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Closing their discussion, the panel shares advice for new nurse practitioners caring for patients who have endometrial cancer.

Advice for New Nurse Practitioners Working With Patients With Endometrial Cancer

The panel shares the most critical unmet needs for patients with endometrial cancer.

Greatest Unmet Needs for Patients with Endometrial Cancer

The mean cognitive and behavioral outcomes for children aged 9 years who had prenatal exposure to their mother’s cancer were within normal ranges and comparable to the general population, at a long-term follow-up published in the 

Full scale intelligence quotient (FSIQ) was not found to be different by cancer treatment types (

 = .802) were found to have a significant impact. Moreover, for children who were exposed to therapy (n = 109), no associations between the FSIQ and chemotherapeutic agent, exposure level, or timing of treatment emerged.

On average, the FSIQ score increased by 1.6 points for each week increase in gestational age at birth (95% CI, 0.7-2.5; 

“Cognitive and behavioral outcomes of 9-year-old children born to mothers diagnosed with cancer during pregnancy did not differ with norms of the general population,” wrote Indra A. Van Assche, MSc, a PhD researcher in neuropsychology at the University of Leuven, in Leuven, Belgium, and co-investigators, in the study. “We reported average group scores for all intelligence index scores, verbal and visuospatial memory outcomes, attentional functioning outcomes, and behavioral questionnaire measures. We found no impact of sex, treatment type, and cancer stage.”

Previous reports from this study suggested that fetal exposure to chemotherapy was not associated with increased central nervous system, cardiac or auditory morbidity and that the impairments that these children faced in regard to their general health and growth were comparable to the general population.

 At the same time, subtle changes in cardiac and neurocognitive measurements emphasized the importance of long-term follow-up. In this analysis premature birth was the greatest driver of cognitive development impairments.

In total, investigators used neurocognitive tests and parent-reported behavioral questionnaires to assess 151 children (mean age, 9.3 years; range, 7.8-10.6), including 96 from Belgium, 24 from the Netherlands, 9 from Italy, 6 from the Czech Republic, and 7 from New Jersey. In this set of participants, 109 (72.2%) had been exposed to chemotherapy (alone or combination with other treatment modalities), 18 (11.9%) had surgery alone, 16 (10.6%) had been expressed to radiotherapy, 1 to trastuzumab (Herceptin), and 16 (10.6%) had not been exposed to cancer treatment.

As part of the International Network on Cancer, Infertility and Pregnancy Child Follow-up study, children were assessed longitudinally at the age of 18 months, 36 months, and again every 3 years until age 18. This current 9-year analysis used FISQ, which is derived from the Wechsler Intelligence Scale for Children. Secondary outcomes were neurocognitive test scores and behavioral questionnaire results. All children also underwent a clinical neurologic and general pediatric examinations, and parents filled out a survey regarding their children general health and education level. All tests were conducted in the child’s native language.

Of note, gestational age at birth did show a positive association with full FISQ. Observations were also observed with maternal death and maternal education.

Gestational age was linked to verbal intelligence (β, 1.49 points/week; CI, 0.6-2.4; 

= .02), performance intelligence (β, 1.39 points/week; CI, 0.6-2.2; 

 = .002), and processing speed (β, 1.21 points/week; CI, 0.3-2.1; 

Moreover, maternal bereavement was linked to lower FSIQ scores (

 = .022). Children whose mothers passed away before they age 2 years demonstrated lower FSIQs (93.13 ± 12.65) than those with a surviving mother (104.08 ± 14.88). However, adjustments for gestational age caused this association to disappear (

 < .3). Of note, children whose mother passed away before they were 2 years were, on average, born earlier (33.4 weeks ± 2.7), than those whose mother passed away after they were 2 years (37.1 weeks ± 1.7) and those with a surviving mother at the time of follow-up (36.4 weeks ± 2.5; 

In terms of general health, the patient-reported health questionnaire revealed no specific group across the population. Four children had been diagnosed with attention-deficit hyperactivity disorder, 3 of whom needed supportive medication. One child was on the autistic spectrum. Thirty-one children (24.4%) received remedial care, including speech therapy (n = 17), remedial teaching at school (n = 10), a type of physical or exercise therapy (n = 4), and neurofeedback therapy (n = 1).

