Publications by authors named "Sarah E Ferguson"

76 Publications

Endometrial cancer.

CMAJ 2021 Sep;193(36):E1423

Department of Obstetrics & Gynaecology (Sobel), Sinai Health System; Department of Obstetrics & Gynaecology (Sobel), Women's College Hospital; Department of Obstetrics & Gynaecology (Sobel, Simpson, Ferguson), University of Toronto; Department of Obstetrics & Gynaecology (Simpson), St. Michael's Hospital/Unity Health Toronto; Li Ka Shing Knowledge Institute (Simpson), Unity Health Toronto; Division of Gynecologic Oncology (Ferguson), University Health Network/Sinai Health System, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.202731DOI Listing
September 2021

Efficacy and toxicity of intraperitoneal chemotherapy as compared to intravenous chemotherapy in the treatment of patients with advanced ovarian cancer.

Int J Gynaecol Obstet 2021 Jul 2. Epub 2021 Jul 2.

Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, ON, Canada.

Objective: To assess the efficacy and toxicity of intraperitoneal (IP) chemotherapy compared to intravenous (IV) chemotherapy.

Methods: Toxicity profiles, recurrence patterns, and long-term survival outcomes of 271 women with Stage IIIC or IV high-grade serous ovarian cancer (HGSC) treated with primary cytoreductive surgery followed by adjuvant IP or IV chemotherapy during 2001-2015 were reviewed.

Results: Women who received IP chemotherapy (n = 91) were more likely to have undergone aggressive and longer surgery with no residual disease compared to the IV arm (n = 180). Chemotherapy-related toxicities were comparable between the two groups. Extraperitoneal recurrences were more common in the IP arm compared to the IV arm. Five-year progression-free survival was 19% versus 18% (P = 0.63) and overall survival was 73% versus 44% (P < 0.01) in the IP versus IV arms, respectively. After adjustment for significant clinicopathologic factors in a multivariable model, use of IP was no longer a statistically significant predictor of overall survival.

Conclusion: IP chemotherapy in advanced HGSC has not been widely adopted due to concerns about toxicity and inconvenience. Use of IP chemotherapy was associated with comparable safety profile and efficacy to IV chemotherapy in women with Stage IIIC/IV HGSC. Recurrences were more likely to be extraperitoneal with IP treatment.
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http://dx.doi.org/10.1002/ijgo.13813DOI Listing
July 2021

Feasibility and acceptability of a group-mediated exercise intervention for gynecological cancer survivors.

J Psychosoc Oncol 2021 Jun 29:1-20. Epub 2021 Jun 29.

Kinesiology, University of Guelph-Humber, Toronto, Canada.

Purpose: Examine feasibility and acceptability of a group-mediated cognitive-behavioral (GMCB) intervention targeting planned, self-managed physical activity (PA).

Design: Sequential mixed methods, single arm pre-/post-test design with a 4-week follow-up.

Participants: Post-treatment gynecologic cancer survivors.

Methods: Participants attended 8 weekly facilitator-led group sessions and completed assessments at baseline, post-intervention and follow-up. Feasibility was assessed by recruitment rate, retention rate, capture of outcomes, intervention usability and intervention fidelity. Acceptability was examined via qualitative interviews. Preliminary estimates of intervention effectiveness (PA, PA social cognitions and sleep) were collected.

Findings: 355 participants were approached and 38 consented. Twenty took part in the study and 17 (85%) completed the intervention. Thematic content analysis revealed positive group experiences. Cognitive-behavioral strategies were beneficial. Goal-setting and shared cancer recovery experience facilitated connection among group members.

Implications: Program acceptability was high among a diverse sample of gynecologic cancer survivors and delivery of the program is feasible to this group of gynecologic cancer survivors. Recruitment challenges were present but study retention was high.
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http://dx.doi.org/10.1080/07347332.2021.1939474DOI Listing
June 2021

Sentinel lymph node biopsy in high-grade endometrial cancer: a systematic review and meta-analysis of performance characteristics.

Am J Obstet Gynecol 2021 May 29. Epub 2021 May 29.

Division of Gynaecologic Oncology, Department of Obstetrics and Gynecology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objective: A sentinel lymph node biopsy is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer, but its value in high-grade endometrial cancer remains controversial. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of sentinel lymph node biopsy in patients with endometrial cancer with high-grade histology (registered in the International Prospective Register of Systematic Reviews with identifying number CRD42020160280).

Data Sources: We systematically searched the MEDLINE, Epub Ahead of Print, MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase databases all through the OvidSP platform. The search was performed between January 1, 2000, and January 26, 2021. ClinicalTrials.gov was searched to identify ongoing registered clinical trials.

Study Eligibility Criteria: We included prospective cohort studies in which sentinel lymph node biopsy were evaluated in clinical stage I patients with high-grade endometrial cancer (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated or dedifferentiated, and high-grade not otherwise specified) with a cervical injection of indocyanine green for sentinel lymph node detection and at least a bilateral pelvic lymphadenectomy as a reference standard. If the data were not reported specifically for patients with high-grade histology, the authors were contacted for aggregate data.

Methods: We pooled the detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results: We identified 16 eligible studies of which the authors for 9 of the studies provided data on 429 patients with high-grade endometrial cancer specifically. The study-level median age was 66 years (range, 44-82.5 years) and the study-level median body mass index was 28.6 kg/m (range, 19.4-43.7 kg/m). The pooled detection rates were 91% per patient (95% confidence interval, 85%-95%; I=59%) and 64% bilaterally (95% confidence interval, 53%-73%; I=69%). The overall node positivity rate was 26% (95% confidence interval, 19%-34%; I=44%). Of the 87 patients with positive node results, a sentinel lymph node biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% confidence interval, 84%-96%; I=0%), a false negative rate of 8% (95% confidence interval, 4%-16%; I=0%), and a negative predictive value of 97% (95% confidence interval, 95%-99%; I=0%).

