Gynecologic Oncologic Surgery for the Palliation of Life-Limiting Cancer Crises—The Importance of Education and Training in Palliative Care for the Gynecologic Oncologist

Introduction: Palliative care expertise is an important component of the comprehensive care of women with gynecologic cancers. Palliative care ranges from treatment of symptoms experienced by people with cancer such as constipation, nausea, anxiety, pain to careful and the skillful discussion of prognosis and goals of care. The purpose of this review is to summarize the basic issues in palliative care faced by healthcare providers caring for people with cancer and then focus on some examples of diagnostic and treatment dilemmas faced by gynecologic oncologists caring for women with recurrent cancers. Review Summary: Palliative and hospice care strategies are described. Palliative care refers to symptom management from diagnosis through active treatment, problems encountered by survivors, and concerns at the end of life. Hospice care pertains to care during the last six months of life and includes the alleviation of suffering of those dying from cancer and the support for family members. The symptoms at the end of life including pain, anorexia, and intestinal complications are reviewed. Palliative surgical procedures range from the drainage of pleural and abdominal fluid, including the management of intestinal obstruction via drains, diversionary procedures, or the creation of an ostomy. A comparison of outcomes between medical (when surgery was not feasible) and surgical management of bowel obstruction shows the average survival of 54 days compared to 193 days respectively. Conclusion: Gynecologic oncologists are uniquely positioned among other oncologists in managing intestinal obstruction, malignant ascites and pleural effusions, and oligometastatic recurrences where they must decide whether a medical or surgical approach will be effective in palliation and alleviation of suffering. The combination of traditional surgical gynecologic oncology training with palliative care is crucial to become the most effective clinician for each patient with advanced or recurrent gynecologic cancer.

Hospital Admission Less than 30 Days after Chemotherapy: Results from a Chemotherapy-Specific Morbidity and Mortality Conference in Gynecologic Oncology

Introduction: Morbidity and Mortality (M&M) rounds can identify adverse events and improve patient safety however adoption in cancer centers is not routine. Herein we report the results of a chemotherapy-specific gynecologic oncology M&M rounds and identify reasons for hospital admission < 30 days after chemotherapy treatment. Methods: Between July 2014 and April 2016, all admissions < 30 days from chemotherapy administration were prospectively collected along with clinical data. Admissions were described and classified as planned or unplanned and as associated with chemotherapy or with underlying disease. Results: 585 patients were admitted, 78% of whom had ovarian cancer and 43% of whom had recurrent disease. Overall, 47% of admissions were unplanned and these were significantly longer than planned admissions (5.6 vs. 2.4 days, p = 0.0003). Of unplanned admissions, 43% were due to chemotherapy, and 57% were due to disease burden. 74% of patients had received >1 prior line of chemotherapy, and 22% were on clinical trial. The most common causes of unplanned admission were nausea, vomiting or failure to thrive (28.9%), fever (17.9%) and small bowel obstruction (19.9%). Conclusions: There is a high rate of unplanned admission < 30 days after chemotherapy and patients with ovarian cancer and recurrent disease are at the highest risk. This information can be used to counsel patients about complications of chemotherapy and to improve supportive management. M&M conferences surrounding unplanned admissions after chemotherapy may help guide therapy, encourage best supportive care, and prompt re-evaluation of treatment goals in heavily pretreated patients with recurrent.

Art Therapy to Improve Quality of Life of Cancer Patients and Their Carers in Bangladesh

Objective: Art as a therapy helps in reparation and recovery. The aim of this study was to see the response of the cancer patients and their carers residing in Bangladesh towards art therapy and the perceived effect of art therapy on their physical and psychological condition. Method: The study was a record review study conducted through a cross-sectional descriptive method from July to November 2018. Along with the cancer patients, their immediate carers were enrolled in this study since patients and their carers both suffer from the distress that comes with the diagnosis of cancer. In-depth interviews and focused group discussions of art therapy were conducted with our study population at BPSCF and BSMMU. Findings: After art therapy, there was an improvement in sensory perception and self-perception, physical and psychological condition, communication and social skills and helped in more personal integration and built stronger insight among the patients and carers. Majority of the participants of art therapy felt good and wanted to continue art therapy. Significance of results: The results of this study will help to create awareness among the community about the importance of psychotherapies like art therapy in the life of the cancer patients and their carers. Introducing the concept of art therapy will also help the public health practitioners to improvise palliative care services in Bangladesh in a very cost-effective approach.

