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Financial toxicity is common among gynecologic cancer patients
Correspondence to Dr Larissa A Meyer, Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; lmeyer@mdanderson.org In the USA, many patients experience unexpected out-of-pocket spending following a cancer diagnosis, including direct medical costs from health insurance plan’s cost-sharing requirements. Despite the demographic and economic differences in the two cohorts, the authors found no differences in the proportions of patients reporting moderate or severe financial toxicity. Patients being treated for early stage endometrial or cervical cancer might expect relief from the financial toxicity following frontline treatment, even if it were to involve multiple modalities of treatment.
Journal Article
Fate and the clinic: a multidisciplinary consideration of fatalism in health behaviour
The role of fatalism in health behaviour has stirred significant controversy in literature across several disciplines. Some researchers have demonstrated a negative correlation between fatalistic beliefs and healthy behaviours such as cancer screening, arguing that fatalism is a barrier to health-seeking behaviours. Other studies have painted a more complicated picture of fatalistic beliefs and health behaviours that ultimately questions fatalism’s causality as a distinct factor. Unpacking this debate raises thought-provoking questions about how epistemological and methodological frameworks present particular pictures about the connections between belief, race, class and behaviour. The discussion surrounding fatalism illuminates larger tensions between structural and cultural determinants of health behaviour. This article argues for a more rigorous delineation of culture and structure and suggests that future theory-informed and ethnographic research may more precisely parse the role of fatalism in health attitudes, beliefs and behaviours.
Journal Article
Otitis media and Bell palsy
I read the article by deAlmeida and colleagues1 and found it very informative.
Journal Article
Impact of timing of urinary catheter removal on voiding dysfunction after radical hysterectomy for early cervical cancer
ObjectivesTo evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.MethodsWe performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100 mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.ResultsAmong 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used enhanced recovery after surgery (ERAS) pathways. 29 (12.4%) patients had urinary catheter removal between 1–5 days postoperatively (group 1), 141 (60.3%) between 6–10 days (group 2), and 64 (27.3%) between 11–15 days (group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between group 1 (17.2%), group 2 (11.3%), and group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3–5 days) compared with group 2 (8 days, IQR 7–10 days) and group 3 (13 days, IQR 11–15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or re-admission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.ConclusionThere was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.
Journal Article
Implementation of a sentinel lymph node mapping algorithm for endometrial cancer: surgical outcomes and hospital charges
IntroductionThe purpose of this study was to compare operative times, surgical outcomes, resource utilization, and hospital charges before and after the implementation of a sentinel lymph node (SLN) mapping algorithm in endometrial cancer.MethodsAll patients with clinical stage I endometrial cancer were identified pre- (2012) and post- (2017) implementation of the SLN algorithm. Clinical data were summarized and compared between groups. Total hospital charges incurred on the day of surgery were extracted from the hospital financial system for each patient and all charges were adjusted to 2017 US dollars.ResultsA total of 203 patients were included: 71 patients in 2012 and 130 patients in 2017. There was no difference in median age, body mass index, or stage. In 2012, 35/71 patients (49.3%) underwent a lymphadenectomy. In 2017, SLN mapping was attempted in 120/130 patients (92.3%) and at least one SLN was identified in 110/120 (91.7%). Median estimated blood loss was similar between groups (100 mL vs 75 mL, p=0.081). There was a significant decrease in both median operative time (210 vs 171 min, p=0.007) and utilization of intraoperative frozen section (63.4% vs 14.6%, p<0.0001). No significant differences were noted in intraoperative (p=1.00) or 30 day postoperative complication rates (p=0.30). The median total hospital charges decreased by 2.73% in 2017 as compared with 2012 (p=0.96).DiscussionImplementation of an SLN mapping algorithm for high- and low-risk endometrial cancer resulted in a decrease in both operative time and intraoperative frozen section utilization with no change in surgical morbidity. While hospital charges did not significantly change, further studies are warranted to assess the true cost of SLN mapping.