Conclusion: Sentinel lymph node biopsy accurately detect lymph node metastases in patients with high-grade endometrial cancer with a false negative rate comparable with that observed in low-grade endometrial cancer, melanoma, vulvar cancer, and breast cancer. These findings suggest that sentinel lymph node biopsy can replace complete lymphadenectomies as the standard of care for surgical staging in patients with high-grade endometrial cancer.
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http://dx.doi.org/10.1016/j.ajog.2021.05.034DOI Listing
May 2021

Maximizing cancer prevention through genetic navigation for Lynch syndrome detection in women with newly diagnosed endometrial and nonserous/nonmucinous epithelial ovarian cancer.

Cancer 2021 Sep 13;127(17):3082-3091. Epub 2021 May 13.

Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada.

Background: Despite recommendations for reflex immunohistochemistry (IHC) for mismatch repair (MMR) proteins to identify Lynch syndrome (LS), the uptake of genetic assessment by those who meet referral criteria is low. The authors implemented a comprehensive genetic navigation program to increase the uptake of genetic testing for LS in patients with endometrial cancer (EC) or nonserous/nonmucinous ovarian cancer (OC).

Methods: Participants with newly diagnosed EC or OC were prospectively recruited from 3 cancer centers in Ontario, Canada. Family history questionnaires were used to assess LS-specific family history. Reflex IHC for MMR proteins was performed with the inclusion of clinical directives in pathology reports. A trained genetic navigator initiated a genetic referral on behalf of the treating physician and facilitated genetic referrals to the closest genetics center.

Results: A total of 841 participants (642 with EC, 172 with OC, and 27 with synchronous EC/OC) consented to the study; 194 (23%) were MMR-deficient by IHC. Overall, 170 women (20%) were eligible for a genetic assessment for LS: 35 on the basis of their family history alone, 24 on the basis of their family history and IHC, 82 on the basis of IHC alone, and 29 on the basis of clinical discretion. After adjustments for participants who died (n = 6), 149 of 164 patients (91%) completed a genetic assessment, and 111 were offered and completed genetic testing. Thirty-four women (4.0% of the total cohort and 30.6% of those with genetic testing) were diagnosed with LS: 5 with mutL homolog 1 (MLH1), 9 with mutS homolog 2 (MSH2), 15 with mutS homolog 6 (MSH6), and 5 with PMS2.

Conclusions: The introduction of a navigated genetic program resulted in a high rate of genetic assessment (>90%) in patients with gynecologic cancer at risk for LS.
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http://dx.doi.org/10.1002/cncr.33625DOI Listing
September 2021

Sentinel Lymph Node Concept in High-Risk Profile Endometrial Cancer-Reply.

JAMA Surg 2021 Aug;156(8):799-800

Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1001/jamasurg.2021.1470DOI Listing
August 2021

Gynecologic oncology treatment modifications or delays in response to the COVID-19 pandemic in a publicly funded versus privately funded North American tertiary cancer center.

Gynecol Oncol 2021 07 28;162(1):12-17. Epub 2021 Apr 28.

Division of Gynecologic Oncology, Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada. Electronic address:

Objective: To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer center.

Methods: This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders.

Results: A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively. On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81-49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14-3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11-5.33, p = 0.03).

Conclusion: During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.
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http://dx.doi.org/10.1016/j.ygyno.2021.04.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080163PMC
July 2021

Consolidation or maintenance systemic therapy for newly diagnosed stage II, III, or IV epithelial ovary, fallopian tube, or primary peritoneal carcinoma: A systematic review.

Crit Rev Oncol Hematol 2021 Jun 16;162:103336. Epub 2021 Apr 16.

Department of Oncology, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada. Electronic address:

Backgrounds: To systematically review the effectiveness and harm of consolidation or maintenance therapy in patients with newly diagnosed stage II-IV EOC.

Methods: MEDLINE, EMBASE, PubMed, Cochrane Library, and PROSPERO databases, and four relevant conferences were systematically searched. We adhered to PRISMA guidelines, and used the GRADE approach to aggregate data.

Results: Among 12,675 citations, 28 comprising 16,310 patients were analyzed. The certainty of aggregated study evidence ranged from high to low.

Conclusions: The existing evidence does not find overall survival benefit for consolidation therapy with chemotherapy. For maintenance therapy, comparing with placebo, olaparib, niraparib, veliparib, and bevacizumab are effective as maintenance therapy for certain patients with newly diagnosed stage III-IV epithelial ovarian, fallopian tube, or primary peritoneal carcinoma respectively without reducing quality of life. Longer follow-up with more mature results of overall survival will better define the effect of these agents.
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http://dx.doi.org/10.1016/j.critrevonc.2021.103336DOI Listing
June 2021

The Prevent Ovarian Cancer Program (POCP): Identification of women at risk for ovarian cancer using complementary recruitment approaches.

Gynecol Oncol 2021 Jul 13;162(1):97-106. Epub 2021 Apr 13.

Gynecologic Oncology, The University Health Network, Toronto, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada. Electronic address:

Background: Up to 20% of high-grade serous ovarian carcinomas (HGSOC) are hereditary; however, historical uptake of genetic testing is low. We used a unique combination of approaches to identify women in Ontario, Canada, with a first-degree relative (FDR) who died from HGSOC without prior genetic testing, and offer them multi-gene panel testing.

Methods: From May 2015-Sept 2019, genetic counseling and testing was provided to eligible participants. Two recruitment strategies were employed, including self-identification in response to an outreach campaign and direct targeting of FDRs of deceased HGSOC patients treated at our institution. The rate of pathogenic variants (PV) in established/potential ovarian cancer risk genes and the benefits/challenges of each approach were assessed.

Results: A total of 564 women enrolled in response to our outreach campaign (n = 473) or direct recruitment (n = 91). Mean age at consent was 52 years and 96% did not meet provincial testing criteria. Genetic results were provided to 528 individuals from 458 families. The rate of PVs in ovarian cancer risk genes was highest when FDRs were diagnosed with HGSOC <60 years (9.4% vs. 3.9% ≥ 60y, p = 0.0160). Participants in the outreach vs. direct recruitment cohort had a similar rate of PVs; however, uptake of genetic testing (97% vs. 89%; p = 0.0036) and study completion (95% vs. 87%; p = 0.0062) rates were higher in the former. Eleven participants with pathogenic variants have completed risk-reducing gynecologic surgery, with one stage I HGSOC and two breast cancers identified.

