Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: For some time now, the question of de-escalation in axillary staging in breast cancer patients has been raised. The aim is to improve the patients' quality of life and reduce morbidity by optimizing surgical strategies with a high level of oncological safety. This review offers a current overview of published evidence and clinical practice, aiming to guide the surgical community as they reassess and reshape their practices.

Recent findings: Years after introducing sentinel lymph node biopsy (SLNB) in clinically node negative breast cancer patients several guidelines suggest completely omitting SLNB in older patients with low-risk tumors. It is worth noting that for patients with a metastatic sentinel lymph node in the upfront surgery setting, a de-escalation of axillary surgery may in fact lead to an escalation of radiation therapy. Currently, there is limited evidence on the axillary surgical approach for patients with initially positive node status achieving complete axillary response (ycN0), resulting in heterogenous guideline recommendations.

Summary: Innovative trials are contributing to a growing evidence on de-escalation of axillary surgery with the aim of reducing arm morbidity and improving long-term health-related quality of life.

Purpose of review: Epithelial ovarian cancer (EOC) is the fifth cause of cancer death among women, and 70-80% of patients relapse within 2 years from the last cycle of first-line chemotherapy despite a complete response to chemotherapy and optimal debulking surgery. In this context, the goal of the maintenance treatment strategy is to prolong the time to recurrence. The recent development of targeted molecular therapies resulted in a broader spectrum of maintenance therapeutic options with consequent higher clinical benefit but less toxicity. This review summarizes the currently available maintenance strategies for newly and recurrent EOC, focusing on the decision-making process to personalize treatment and future perspectives.

Recent findings: Over the past 10 years, several studies have demonstrated the clear benefit in terms of survival with the addition of a maintenance treatment strategy over the 'watchful waiting' approach both in the first line and recurrent setting. Since December 2016, the United States Food and Drug Administration and European Medicines Agency have approved four drugs for ovarian cancer maintenance based on the results of several clinical trials demonstrating efficacy and tolerability. These include the antiangiogenic drug Bevacizumab and three polyadenosine diphosphate-ribose polymerase (PARP) inhibitors: olaparib, niraparib, and rucaparib.

Summary: These data led American and European Treatment guidelines to include bevacizumab, olaparib, niraparib, rucaparib, and combination bevacizumab-olaparib as maintenance treatment options in first-line and recurrent ovarian cancer therapy. However, with the availability of different maintenance options, identifying the best treatment choice for each patient can be challenging, and several clinical and molecular aspects have to be taken into account in the decision-making process.

Purpose of review: Breast cancer (BC) is the most common cancer among women in the United States and the second leading cause of cancer death. BC research, diagnostics, drug development, and expansion of therapies for novel indications advances so rapidly that BC treatment standards change month-by-month. Herein we discuss notable advancements in the past year for hormone receptor positive (HR+) HER2 negative (HER2-) BC.

Recent findings: Radiolabeled estradiol imaging and circulating tumor DNA (ctDNA) have changed our approach to metastatic BC (mBC) detection. Amongst an abundance of therapy options, treatment de-escalation to avoid toxicities is a priority. Promising results with CDK4/6 inhibitors in the curative setting have been demonstrated even as we await final data for use in the metastatic setting. Several novel endocrine therapies are expected to gain FDA-approval in the near future. Antibody-drug conjugates have expanded from other mBC types to HR+HER2- mBC. The PROMISE trial helped define disease recurrence outcomes for premenopausal women seeking pregnancy.

Summary: The diagnostic and treatment landscape for HR+HER2- BC continues to rapidly evolve on multiple fronts.

Purpose of review: To summarize the recent updates in cervical cancer from prevention and early detection to the management of early stage and recurrent disease as well as future areas of exploration.

Recent findings: The importance of the human papilloma virus vaccine and screening continue to make an impact in reducing the global burden of cervical cancer. In early-stage, low risk disease, new studies have demonstrated the role of less radical surgery with similar disease related outcomes. Efforts to improve outcomes in locally advanced cervical cancer have been reported. The incorporation of adjuvant chemotherapy, novel agents and checkpoint inhibitors, with the latter impacting disease free survival. In advanced/recurrent disease, the role of immunotherapy continues to make an impact and, in addition to recurrent disease, has now moved to the frontline for patients with programmed cell death ligand 1 expression. Tisotumab vedotin, an antibody drug conjugate, and other novel agents continue to be studied in this setting.

Summary: In this review, we discuss prevention measures and the outcomes of recent trials in all stages of cervical cancer. As therapies continue to evolve, ongoing trials and new areas of exploration will continue to identify opportunities to improve survival in cervical cancer.

Purpose of review: In recent years, there has been a flurry of activity in the human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer space. New, powerful drugs like trastuzumab deruxtecan have challenged our fundamental definition of what HER2 expression means as a predictive biomarker.

Recent findings: Recent approvals of multiple agents in the second line-metastatic setting have given patients access to a variety of new agents, but also raise questions with regard to optimal sequencing.

Summary: This review will explore current issues with HER2 testing, recently approved drugs in the HER2+ and HER2 low spaces, as well as novel agents/combinations on the horizon.

Purpose of review: Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications.

Recent findings: There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing.

Summary: Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications.

Purpose of review: The emergency department serves as an essential access point for a variety of healthcare services. This review will examine the recent expansion of family planning and reproductive health services in the emergency department.

Recent findings: An increasing number of patients present to emergency departments for early pregnancy loss (EPL), abortion care, and contraceptive management. Availability of comprehensive EPL management varies dramatically, possibly due to lack of provider knowledge or training. Particularly in remote settings, educational interventions - such as providing information about medication management and training in uterine aspiration - may standardize this management. Restrictive abortion laws raise concerns for changing and increased patient presentations to the emergency department for complications related to unsafe or self-managed abortion. Emergency medicine providers should anticipate that more patients will present without a prior ultrasound confirming intrauterine pregnancy prior to initiating no-touch or self-managed abortions. Particularly among pediatric patients, there may be a role for contraceptive counseling during an emergency department visit. Novel strategies, including web-based interventions and emergency department-based curricula for contraceptive counseling, may help reach those who otherwise may not seek reproductive healthcare in a clinic setting.

Summary: The intersection of emergency medicine and reproductive healthcare is a promising frontier for providing immediate, patient-centered, family planning care. Continued research and provider education are necessary to refine these approaches, address disparities, and respond to the changing reproductive healthcare landscape.

Purpose of review: Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care.

Recent findings: Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources.

Summary: There are many opportunities to optimize clinical practice to support those traveling for abortion care.