Study authors noted that maternal death was not associated with not associated with a specific cancer type, cancer stage, or treatment type in this study and that, therefore, children who consequently developed cognitive development problems may have been equally affected by the maternal stress or an insecure mother-child attachment as they were by treatments. Moreover, for children who were prenatally exposed to chemotherapy, maternal education level was the only driving factor in FSIQ scores; prematurity was not found to have an effect, suggesting that more research into the effect of prematurity may be warranted in a larger chemotherapy group.

“Seventeen percent of the children in this study had lost their mother (of which almost 58% died before their child turned 2 years old),” study authors concluded. “The results suggest a relationship between maternal bereavement in the first 1000 days of life and full-scale intelligence, although a larger sample is necessary to disentangle effects of maternal loss and often coinciding premature birth.”

In accordance with the study guidelines, follow-up with this group of children will continue to be ongoing until they are age 18 years.

Van Assche IA, Huis In 't Veld EA, Van Calsteren K, et al. Cognitive and behavioral development of 9-year-old children after maternal cancer during pregnancy: a prospective multicenter cohort study. 

. Published online January 12, 2023. doi:10.1200/JCO.22.02005

Amant F, Van Calsteren K, Halaska MJ, et al: Long-term cognitive and cardiac outcomes after prenatal exposure to chemotherapy in children aged 18 months or older: An observational study. 

 2012;13(3):256-264. doi:10.1016/S1470-2045(11)70363-1

Articles

An analysis of 141 children who had prenatal exposure to maternal cancer showed promising cognitive and behavioral functions at age 9 years. 

Children Exposed to Maternal Cancer Show Normal Cognitive and Behavioral Outcomes

Oncology nurses and social workers working with patients with cervical cancer must have the most current information regarding available cancer treatment modalities and actively enrolling clinical trials. After a patient receives a diagnosis of cervical cancer, the patient along with her gynecologist can select from a whole host of treatment options. The first step in this journey is to find a board-certified gynecologist oncologist, or GYO. Treatment options are then determined by the stage the cancer at diagnosis.

Surgery, such as a TAHBSO (total abdominal hysterectomy and bilateral salpingoophorectomy) wherein the cervix is also removed, is an option available to patients. The following surgical procedures may also be used: cold knife conization, sentinel lymph node biopsy, total hysterectomy and radical trachelectomy, and a total pelvic exenteration.

This is invasive surgery done in a hospital setting wherein tissue that is in a cone shape is excised from the cervix and cervical canal.

 If circumstances are correct, the whole cancer can be removed at this time.This procedure is performed under general anesthesia.

The sentinel lymph node, or the first lymph node to receive drainage from the primary tumor, is the target here. If cancer is going to spread from the original site, it will usually travel here first.

To determine where the sentinel lymph node is located, the patient is injected with a radioactive material and/or a blue dye. This material then travels to the lymph nodes and the first lymph node identified is excised. This is then reviewed by the pathology department to find the cervical malignancy. A lymph node dissection will be done if there are more affected lymph nodes found.The entire cancer can then be removed at this time.

A hysterectomy is a surgical procedure to remove the uterus. In the case of cervical cancer, the cervix, and oftentimes surrounding structures, are removed. There are multiple types of hysterectomy may be used to treat cervical cancer.

A total hysterectomy removes both the uterus and the cervix. A total vaginal hysterectomy means that there are no incisions on the abdomen and the structures are removed through the vagina. A total abdominal hysterectomy means that these structures were removed through a large incision in the abdomen. A series of small incisions on the abdomen is called a total laparoscopic hysterectomy.

A radical hysterectomy involves the removal of the uterus, cervix, part of the vagina, and an array of ligament and tissues around these organs. In this procedure, the ovaries, fallopian tubes, or nearby lymph nodes may also be removed.

In a modified radical hysterectomy, the uterus, the cervix, the upper part of the vagina, as well as the ligaments and tissues that closely surround these organs, are removed. In this procedure, the ovaries, fallopian tubes, or nearby lymph nodes may also be removed.

Also called a radical cervicectomy, in a radical trachelectomy the cervix, surrounding tissue, and the part of the upper vagina are excised. In addition, lymph nodes can be removed. The rest of the vagina and uterus are then repaired. If pregnancy is a consideration, a cerclage band or stitch is placed in the uterus to prevent a miscarriage.