Conclusion: Overall PV rates in this large cohort were lower than expected; however, we provide evidence that genetic testing criteria in Ontario should include individuals with a deceased FDR diagnosed with HGSOC <60 years of age.
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http://dx.doi.org/10.1016/j.ygyno.2021.04.011DOI Listing
July 2021

An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline: Consolidation or Maintenance Systemic Therapy for Newly Diagnosed Stage II, III, or IV Epithelial Ovary, Fallopian Tube, or Primary Peritoneal Carcinoma.

Curr Oncol 2021 03 1;28(2):1114-1124. Epub 2021 Mar 1.

Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada.

Objective: To provide recommendations on systemic therapy options in consolidation or maintenance therapy for women with newly diagnosed stage II, III, or IV epithelial ovary, fallopian tube, or primary peritoneal carcinoma including all histological types.

Methods: Consistent with the Program in Evidence-based Program's standardized approach, MEDLINE, EMBASE, PubMed, Cochrane Library, and PROSPERO (the international prospective register of systematic reviews) databases, and four relevant conferences were systematically searched. The Working Group drafted recommendations and revised them based on the comments from internal and external reviewers.

Results: We have one recommendation for consolidation therapy and eight recommendations for maintenance therapy. Overall, consolidation therapy with chemotherapy should not be recommended in the target population. For maintenance therapy, we recommended olaparib (Recommendation), niraparib (Weak Recommendation), veliparib (Weak Recommendation), and bevacizumab (Weak Recommendation) for certain patients with newly diagnosed stage III-IV epithelial ovarian, fallopian tube, or primary peritoneal carcinoma, respectively. We do not recommend some agents as maintenance therapy in four recommendations. We are unable to specify the patient population by histological types for different maintenance therapy recommendations. When new evidence that can impact the recommendations is available, the recommendations will be updated as soon as possible.
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http://dx.doi.org/10.3390/curroncol28020107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025745PMC
March 2021

Understanding the clinical implication of mismatch repair deficiency in endometrioid endometrial cancer through a prospective study.

Gynecol Oncol 2021 04 19;161(1):221-227. Epub 2021 Jan 19.

Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network/Sinai Health Systems, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada; Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada. Electronic address:

Objectives: Findings on impact of mismatch repair deficiency (MMRd) on patient outcomes in endometrial cancer (EC) have been inconsistent to date. The objective of this study was to compare the oncologic outcomes and recurrence patterns between MMRd and MMR-intact (MMRi) endometrioid EC (EEC).

Methods: Between 2015 and 2018, we prospectively recruited 492 EEC cases from three cancer centers in Ontario, Canada. Tumors were reflexively assessed for MMR protein expression by immunohistochemistry (IHC). Clinicopathological, survival and recurrence patterns were compared between MMRd and MMRi cases.

Results: Of 492 EEC, 348 were MMRi (71%) and 144 were MMRd (29%) with median follow-up of 16.8 months (0-69.6). MMRd tumors tended to be grade 2 or 3 (56% vs. 29%, p < 0.001), with propensity for lymphovascular space invasion (28% vs. 18%, p = 0.024), lymph node involvement (7% vs. 5%, p < 0.001) and received more adjuvant treatment (46% vs. 33%, p = 0.027). This group also had significantly lower 3-year recurrence-free survival (78% vs. 90%, p = 0.014) although there was no difference in OS (p = 0.603). MMRd cases were more likely to recur in retroperitoneal lymph nodes (p = 0.045). Upon subgroup analysis, MLH1 methylated tumors had the worst prognostic features and survival outcomes.

Conclusions: MLH1 methylated EECs exhibit more aggressive features compared to other MMRd and MMRi EECs. This may indicate an inherent difference in tumor biology, suggesting the importance of individualized management based on EC molecular phenotype.
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http://dx.doi.org/10.1016/j.ygyno.2021.01.002DOI Listing
April 2021

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study.

Am J Obstet Gynecol 2021 06 24;224(6):585.e1-585.e30. Epub 2020 Dec 24.

Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia. Electronic address:

Background: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown.

Objective: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research.

Study Design: We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications.

Results: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records.

Conclusion: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.
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http://dx.doi.org/10.1016/j.ajog.2020.12.1206DOI Listing
June 2021

The impacts of neoadjuvant chemotherapy and of cytoreductive surgery on 10-year survival from advanced ovarian cancer.

Int J Gynaecol Obstet 2021 Jun 13;153(3):417-423. Epub 2021 Jan 13.

Division of Gynecologic Oncology, Princess Margaret Cancer Center, University Health Networks, Toronto, ON, Canada.

Objective: To compare the long-term survival outcomes for women with advanced ovarian cancer treated with chemotherapy either before or after surgery (neoadjuvant chemotherapy vs primary cytoreductive surgery) at a single tertiary cancer center.

Methods: Retrospective cohort study of 326 patients with Stage IIIC or IV high-grade serous ovarian cancer who received neoadjuvant chemotherapy or primary cytoreductive surgery between 2001 and 2011. Clinical treatments were recorded and 10-year survival rates were measured.

Results: A total of 183 women (56.1%) underwent primary cytoreductive surgery and 143 women (43.9%) received neoadjuvant chemotherapy. Women who received neoadjuvant chemotherapy were more likely to have no residual disease than those who underwent primary cytoreductive surgery (51.4% vs 41.5%; P = 0.030) but experienced inferior 10-year overall survival (9.1% vs 19.3%; P < 0.001). Among those who had primary cytoreductive surgery, those with no residual disease had superior 10-year overall survival than those who had any evidence of residual disease (36.0% vs 7.2%; P < 0.001).