Journal Article
Enhanced recovery for obese patients undergoing gynecologic cancer surgery
ObjectiveTo compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery.MethodsWe performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance.ResultsAfter matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48–66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, p<0.001) and greater median estimated blood loss (300 mL vs 200 mL, p<0.001). Median (IQR) post-operative length of stay was the same for obese and non-obese patients: 3 days (IQR 2–4). Obese and non-obese patients had similar rates of grade III–IV complications (10.9% and 6.6%, respectively, p=0.06), re-operation (2.3% and 1.4%, respectively, p=0.58), and re-admission (11.8% and 8.0%, respectively, p=0.13). Grade I–II complications were more common among obese patients (62.4% vs 48.3%, p<0.001) because they had more wound complications (17.8% vs 4.9%, p<0.001). Obese patients received more opioids both during surgery (morphine equivalent dose 57.25 mg (IQR 35–72.5) vs 50 mg (IQR 25–622.5), p=0.003) and after surgery (morphine equivalent daily dose 45 mg/day (IQR 10–96.2) vs 29.37 mg/day (IQR 7.5–70), p=0.01). Obese and non-obese patients had similar ERAS program compliance (70.1% and 69.8%, respectively, p=0.32).ConclusionsNeither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.
Journal Article
Exceptional Response to Pembrolizumab for Treatment of Metastatic Chemorefractory Endometrial Carcinoma in a Patient with Lynch Syndrome: A Case Report
Abstract
Advanced endometrial cancer is associated with poor outcomes and few treatment options exist. Recently, the US Federal Drug Administration approved pembrolizumab for the treatment of endometrial cancers that are deficient in mismatch repair and have high microsatellite instability (MSI). Lynch syndrome is an autosomal dominant disease that causes MSI-high endometrial cancer. We report a case of a 46-year-old woman with Lynch syndrome and advanced endometrial cancer who experienced progressive disease after treatment with chemotherapy with carboplatin and paclitaxel. She was then treated with single-agent pembrolizumab and had an exceptional response. She was noted to have a significant decrease in the size of a large uterine mass extending into the vagina and vulva, as well as decrease in the size of lymphadenopathy. Data are limited at this time for patients with Lynch syndrome treated with single-agent pembrolizumab. Our case report seeks to add to the body of literature that suggests that this patient population may particularly benefit from this novel therapy.
Journal Article
Strategic Thinking in 3D
Effective strategic thinking requires a clear understanding of one's external environment. Each organization has a unique environment, but as Ross Harrison explains inStrategic Thinking in 3D, any environment-whether in the fields of national security, foreign policy, or business-has three dimensions: systems, opponents, and groups. Systems strategy involves the challenge of creating leverage against opponents by shaping the external environments they rely on for sustaining their power. Opponents-based strategy requires analyzing a competitor's capability, motivation, and strategy, assessing one's own competitive challenges, and then developing approaches for directly confronting the opponent. Group strategy aims to mobilize political, consumer, and market groups against the power of an opponent.Strategic Thinking in 3Dmakes strategy \"portable\" for individuals who switch careers multiple times during their professional lives, moving among public, nonprofit, and private sector jobs. Harrison uses al Qaeda's strategy against the United States as a \"capstone\" case study to demonstrate how strategic success often results from the cascading effect of \"wins\" in all three of these dimensions. Conversely, strategic failure can come from the mutual reinforcement of \"losses\" across these same three dimensions. Reinforcing and integrating the concepts, Harrison shows how strategy in 3D actually works in practice.
eBook
Shorts RAI Film Festival 2021. Spirit
Saraswati is a new arrival in an Indian Himalayan village. She wonders how she will ever feel at home in the new setting. “Spirit” by Jane Dyson and Ross Harrison is a story of longing and belonging that explores what it takes to carve out a home in a remote community. The film charts the everyday work and spiritual practices that bind people to each other and the land, even as life changes. Spirit reveals how belonging is not a given; it cannot be assumed. Instead, it is the slow alchemy of work, friendships, love, loss and belief. It shadows the contours of individual lives and is tested by the rapid social change that is transforming rural areas. In a final scene, as villagers celebrate the Pandav Lila festival in collective euphoria, Saraswati explains how it feels to belong.
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