In a bilateral salpingo-oophorectomy, both the ovaries and the fallopian tubes are removed. This is performed when the cancer has already spread to these organs.

During this procedure, which is very extensive, the lower colon, rectum, and bladder are removed. The vagina, ovaries, cervix, and adjacent lymph nodes are also excised. A colostomy and a urostomy are then created to remove stool and urine. In addition, plastic surgery may also be needed to create an artificial vagina.

Beyond surgery, systemic treatments such as chemotherapy and radiation, targeted therapy, and immunotherapy may be considered depending on the stage of the cervical malignancy.

In general, radiation therapy is a modality that uses either external radiation or internal radiation to kill cancer. Brachytherapy is another term for internal radiation. Fortunately, radiation therapy is used for ongoing treatment as a curative or palliative treatment. If it is palliative, it can be used to help a woman suffering from cervical cancer survive its’ ravages.

Chemotherapy is given to deter cancer cells from multiplying in the cervix.

There are several types of chemotherapy that are used in the treatment of cervical cancer.Some of the chemotherapies are the following: cisplatin, carboplatin, gemcitabine, isofasfamide, irinotecan, paclitaxel, topotecan, and vinorelbine.

Enzymes and proteins promoting the growth of cervical cancer are stopped with targeted therapy treatments. Bevacizumab (Avastin) and tisotumab vedotin (Tivdak) are given as targeted therapies.

Immunotherapy is given to boost a woman’s immune system to fight cervical cancer. An example of a drug given for this purpose is pembrolizumab (Keytruda) if the patient has the biomarker PD-L1.

The National Cancer Institute (NCI) has a listing of available clinical trials for cervical cancer patients. Women can participate in clinical trials to find more progressive treatment options and also as a way of helping to further refine standard treatment options. 

 website that will give the patient information about ongoing trials outside of NCI. The 

 is also available to the public wherein clinical trials can be located through either phone, or the web in English and Spanish.

How is cervical cancer diagnosed and treated? Centers for Disease control and Prevention. December 6, 2022. Accessed January 14, 2023. 

Cervical cancer treatment. National Institute of Health. October 13, 2022. Accessed January 15, 2023. 

January is cervical cancer awareness month. This third article in a series highlights current cervical cancer treatment options.

Nurses Must Stay Up-to-Date With Treatments and Clinical Trials for Patients With Cervical Cancer

Kimberly A. Spickes, CNP, discusses how often patients with endometrial cancer have dose reductions or interruptions at her institution, and who is involved in the decision to dose-reduce.

Discussing Dose Reductions and Interruptions with Patients on Therapy for Endometrial Cancer

Nurse Practitioner Kimberly Halla explains the proactive measures she takes to ensure patients with endometrial cancer are prepared to experience and manage the adverse effects of treatment.

Proactive Adverse Effect Management for Patients on Therapy for Endometrial Cancer

It is important that oncology RNs and social workers be aware of the screening and testing guidelines for cervical cancer. For this second article in a weekly series for cervical cancer awareness month, we will look at the current screening recommendations.

The Papanicolaou test can detect changes involving the cervix before they evolve into cancer. In addition, it can reveal changes after cancer has occurred. The goal of the Papanicolaou test is to find precancerous changes when it still at a precancerous stage.

When a woman goes for cervical cancer screening, the cervix is examined. The provider uses a speculum, which is plastic or metal, and is inserted inside the vagina. The physician, ARNP or physician assistant (PA) will then retrieve cervical cells as well as mucus from this area.

 The specimen is then shipped to a laboratory for analysis.

The ordering provider will order a human papillomavirus (HPV) test if this is indicated.Unfortunately, cervical cancer is a silent killer. Unlike lung cancer, where the patient might have a cough, cervical precancer does not have clinical symptoms. Cervical precancer is a painless disease. That is why going for screening is vital.

An HPV test looks for the presence of HPV DNA in the cervix. The HPV test is similar to the Papanicolaou test; a provider will insert a speculum and then use a soft brush to collect cells from the outside of the cervix.

HPV is a sexually transmitted infection (STI).

 In many healthy individuals, this virus can disappear without treatment. Other times, this does not occur, and the patient may develop cervical cancer from this virus down the road.

Screening can start at age 21 to 29 years. Women within this age range should get a Papanicolaou test every 3 years.

 Normal results will trigger the gynecology provider to instruct patients to have the next screening in 3 years.