Conclusion: Among women with advanced ovarian cancer, those who underwent primary cytoreductive surgery had better survival than those who received neoadjuvant chemotherapy. Neoadjuvant chemotherapy should be reserved for those in whom optimal primary cytoreductive surgery is not feasible.
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http://dx.doi.org/10.1002/ijgo.13542DOI Listing
June 2021

An Integrative DNA Sequencing and Methylation Panel to Assess Mismatch Repair Deficiency.

J Mol Diagn 2021 02 28;23(2):242-252. Epub 2020 Nov 28.

Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada. Electronic address:

Clinical testing for mismatch repair (MMR) deficiency often entails serial testing of tumor and constitutional DNA using multiple assays. To minimize cost and specimen requirements of MMR testing, we developed an integrated targeted sequencing protocol (termed MultiMMR) that tests for promoter methylation, mutations, copy number alterations, copy neutral loss of heterozygosity, and microsatellite instability from a single aliquot of DNA. Hybrid capture of DNA-sequencing libraries constructed with methylated adapters was performed on 142 samples (60 tumors and 82 constitutional samples) from 82 patients with MMR-associated colorectal, endometrial, and brain cancers as well as a synthetic DNA mix with 11 known mutations. The captured material was split to enable parallel bisulfite and conventional sequence analysis. The panel targeted microsatellite regions and 13 genes associated with MMR, hypermutation, and hereditary colorectal cancer. MultiMMR recapitulated clinical testing results in 23 of 24 cases, was able to explain MMR loss in an additional 29 of 48 patients with incomplete or inconclusive testing, and identified all 11 MMR variants within the synthetic DNA mix. Promoter methylation and microsatellite instability analysis found 95% and 97% concordance with clinical testing, respectively. We report the feasibility for amalgamation of the current stepwise and complex clinical testing workflow into an integrated test for hereditary and somatic causes of MMR deficiency.
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http://dx.doi.org/10.1016/j.jmoldx.2020.11.006DOI Listing
February 2021

Assessment of Sentinel Lymph Node Biopsy vs Lymphadenectomy for Intermediate- and High-Grade Endometrial Cancer Staging.

JAMA Surg 2021 Feb;156(2):157-164

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.

Importance: Whether sentinel lymph node biopsy (SLNB) can replace lymphadenectomy for surgical staging in patients with high-grade endometrial cancer (EC) is unclear.

Objective: To examine the diagnostic accuracy of, performance characteristics of, and morbidity associated with SLNB using indocyanine green in patients with intermediate- and high-grade EC.

Design, Setting, And Participants: In this prospective, multicenter cohort study (Sentinel Lymph Node Biopsy vs Lymphadenectomy for Intermediate- and High-Grade Endometrial Cancer Staging [SENTOR] study), accrual occurred from July 1, 2015, to June 30, 2019, with early stoppage because of prespecified accuracy criteria. The study included patients with clinical stage I grade 2 endometrioid or high-grade EC scheduled to undergo laparoscopic or robotic hysterectomy with an intent to complete staging at 3 designated cancer centers in Toronto, Ontario, Canada.

Exposures: All patients underwent SLNB followed by lymphadenectomy as the reference standard. Patients with grade 2 endometrioid EC underwent pelvic lymphadenectomy (PLND) alone, and patients with high-grade EC underwent PLND and para-aortic lymphadenectomy (PALND).

Main Outcomes And Measures: The primary outcome was sensitivity of the SLNB algorithm. Secondary outcomes were additional measures of diagnostic accuracy, sentinel lymph node detection rates, and adverse events.

Results: The study enrolled 156 patients (median age, 65.5 years; range, 40-86 years; median body mass index [calculated as weight in kilograms divided by height in meters squared], 27.5; range, 17.6-49.3), including 126 with high-grade EC. All patients underwent SLNB and PLND, and 101 patients (80%) with high-grade EC also underwent PALND. Sentinel lymph node detection rates were 97.4% per patient (95% CI, 93.6%-99.3%), 87.5% per hemipelvis (95% CI, 83.3%-91.0%), and 77.6% bilaterally (95% CI, 70.2%-83.8%). Of 27 patients (17%) with nodal metastases, 26 patients were correctly identified by the SLNB algorithm, yielding a sensitivity of 96% (95% CI, 81%-100%), a false-negative rate of 4% (95% CI, 0%-19%), and a negative predictive value of 99% (95% CI, 96%-100%). Only 1 patient (0.6%) was misclassified by the SLNB algorithm. Seven of 27 patients with node-positive cancer (26%) were identified outside traditional PLND boundaries or required immunohistochemistry for diagnosis.

Conclusions And Relevance: In this prospective cohort study, SLNB had acceptable diagnostic accuracy for patients with high-grade EC at increased risk of nodal metastases and improved the detection of node-positive cases compared with lymphadenectomy. The findings suggest that SLNB is a viable option for the surgical staging of EC.
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http://dx.doi.org/10.1001/jamasurg.2020.5060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658802PMC
February 2021

Evaluating the effect of a group pre-treatment chemotherapy psycho-education session for chemotherapy-naive gynecologic cancer patients and their caregivers.

Gynecol Oncol 2021 01 17;160(1):234-243. Epub 2020 Oct 17.

Princess Margaret Cancer Centre, 610 University Ave, Toronto, Ontario M5G 2M9, Canada; Ontario Health, Cancer Care Ontario, 620 University Ave, Toronto, Ontario M5G 2L7, Canada; University of Toronto, 27 King's College Circle, Toronto, Ontario M5S 1A1, Canada. Electronic address:

Objective: The objective was to evaluate the effects of a pre-chemotherapy education class on chemotherapy-naïve patients diagnosed with gynecologic cancer and their informal caregivers.

Methods: A prospective cohort study was conducted at a cancer centre in Toronto, Canada. All women diagnosed with gynecologic cancer, who were scheduled to receive chemotherapy treatment, and their caregivers were invited to attend the GyneChemo class, newly introduced as the centre's standard of care. Consenting attendees were asked to complete pre-and post-class survey measures assessing anxiety, self-efficacy, information needs, preparedness to begin chemotherapy treatment, and satisfaction with the class.

