality of teaching received on management of ovarian cancer significantly higher than management of patients at end of life (EOL), independent of level of training (8.25 vs. 6.23; p<0.0005). Forty-six percent reported never being observed discussing transition of care from curative to palliative with a patient, and 56% never received feedback about technique regarding discussions on EOL care. When asked to recall their most recent patient who had died, 83% reported enrollment in hospice within 4 weeks of death. Fellows reporting higher quality EOL education were significantly more likely to feel prepared to care for patients at EOL (p<0.0005). Mean ranking of preparedness increased with the number of times a fellow reported discussing changing goals from curative to palliative and the number of times he/she received feedback from an attending (p<0.0005). CONCLUSIONS Gynecologic oncology fellow/candidate members reported insufficient palliative care education. Those respondents reporting higher quality EOL training felt more prepared to care for dying patients and to address complications commonly encountered in this setting.
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Affiliation(s)
- Ramez N Eskander
- University of California Irvine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Orange, CA, United States.
| | - Kathryn Osann
- University of California Irvine, Department of Medicine, Irvine, CA, United States
| | - Elizabeth Dickson
- University of Minnesota, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Minneapolis, MN, United States
| | - Laura L Holman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - J Alejandro Rauh-Hain
- The Massachusetts General Hospital, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Boston, MA, United States
| | - Lori Spoozak
- Albert Einstein College of Medicine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Bronx, NY, United States
| | - Eijean Wu
- University of Southern California Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Los Angeles, CA, United States
| | - Lauren Krill
- University of California Irvine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Orange, CA, United States
| | - Amanda Nickles Fader
- The Johns Hopkins Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Baltimore, MD, United States
| | - Krishnansu S Tewari
- University of California Irvine, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Orange, CA, United States
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Wu ES, Oduyebo T, Cobb LP, Cholakian D, Long-Roche KC, Tanner E, Grossman SA, Armstrong DK, Alsahafi AA, Nickles Fader A. Effect of lymphopenia on survival in women with cervical cancer treated with primary chemoradiation. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e16507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emily S. Wu
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
| | | | - Lauren P. Cobb
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
| | - Diana Cholakian
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
| | - Kara C. Long-Roche
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
| | - Edward Tanner
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
| | - Stuart A. Grossman
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | - Akram Abdulaziz Alsahafi
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD
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Koh WJ, Greer BE, Abu-Rustum NR, Apte SM, Campos SM, Chan J, Cho KR, Cohn D, Crispens MA, DuPont N, Eifel PJ, Fader AN, Fisher CM, Gaffney DK, George S, Han E, Huh WK, Lurain JR, Martin L, Mutch D, Remmenga SW, Reynolds RK, Small W, Teng N, Tillmanns T, Valea FA, McMillian N, Hughes M. Uterine Neoplasms, Version 1.2014. J Natl Compr Canc Netw 2014; 12:248-80. [DOI: 10.6004/jnccn.2014.0025] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Fader AN, Java J, Krivak TC, Bristow RE, Tergas AI, Bookman MA, Armstrong DK, Tanner EJ, Gershenson DM. The prognostic significance of pre- and post-treatment CA-125 in grade 1 serous ovarian carcinoma: a gynecologic Oncology Group study. Gynecol Oncol 2013; 132:560-5. [PMID: 24333362 DOI: 10.1016/j.ygyno.2013.11.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/08/2013] [Accepted: 11/09/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The study objective was to determine the prognostic significance of serum CA-125 levels in patients with grade 1 serous ovarian carcinoma (SOC) enrolled in a Phase III study. METHODS An ancillary analysis of a phase III study of women with advanced epithelial ovarian cancer treated with carboplatin/paclitaxel versus triplet or sequential doublet regimens. Grade 1 SOC was used as a surrogate for low-grade serous carcinoma. RESULTS Among 3686 enrolled patients, 184 (5%) had grade 1 disease and CA-125 levels available. For those with grade 1 SOC, the median patient age was 56.5; 87.3% had Stage III disease. Median follow-up was 102 months and there was no difference in pre-chemotherapy CA-125 by treatment arm (P=0.91). Median pretreatment CA-125 for those with grade 1 SOC was lower (119.1) than for patients with grade 2-3 SOC (246.7; P<0.001). In those with grade 1, pretreatment CA-125 was not prognostic of outcome. However, patients with CA-125 levels that normalized after cycle 1, 2 or 3 were 60-64% less likely to experience disease progression as compared to those who never normalized or normalized after 4 cycles (P ≤ 0.024). Normalization of CA-125 levels before the second cycle was negatively associated with death, with a HR of 0.45 (P=0.025). CONCLUSIONS Pretreatment CA-125 level was significantly lower in women with grade 1 SOC compared to those with high-grade SOC. While pretreatment CA-125 was not associated with survival, serial CA-125 measurements during chemotherapy treatment were prognostic, with normalization before the second chemotherapy cycle associated with a decreased risk of death.