For women between the ages 30 to 65 years, there are some options. Women can either get a Papanicolaou test every 3 weeks, or an HPV test every 5 years, or both a Papanicolaou test and HPV test together every 5 years. Going for only an HPV test is known as primary HPV testing

 If it comes back normal, the gynecology provider will usually tell the patient that they can wait 5 years for the next test.

Getting an HPV test and a Papanicolaou test simultaneously is known as co

Again, the patient can wait 5 years between tests if the results are negative. If the patient only has a Papanicolaou test, and this test result is negative, the patient will be told that they can wait 3 years till their next Papanicolaou test.

Women older than 65 years have different guidelines depending on their health care history. Women who had a hysterectomy because of an abnormal cervical cells or cervical cancer, should continue to get Papanicolaou and HPV tests.

Women who have had their uterus removed but still have a cervix (which is uncommon), should continue to get Papanicolaou tests until they are age 65 years. Once they reach age 65 years, if they have 3 normal tests, or 2 normal co-tests in a row in the past 10 years, they may be able to stop testing.

Results can take 3 weeks to receive despite today’s technology. The results will then determine if further testing is needed. If the patient has cervical cancer or precancer, following the health care provider’s recommendations are very important. Being lost to follow-up is not an option since because this cancer can metastasize.

Cost should not be a factor. In the United States, there is reduced or even free screening available at the National Breast and Cervical cancer Early Detection Program

Screening those who belong to marginalized of minority and economically disadvantaged communities women is a priority in this country. In general, the National Institutes of Health (NIH) has published statistics that reveal that, in general, rates for cervical cancer have decreased since the year 2000. In addition, Hispanic women, some LGBTQ women, and women belonging to low-income communities, have lower cervical cancer testing rates.

Cancer Epidemiology, Biomarkers and Prevention

, a systematic review of 43 studies indicated that medically underserved women prefer a self-test as well as providers who speak their language.Female health care providers are also wanted.

 The authors of the study concluded by noting that if these considerations are not included in cervical cancer screening, the gap in health care between the have and have nots will get worse.

What Should I Know About Screening? Centers for Disease Control and Prevention. December 14, 2022. Accessed January 13, 2023. Web site: https://bit.ly/3Hev5f7

Pap and HPV tests. Office on Women’s Health.February 22, 2021. Accessed January 12, 2023. https://bit.ly/3iLcRIM

Mix JM, Van Dyne EA, Saraiya M, Hallowell BD, Thomas CC. Assessing impact of HPV vaccination on cervical cancer incidence among women aged 15-29 years in the United States, 1999-2017: an ecologic study. 

. 2021;30(1):30-37. doi:10.1158/1055-9965.EPI-20-0846

January is cervical cancer awareness month. This second article in a series highlights current cervical screening guidelines.

Opinion: Oncology Nurses Require an Understanding of Cervical Cancer Testing and Screening

In a small set of patients with heavily pretreated, platinum-resistant ovarian cancer, a triplet regimen comprised of COM701, BMS-986207, and nivolumab (Opdivo) showed promising antitumor activity, according to data from a phase 1/2 trial (NCT04570839) presented at the 2022 ESMO Immuno-Oncology Annual Congress.

In the 20 patients who received the triplet, the regimen resulted in an investigator-assessed overall response rate (ORR) of 20% (95% CI, 6%-44%) by RECIST v1.1 criteria. Of those who responded to treatment, 20% had a partial response, 25% achieved stable disease, and 55% experienced disease progression. The combination resulted in a disease control rate of 45% (95% CI, 23%-68%).

“We had impressive responses in heavily pretreated patients,” lead study author John Moroney, MD, said during an interview with 

. “Of the 20 patients who received this drug, there were 4 confirmed durable and deep responses. It was exciting in an ovarian cancer [setting] to see that at all.”

Limited activity has been observed with immune checkpoint inhibitors in those with platinum-resistant epithelial ovarian cancer, defined as experiencing disease recurrence less than 6 months after having received platinum-based treatment. For example, pembrolizumab (Keytruda) monotherapy or in combination with the anti-TIGIT inhibitor vibostolimab (MK 7684a) has only resulted in an ORR of approximately 8%. As such, a high unmet need remains for this population.