Results: Between September 2014 to September 2016, 642 individuals attended the GyneChemo class. 75 patients and 64 caregivers completed both pre- and post-class measures. Over 80% of participants agreed that the class was beneficial, specific to their needs, and administered in an appropriate setting. Significant increases in patient and caregiver self-efficacy (p < 0.001) and preparedness to begin chemotherapy treatment (p < 0.001) were found following class completion. Significant differences in patient's anxiety scores were found, with patients who reported an annual household income of <$25,000 experiencing increased anxiety (MD = +5.33) and patients reporting an income of $25,000-$75,000 reporting decreased anxiety (MD = -4.75) following class completion (p = 0.034). No significant difference in the average pre-post caregiver anxiety score (p = 0.207) was found.

Conclusion: This educational model provides patients and informal caregivers with information specific to their chemotherapy regimen and disease site. Integrating pre-treatment education into cancer care has the potential to improve the survivorship experience by increasing self-efficacy, treatment preparedness, and psychological well-being.
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http://dx.doi.org/10.1016/j.ygyno.2020.10.007DOI Listing
January 2021

Outcomes after the regionalization of care for high-grade endometrial cancers: a population-based study.

Am J Obstet Gynecol 2021 03 12;224(3):274.e1-274.e10. Epub 2020 Sep 12.

Division of Gynecologic Oncology, Odette Cancer Center, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Electronic address:

Background: In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that gynecologic oncologists at tertiary care centers manage the treatment of patients with high-grade endometrial cancers. This study examines the effects of this regionalization of care on patient outcomes.

Objective: This study aimed to evaluate the impact of the regionalization of surgery for high-grade endometrial cancer on patient and treatment outcomes.

Study Design: In this retrospective cohort study, patients diagnosed with nonendometrioid high-grade endometrial cancer from 2003 to 2017 were identified using province-wide administrative databases. To allow 6 months for knowledge translation, 2 periods were defined, with January 1, 2014, as the cutoff. Methods for segmented regression were used to test the effect of the guidelines. Multivariable Cox proportional hazards regression was used to evaluate whether regionalization of care had an impact on patient survival.

Results: There were 3518 patients with nonendometrioid high-grade endometrial cancer identified. The case mix as represented by patient comorbidities and the disease stage distribution did not differ significantly between the 2 regionalization periods. There was a significant increase (69%-85%; P<.001) in the proportion of primary surgeries performed by gynecologic oncologists after regionalization, which was not explained by secular trends. After regionalization, the proportion of patients who had surgical staging (50%-63%; P<.001) and the proportion of patients who received adjuvant treatment (65%-71%; P<.001) increased significantly. After adjusting for age, stage, and comorbidities, there was a decrease in the hazard of mortality (hazard ratio, 0.85 [95% confidence interval, 0.73-0.99]; P=.04) after regionalization.

Conclusion: The publication of a regionalization policy for the treatment of high-grade endometrial cancers in Ontario led to an increase in the proportion of surgeries performed by gynecologic oncologists. This also translated into a significant improvement in patient survival.
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http://dx.doi.org/10.1016/j.ajog.2020.09.012DOI Listing
March 2021

Performance characteristics of screening strategies to identify Lynch syndrome in women with ovarian cancer.

Cancer 2020 11 18;126(22):4886-4894. Epub 2020 Aug 18.

Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Sinai Health Systems, Toronto, Ontario, Canada.

Background: For women with ovarian cancer (OC), the optimal screening strategy to identify Lynch syndrome (LS) has not been determined. In the current study, the authors compared the performance characteristics of various strategies combining mismatch repair (MMR) immunohistochemistry (IHC), microsatellite instability testing (MSI), and family history for the detection of LS.

Methods: Women with nonserous and/or nonmucinous ovarian cancer were recruited prospectively from 3 cancer centers in Ontario, Canada. All underwent germline testing for LS and completed a family history assessment. Tumors were assessed using MMR IHC and MSI. The sensitivity, specificity, and positive and negative predictive values of screening strategies were compared with the gold standard of a germline result.

Results: Of 215 women, germline data were available for 189 (88%); 13 women (7%) had pathogenic germline variants with 7 women with mutS homolog 6 (MSH6); 3 women with mutL homolog 1 (MLH1); 2 women with PMS1 homolog 2, mismatch repair system component (PMS2); and 1 woman with mutS homolog 2 (MSH2). A total of 28 women had MMR-deficient tumors (13%); of these, 11 had pathogenic variants (39%). Sequential IHC (with MLH1 promoter methylation analysis on MLH1-deficient tumors) followed by MSI for nonmethylated and/or MMR-intact patients was the most sensitive (92.3%; 95% confidence interval, 64%-99.8%) and specific (97.7%; 95% confidence interval, 94.2%-99.4%) approach, missing 1 case of LS. IHC with MLH1 promoter methylation analysis missed 2 patients of LS. Family history was found to have the lowest sensitivity at 55%.

Conclusions: Sequential IHC (with MLH1 promoter methylation analysis) followed by MSI was found to be most sensitive. However, IHC with MLH1 promoter methylation analysis also performed well and is likely more cost-effective and efficient in the clinical setting. The pretest probability of LS is high in patients with MMR deficiency and warrants universal screening for LS.
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http://dx.doi.org/10.1002/cncr.33144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693219PMC
November 2020

Impact of rarity on Canadian oncology health technology assessment and funding.

Int J Technol Assess Health Care 2020 Aug 11:1-6. Epub 2020 Aug 11.

Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Objectives: The pan-Canadian Oncology Drug Review (pCODR) evaluates new cancer drugs for public funding recommendations. While pCODR's deliberative framework evaluates overall clinical benefit and includes considerations for exceptional circumstances, rarity of indication is not explicitly addressed. Given the high unmet need that typically accompanies these indications, we explored the impact of rarity on oncology HTA recommendations and funding decisions.

Methods: We examined pCODR submissions with final recommendations from 2012 to 2017. Incidence rates were calculated using pCODR recommendation reports and statistics from the Canadian Cancer Society. Indications were classified as rare if the incidence rate was lower than 1/100,000 diagnoses, a definition referenced by the Canadian Agency for Drugs and Technologies in Health. Each pCODR final report was examined for the funding recommendation/justification, level of supporting evidence (presence of a randomized control trial [RCT]), and time to funding (if applicable).