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Affiliation(s)
| | - James Java
- Gynecologic Oncology Group Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Thomas C Krivak
- Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Ana I Tergas
- Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Gunderson CC, Dutta S, Fader AN, Maniar KP, Nasseri-Nik N, Bristow RE, Diaz-Montes TP, Palermo R, Kurman RJ. Pathologic features associated with resolution of complex atypical hyperplasia and grade 1 endometrial adenocarcinoma after progestin therapy. Gynecol Oncol 2013; 132:33-7. [PMID: 24316307 DOI: 10.1016/j.ygyno.2013.11.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/24/2013] [Accepted: 11/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the response of complex atypical hyperplasia (CAH) and well differentiated endometrioid adenocarcinoma of the uterus (WDC) to progestin therapy and whether pre-treatment estrogen and progesterone receptor status predicts outcome. METHODS We performed a retrospective review encompassing women treated with progestin therapy for CAH or WDC at two institutions. Clinicopathologic, treatment, and recurrence data were recorded. Pre/post-treatment pathologic evaluation was performed. SAS 9.2 was used for statistical analyses. RESULTS Forty-six patients were included. The median age was 35, and median BMI was 36.9. Thirty-seven percent were diagnosed with CAH and 63% had WDC. Megestrol acetate was the most commonly used agent (89%); 24% received multiple progestin therapies. Median treatment length was 6 months (range, 1-84); 36% of the patients underwent eventual hysterectomy, and 17.4% had carcinoma in their uterine specimens (8 primary endometrial, 1 primary ovarian). After a median follow-up of 35 months (range, 2-162), 65% experienced a complete response (CR), 28% had persistent or progressive disease, and 23% had a CR followed by recurrence. On univariate analysis, decreased post-treatment glandular cellularity (p = 0.0006), absence of post-treatment mitotic figures (p = 0.0008), and use of multiple progestin agents (p = 0.025) were associated with CR; however, only decreased glandular cellularity was significant on multivariate analysis (p = 0.007). Estrogen and progesterone receptor expression was not associated with treatment response. CONCLUSION In women with CAH or WDC, the overall response rate to progestin therapy was 65%; pre-treatment estrogen/progesterone receptor status did not predict response to treatment.
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Affiliation(s)
- Camille C Gunderson
- University of Oklahoma Health Sciences Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology; Oklahoma City, OK, USA.
| | - Sonia Dutta
- Johns Hopkins Hospital, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology; Baltimore, MD, USA.
| | - Amanda Nickles Fader
- Johns Hopkins Medical Institutions/Greater Baltimore Medical Center, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology; Baltimore, MD, USA.
| | - Kruti P Maniar
- Johns Hopkins Hospital, Departments of Gynecology and Obstetrics, Pathology, Division of Gynecologic Pathology and Oncology; Baltimore, MD, USA.