Development of a cervical cancer screening program in a slum setting using visual inspection with acetic acid: Analysis of feasibility and cost

Objective: In Bangladesh, cervical cancer is the second most common cause of cancer deaths in women. Annually, over 50 million women are at risk for cervical cancer, with 17,686 cases diagnosed and 10,362 deaths each year. Visual inspection with acetic acid (VIA) is a well validated tool in low resource areas for identifying cervical lesions. In this pilot study, AK Khan Health Care Trust (AKKHCT), in collaboration with oncologists at Massachusetts General Hospital (LB, BD, AG), launched a VIA cervical cancer-screening program. Methods: A clinic was established in the Korail Slum of Dhaka, a 90-acre slum with over 70,000 inhabitants, in the summer of 2011. From September 17, 2011 to November 1, 2011, ten women living in the Korail Slum were recruited and completed the three-month training program to learn how to do a pelvic examination and to evaluate the cervix using VIA. Three of the ten women performed VIA screening during the study period. Results: 44 patients were recruited and 8 women were identified to have VIA-positive results for a screen-positive rate of 18.2%. Two of the eight women underwent treatment. One woman underwent an excisional procedure for pre-invasive disease in the slum clinic. The other woman had an early invasive cervical cancer and was successfully treated in a local hospital. Conclusion: Our pilot project demonstrates some important factors in developing and implementing a successful screening program. Involving laywomen as healthcare workers provides a strong tie to community, as well as education, economic independence, and empowerment for women who would otherwise occupy a lower social standing in their community. VIA is feasible in the complicated environment of an inner city slum. It was feasible to perform minor excisional procedures to treat pre-invasive cervical disease in the slum clinic.

Quality of Life in Ovarian-Cancer Patients Receiving Chemotherapy

Background: Ovarian cancer accounts for 4% of cancers occurring in women and ranks first in gynecological cancer mortality. Maintaining and improving quality of life is an important goal of cancer treatment. The toxicities of cancer treatment particularly chemotherapy can impact an individual’s wellbeing. Objective: Assessment of quality of life among ovarian cancer patients receiving chemotherapy. Method: A descriptive study was conducted among 202 patients with ovarian cancer treated at the National Institute of Cancer Research and Hospital in Bangladesh. Ethical approval was received from the ethics committee of NICRH. Data was collected using the EORTC QLQC30 questionnaire and the ovarian cancer specific EORTC QOL OV-28 module. Functional, symptomatic and global variables were scored and analyzed by SPSS. Multiple linear regressions determined the effects of predictor variables and correlation of the global health status with other variables. Results: 48.6% of patients were ages 41 to 50 years. The mean score of global health status was 55.77. Deteriorating emotional function, distressing physical and psychological symptoms, sexual dysfunction and financial difficulties adversely affect the quality of life. Their correlation with global health status was strongly significant (P value < 0.05). Fatigue (r value -0.604;p < 0.05) loss of appetite (r value -0.442;p < 0.05), insomnia (r value -0.339;p < 0.05), dyspnea (r value -0.377;p < 0.05), heartburn (r value -0.369;p < 0.05), and alopecia (r value -0.262;p < 0.05) were negatively associated with QOL. Conclusion: The overall quality of life among the ovarian cancer patients receiving chemotherapy is low. Increasing knowledge in this area will help clinicians to optimize patient management. Interventions should focus on both physical and psychological and sexual health issues that adversely affect the quality of life.