Results: Of the ninety-six pCODR reviews examined, 16.6 percent were classified as rare indications per above criteria. While the frequency of positive funding recommendations were similar between rare and nonrare indication (78.6 vs. 75 percent), rare indications were less likely to be presented with evidence from RCT (50 vs. 90 percent). The average time to funding did not differ significantly across provinces.

Conclusion: Rare indications appear to be associated with weaker clinical evidence. There appears to be no association between rarity, positive funding recommendations, and time to funding. Further work will evaluate factors associated with positive recommendations and the real-world utilization of funded treatments for rare indications.
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http://dx.doi.org/10.1017/S0266462320000483DOI Listing
August 2020

Year 1: Experiences of a tertiary cancer centre following implementation of reflex BRCA1 and BRCA2 tumor testing for all high-grade serous ovarian cancers in a universal healthcare system.

Gynecol Oncol 2020 09 14;158(3):747-753. Epub 2020 Jul 14.

Lawrence S Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, ON M5T 1P8, Canada; Women's College Research Institute, 72 Grenville Street, Toronto, ON M5S 1B2, Canada.

Objective: This study compares the rate and time to genetic referral, and patient uptake of germline genetic services, before and after implementation of reflex BRCA1/2 tumor testing for high-grade serous ovarian cancer (HGSOC) in a universal healthcare system.

Methods: A retrospective chart review of HSGOC patients diagnosed in the year before (PRE) and after (POST) implementation of reflex BRCA1/2 tumor testing was conducted. Clinical information (date/age at diagnosis, personal/family history of breast/ovarian cancer, cancer stage, primary treatment, tumor results) and dates of genetics referral, counseling, and germline testing were obtained. Incident rate ratios (IRR) and 95% CI were calculated using negative binomial regression. Time to referral was evaluated using Kaplan-Meier survival analysis. Fisher Exact tests were used to evaluate uptake of genetic services.

Results: 175 HGSOC patients were identified (81 PRE; 94 POST). Post-implementation of tumor testing, there was a higher rate of genetics referral (12.88 versus 7.10/1000 person-days; IRR = 1.60, 95% CI: 1.07-2.42) and a shorter median time from diagnosis to referral (59 days PRE, 33 days POST; p = .04). In the POST cohort, most patients were referred prior to receiving their tumor results (n = 63/77; 81.8%). Once referred, most patients attended genetic counseling (94.5% PRE, 97.6% POST; p = .418) and pursue germline testing (98.6% PRE; 100% POST; p = .455).

Conclusions: Following implementation of reflex BRCA1/2 tumor testing for HGSOC, significant improvements to the rate and time to genetics referral were identified. Additional studies are needed to evaluate physician referral practices and the long-term impact of reflex tumor testing.
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http://dx.doi.org/10.1016/j.ygyno.2020.06.507DOI Listing
September 2020

Class III Obesity and Other Factors Associated with Longer Wait Times for Endometrial Cancer Surgery: A Population-Based Study.

J Obstet Gynaecol Can 2020 Sep 27;42(9):1093-1102.e3. Epub 2020 Mar 27.

Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto; ICES, Toronto, ON; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON; Department of Surgery, St. Michael's Hospital/Unity Health Toronto, Toronto, ON.

Objective: To evaluate the impact of class III obesity (body mass index >40 kg/m) on wait times for endometrial cancer surgery in Ontario, as well as other factors that influence wait time.

Methods: We performed a population-based cross-sectional study evaluating diagnosis-to-surgery time for women with endometrioid adenocarcinoma of the endometrium, during the period of 2006 to 2015, using linked administrative databases. Wait time differences between women with and without class III obesity were evaluated using a Wilcoxon rank-sum test. A multivariable generalized linear model under a generalized estimating equations approach was used to evaluate patient factors (i.e., obesity, age, comorbidities, marginalization, recent immigration, diagnosis year, geographic location), tumour characteristics (i.e., grade, stage), provider type (i.e., surgeon specialty), and institutional characteristics (i.e., rurality, hysterectomy volume, availability of minimally invasive surgery) that influence wait times.

Results: In total, 9797 women met the criteria for inclusion; 2171 (22%) had class III obesity. The overall median wait time was 55 days (interquartile range [IQR] 37-77 d) and the median wait time was significantly longer for women with class III obesity (62 [IQR 43-88] vs. 53 [IQR 36-74] d, standardized mean difference, 0.30). Age <40 or >70 years, comorbidities, lower-grade disease, surgery at an urban teaching hospital, and surgery at a high-volume hospital with greater availability of minimally invasive surgery were associated with longer wait times. After adjusting for these variables, women with class III obesity waited 12% longer.

Conclusion: Class III obesity, comorbidities, and older age are associated with a longer diagnosis-to-surgery time. As the prevalence of obesity and endometrial cancer rise, processes are needed to promote equitable, timely access to care.
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http://dx.doi.org/10.1016/j.jogc.2020.03.006DOI Listing
September 2020

The use of indocyanine green fluorescence angiography to assess anastomotic perfusion following bowel resection in surgery for gynecologic malignancies - A report of 100 consecutive anastomoses.

Gynecol Oncol 2020 08 15;158(2):402-406. Epub 2020 May 15.

Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Department of Surgical Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada. Electronic address:

Objective: Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that is found to assist intraoperative decision-making and decrease risk of anastomotic leak in the General Surgery literature. No studies to date evaluate its use in Gynecologic Oncology. Our objectives were to assess the safety and feasibility of ICG-FA use and to describe the intraoperative assessment of anastomotic perfusion with ICG-FA.

Methods: A retrospective study of a prospectively-collected database of patients with a gynecologic malignancy who underwent a bowel resection at Princess Margaret Cancer Centre in Toronto, Canada, between November 1, 2017 and December 15, 2019 was conducted. ICG-FA was administered intravenously, and a near infrared imaging system (Pinpoint, Novadaq, Canada; SPY-PHI, Stryker, USA) was used to objectively assess bowel perfusion.