| | - Niloo Nasseri-Nik
- Johns Hopkins Hospital, Departments of Gynecology and Obstetrics, Pathology, Division of Gynecologic Pathology and Oncology; Baltimore, MD, USA.
| | - Robert E Bristow
- University of California Irvine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology; Orange, CA, USA.
| | - Teresa P Diaz-Montes
- Johns Hopkins Hospital, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology; Baltimore, MD, USA.
| | - Robert Palermo
- Greater Baltimore Medical Center, Department of Pathology; Baltimore, MD, USA.
| | - Robert J Kurman
- Johns Hopkins Hospital, Departments of Gynecology and Obstetrics, Pathology, Division of Gynecologic Pathology and Oncology; Baltimore, MD, USA.
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Ricci S, Giuntoli RL, Eisenhauer E, Lopez MA, Krill L, Tanner EJ, Gehrig PA, Havrilesky LJ, Secord AA, Levinson K, Frasure H, Celano P, Fader AN. Does adjuvant chemotherapy improve survival for women with early-stage uterine leiomyosarcoma? Gynecol Oncol 2013; 131:629-33. [DOI: 10.1016/j.ygyno.2013.08.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 08/27/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
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Boruta DM, Fagotti A, Bradford LS, Escobar PF, Scambia G, Kushnir CL, Michener CM, Fader AN. Laparoendoscopic single-site radical hysterectomy with pelvic lymphadenectomy: initial multi-institutional experience for treatment of invasive cervical cancer. J Minim Invasive Gynecol 2013; 21:394-8. [PMID: 24161887 DOI: 10.1016/j.jmig.2013.10.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/11/2013] [Accepted: 10/11/2013] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To describe the feasibility, safety, and outcomes of women with stage I cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy (LESS-RH). DESIGN A retrospective descriptive study (Canadian Task Force classification III). SETTING Multiple academic teaching hospitals. PATIENTS Women with Fédération Internationale de Gynécologie et d'Obstétrique FIGO stage IA1 to IB1 cervical cancer. INTERVENTIONS LESS-RH as the primary therapy for cervical cancer performed by a gynecologic oncologist with expertise in LESS. A multichannel, single-port access device; a flexible-tipped 5-mm laparoscope; and a multifunctional instrument were used in all cases. Clinicopathologic, surgical, and perioperative outcomes were analyzed. MEASUREMENTS AND MAIN RESULTS Twenty-two women were identified in whom a LESS-RH was attempted; 20 (91%) successfully underwent the procedure, including 19 in whom pelvic lymphadenectomy (PLND) was completed. Of the 2 converted procedures, 1 patient underwent 2-port laparoscopy secondary to truncal obesity, and 1 patient underwent conversion to laparotomy secondary to external iliac vein laceration during PLND. The median age and body mass index were 46 years and 23.3 kg/m(2), respectively. The median number of pelvic lymph nodes removed was 22. One patient experienced an intraoperative complication, and no patient required reoperation. The margins of excision were negative. One patient with 2 positive pelvic nodes and 1 patient with microscopic parametrial disease received adjuvant chemosensitized radiation; 3 additional patients received adjuvant radiation therapy secondary to an intermediate risk for recurrence. After a median follow up of 11 months, no recurrences were detected. CONCLUSION LESS-RH/PLND is feasible and safe for select patients with stage I cervical cancer. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.
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Affiliation(s)
- David M Boruta
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Anna Fagotti
- Division of Minimally Invasive Gynecology, University of Perugia, St. Maria Hospital, Terni, Italy
| | - Leslie S Bradford
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pedro F Escobar
- Division of Gynecologic Oncology, HIMA-San Pablo, Caguas, Puerto Rico; Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina L Kushnir
- Division of Gynecologic Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Chad M Michener
- Division of Gynecologic Oncology, Cleveland Clinic, Cleveland, Ohio
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Ricci S, Fader AN. Treatment of uterine papillary serous carcinoma. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.847365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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