Results: ICG-FA was used to assess a total of 100 bowel anastomoses in 82 consecutive surgeries: 56 low anterior resections, 19 small bowel resections, 15 right hemi-colectomies, 6 left hemi-colectomies, 3 transverse colectomies, and 1 total colectomy. Fifty-five end-to end, 44 side-to-side and 1 end-to-side anastomoses were assessed. ICG angiography was successful in all patients, allowing complete visualization of anastomotic perfusion in all cases. Hypoperfusion detected by ICG-FA resulted in change in operative plan for three patients (two anastomotic revisions and one diverting ileostomy). There were no adverse reactions to ICG. In this cohort, there was one postoperative anastomotic leak.

Conclusions: ICG-FA enables objective and accurate intraoperative evaluation of anastomotic perfusion in surgeries for gynecologic malignancies. Its implementation and routine use were found to be safe and well-tolerated without side effects in our study cohort. ICG-FA can be used with other risk-assessment strategies to guide operative decision-making in Gynecologic Oncology.
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http://dx.doi.org/10.1016/j.ygyno.2020.05.008DOI Listing
August 2020

Oncologic outcomes and morbidity following heated intraperitoneal chemotherapy at cytoreductive surgery for primary epithelial ovarian cancer: A systematic review and meta-analysis.

Gynecol Oncol 2020 07 6;158(1):218-228. Epub 2020 May 6.

Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada.

Objectives: Heated intraperitoneal chemotherapy (HIPEC) has not been universally adopted at the time of interval cytoreductive surgery for primary epithelial ovarian cancer (EOC) despite evidence of a 12-month overall survival (OS) benefit in a recent landmark randomized trial. We performed a systematic review and meta-analysis to assess oncologic outcomes and perioperative morbidity following HIPEC among primary EOC patients.

Methods: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, from inception to August 2019, for observational and randomized studies of primary EOC patients undergoing HIPEC. We assessed risk of bias using the Institute of Health Economics Quality Appraisal Checklist for single-arm cohort studies, Newcastle-Ottawa Scale for comparative cohort studies, and Cochrane Collaboration's Tool for randomized trials. We qualitatively summarized survival outcomes and calculated the pooled proportion of 30-day grade III-IV morbidity and postoperative death.

Results: We identified 35 articles including 2252 primary EOC patients; one study was a randomized trial, and only six studies included a comparator group of surgery alone. The timing, temperature, and chemotherapeutic agents used for HIPEC differed across studies. Reported OS was highly variable (3-year OS range: 46-77%); three comparative cohort studies and the sole randomized trial reported statistically significant survival benefits for HIPEC over surgery alone, while two comparative cohort studies did not. The pooled proportions for grade III-IV morbidity and postoperative death at 30 days were 34% (95% CI 20-52) and 0% (95% CI 0-5) respectively.

Conclusion: One randomized trial suggests that HIPEC at time of interval cytoreductive surgery should be considered in patients with primary EOC. However, there is significant heterogeneity in literature with respect to an appropriate HIPEC regimen, short- and long-term outcomes. High-quality prospective randomized trials are urgently needed to clarify the role of HIPEC in the first-line treatment of primary EOC.
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http://dx.doi.org/10.1016/j.ygyno.2020.03.034DOI Listing
July 2020

Supported self-management as a model for end-of-life care in the setting of malignant bowel obstruction: A qualitative study.

Gynecol Oncol 2020 06 23;157(3):745-753. Epub 2020 Mar 23.

Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada. Electronic address:

Objective: Women with advanced gynecologic cancer and malignant bowel obstruction (MBO) undergo repeated hospitalizations, experience feelings of isolation and abandonment, and often die in acute settings. Innovative outpatient models of care are needed to address the unmet needs of this population at the end-of-life. We implemented a novel supported self-management (SMS) program focused on increasing patients' skill and confidence in managing MBO proactively in the ambulatory setting.

Methods: We performed a qualitative descriptive study embedded in a prospective single-arm evaluative trial (Clinicaltrials.gov ID: NCT03260647) to understand the impact of this program on patients' sense of support, degree of distress, quality of care, and capacity to self-manage. Semi-structured interviews were completed and analysed using the Chronic Care Model as a theoretical framework. Data saturation was confirmed after 15 interviews.

Results: Fifteen patients (age range: 47-82) with diagnoses of advanced ovarian, endometrial, and cervical cancer were interviewed; 10 had died by end of follow-up, with a median interval from interview to death of 5 months. Patients were able to self-manage the: (i) medical aspects; (ii) psychological consequences, and (iii) changes in life roles and expectations resulting from their condition. Patients felt greatly supported, less isolated, and secure in their knowledge and ability to access care due to SMS. While patients understood their disease was not curative they did not fully appreciate that MBO signalled a significantly poorer prognosis.

Conclusion: Outpatient SMS interventions can be successfully implemented even for rapidly fatal conditions at the end-of-life and offer significant benefit to gynecologic cancer patients with MBO. Counselling should focus on the specific trajectory of MBO, and early palliative care referrals should be standard practice.
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http://dx.doi.org/10.1016/j.ygyno.2020.03.009DOI Listing
June 2020

Optimizing the Care of Malignant Bowel Obstruction in Patients With Advanced Gynecologic Cancer.

J Oncol Pract 2019 12 24;15(12):e1066-e1075. Epub 2019 Sep 24.

Princess Margaret Cancer Centre, Toronto, ON, Canada.

Purpose: Malignant bowel obstruction (MBO) is a common and distressing complication in women with advanced gynecologic cancer. A pilot, interprofessional MBO program was launched in 2016 at a large Canadian tertiary cancer center to integrate these patients' complex care needs across multiple disciplines and support women with MBO.

Method: Retrospective analysis to evaluate the outcomes of women with advanced gynecologic cancer who were admitted to hospital because of MBO, before (2014 to 2016: baseline group) and after (2016 to 2018) implementation of the MBO program.

Results: Of the 169 women evaluated, 106 and 63 were in the baseline group and MBO program group, respectively. Most had ovarian cancer (n = 124; 73%) and had small-bowel obstruction (n = 131; 78%). There was a significantly shorter cumulative hospital length of stay (LOS) within the first 60 days of MBO diagnosis in the MBO program group compared with the baseline group (13 22 days, respectively; adjusted = .006). The median overall survival for women treated in the MBO program was also significantly longer compared with the baseline group (243 99 days, respectively; adjusted = .002). Using the interprofessional MBO care platform, a greater proportion of patients received palliative chemotherapy (83% 56%) and less surgery (11% 21%) in the MBO program group than in the baseline group, respectively. A subgroup of women (n = 11) received total parenteral nutrition for longer than 6 months.

Conclusion: Implementation of a comprehensive, interprofessional MBO program significantly affects patient care and may improve outcomes. Unique to this MBO program is an integrated outpatient model of care and education that empowers patients to recognize MBO symptoms for early intervention.
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http://dx.doi.org/10.1200/JOP.18.00793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911166PMC
December 2019

Reply.

Am J Obstet Gynecol 2020 01 19;222(1):96-97. Epub 2019 Sep 19.

Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2019.09.017DOI Listing
January 2020

Clinical Outcomes of Surgically Unresectable Endometrial Cancers.

Am J Clin Oncol 2019 10;42(10):777-782

Departments of Radiation Oncology.

Objective: The objective of this study was to determine the outcomes of patients with unresectable endometrial cancer managed with definitive or neoadjuvant radiation (RT) and/or chemotherapy.

Materials And Methods: Patients with unresectable stages II to IVA endometrial cancer who were treated with curative intent between January 2000 and March 2018 were identified. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method and compared using the log-rank test. Multivariate logistic regression analysis was performed to identify factors associated with receipt of surgery. Multivariate Cox regression analysis was performed to identify factors associated with OS and DFS.

Results: Of the 59 patients identified, the median age was 63 years (range: 37 to 88 y) and histology was endometrioid in 59%. Median follow-up was 2.2 years (range: 0.3 to 9.8 y). Seventeen patients (29%) received neoadjuvant chemotherapy, 28 (47%) neoadjuvant radiation, and 14 (24%) definitive RT; 39 (66%) underwent surgery. Patients who received surgery had higher 3-year OS and DFS than those who did not (84% vs. 41%; P<0.001 and 56% vs. 11%; P<0.001, respectively). Factors associated with higher odds of surgical resection included younger age, endometrioid histology, and earlier stage. Younger age, endometrioid histology, and surgical resection were significantly associated with higher OS. Surgical resection was also associated with higher DFS.

Conclusions: Surgical resection following RT and/or chemotherapy for locally advanced, unresectable endometrial cancer is associated with higher DFS and OS and more likely to be achieved in endometrioid subtypes.
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http://dx.doi.org/10.1097/COC.0000000000000600DOI Listing
October 2019

Dyadic coping mediates the effects of attachment on quality of life among couples facing ovarian cancer.

J Behav Med 2020 08 29;43(4):564-575. Epub 2019 Aug 29.

Ryerson University, 350 Victoria Street, Toronto, ON, M5B2K3, Canada.

Cancer is an interpersonal stressor affecting both patient and spouse. To examine the pathways that insecure adult attachment can impact health outcomes by way of dyadic processes, this cross-sectional study used the actor-partner interdependence mediation model to examine whether common dyadic coping (CDC) mediated the associations between attachment and quality of life (QOL). Couples (N = 106) facing ovarian cancer were recruited from a comprehensive cancer center and completed self-report questionnaires. Results indicated that worse social and functional QOL were associated with both one's own and one's partner's greater insecure attachment, by way of one's own use of less CDC. Unexpectedly, greater CDC reported by one's partner was associated with one's own lower functional QOL. Although CDC has beneficial effects on QOL, CDC may also be experienced as draining. Effects of adult attachment on dyadic coping are a significant contributor to subjective health outcomes among couples facing ovarian cancer.
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http://dx.doi.org/10.1007/s10865-019-00096-3DOI Listing
August 2020

Patient-physician relationships, health self-efficacy, and gynecologic cancer screening among women with Lynch syndrome.

Hered Cancer Clin Pract 2019 13;17:24. Epub 2019 Aug 13.

1Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3 Canada.

Background: Lynch syndrome, a hereditary cancer syndrome, predisposes women to colorectal, endometrial, and ovarian cancer. Current guidelines recommend that women with Lynch syndrome undergo risk-reducing gynecological surgery to reduce their chances of developing endometrial or ovarian cancer. Little is known about how women with Lynch syndrome perceive gynecological cancer screening, or the psychosocial factors associated with screening attitudes and behaviour.

Methods: This study used a cross-sectional, quantitative design. Using self-report questionnaire data from a sample of women with Lynch syndrome ( = 50) who had not undergone risk-reducing surgery, the current study sought to: 1) describe the gynecological cancer screening behaviours of women with Lynch syndrome, as well participant-reported sources of information about Lynch syndrome; 2) examine the extent to which women believe gynecological cancer screening is effective and provides them with reassurance and; 3) assess to what extent relationships with one's family physician were associated with gynecological cancer screening, perceptions about screening, and health self-efficacy. Data were analyzed using descriptive statistics and Spearman rank-ordered correlations.

Results: Data analyses showed that transvaginal ultrasound was the most common screening behaviour (57%) followed by pelvic ultrasound (47%). Only 22% of participants underwent endometrial biopsy. Patient-physician relationships were related to greater health self-efficacy to manage Lynch syndrome and greater perceived effectiveness of gynecological screening. However, health self-efficacy and better patient-physician relationships were not associated with increased engagement in gynecological cancer screening.

Conclusions: The data suggest that feeling efficacious about managing one's Lynch syndrome and screening is related to positive interactions and communication with one's family physician. While this is encouraging, future research should examine educating both family physicians and patients about current guidelines for Lynch syndrome gynecological screening recommendations.
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http://dx.doi.org/10.1186/s13053-019-0123-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693236PMC
August 2019
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