“Immune checkpoint inhibition is not a standard [approach] in ovarian cancer because it has a relatively low percentage of responders,” added Moroney, who is also an associate professor of Obstetrics and Gynecology and an associate professor of Medicine at the University of Chicago in Illinois.

COM701, the novel, first-in-class, immune checkpoint inhibitor–blocker that binds to PVRIG, has demonstrated preliminary antitumor activity when utilized as a single agent or when combined with nivolumab in patients with this disease. Investigators hypothesized that triple blockade comprised of PVRIG, TIGIT, and PD-1 would have activity in this population and be well tolerated.

Patients were eligible to enroll to the phase 1/2 trial if they had a histologically confirmed locally advanced or metastatic solid malignancy and they had received or were not eligible to receive all other available standard-of-care treatment options. Moreover, patients were required to have measurable disease and undergo biopsy prior to and while on treatment. Notably, there was no limitation to the number of prior lines of therapy that a patient could have received.

If patients had an active autoimmune disease requiring systemic treatment, they were excluded. Patients were also not allowed to have prior exposure to an anti-TIGIT inhibitor, PD-(L)1 inhibitor, anti–CTLA-4 antibody, anti–OX-40 antibody, or an anti-CD137 antibody. Other exclusion criteria included having a history of immune-related toxicities on previous immunotherapy treatment that resulted in discontinuation.

Study participants received 20 mg/kg of COM701 intravenously (IV) in combination with 480 mg of IV BMS-986207 and 480 mg of IV nivolumab once every 4 weeks.

Antitumor activity was evaluated per RECIST v1.1 criteria with CT imaging done every 8 weeks or when disease progression was suspected. Patients will receive treatment for a total of 2 years, or until disease progression, toxicity, or withdrawn consent, or discontinuation due to principal investigator discretion.

“This was a standard phase 1 design, with a focus toward evaluating the safety and early efficacy of the combination,” Moroney noted. “First-in-human and first combination trials [of COM701] have already, for the most part, been done. This [investigation] was also done in parallel with a doublet trial [NCT04354246], evaluating the combination of COM701 with another TIGIT inhibitor [COM902].”

The key primary objective of the research was to evaluate the safety and tolerability of the regimen, and a key secondary objective was to examine antitumor activity. Other exploratory objectives comprised assessing the immunogenicity of COM701 and developing a better understanding of the COM701-mediated pharmacodynamic effect in the blood, as well as immune-associated changes.

Of the 20 patients enrolled to the trial, 50% were aged 65 years or older, and 70% had an ECOG performance status of 1. Regarding histology, 55% of patients had high-grade serous disease, 15% had clear cell disease, and 30% did not have this information available. Moreover, 80% of patients previously received a bevacizumab (Avastin)-containing regimen, and 30% had prior exposure to a PARP inhibitor.

All patients enrolled to the trial received treatment with the investigative regimen. The median number of prior lines of therapy was 4 (range, 1-10). Eighty percent of patients discontinued study treatment. Reasons for discontinuation included progressive disease by RECIST v1.1 criteria (75%) or an adverse effect (AE; 5%).

Regarding safety, 55% of the patients evaluated experienced any-grade treatment-related AEs (TRAEs). Twenty percent of patients experienced a TRAE that was grade 2 or lower, and 35% had a grade 3 TRAE; no grade 4 AEs were observed.

Common AEs included nausea (30%), diarrhea (20%), fatigue (20%), increased alanine aminotransferase (15%), anemia (15%), hyponatremia (15%), and pruritus (15%). Related serious AEs included grade 3 dyspnea (n = 1), grade 3 hypercalcemia (n = 1), grade 1/2 proctalgia (n = 1), grade 1/2 pulmonary embolism (n = 1), and grade 1/2 pyrexia (n = 1).

“Historically, among different trials with immune checkpoint inhibition in ovarian cancer, the number and percentage of severe AEs was extremely low, and [the combination] was well tolerated,” Moroney said.

Additional translational research is ongoing, but investigators concluded that further investigation is warranted.

“It is hoped that with enough thoughtful investigation, we will identify good biomarkers to find who the responders are in advance,” Moroney concluded.

Moroney JW, Yeku O, Fleming G, et al. Triple blockade of the DNAM-axis with COM701 + BMS-986207 + nivolumab demonstrates preliminary antitumor activity in patients with platinum resistant OVCA. 

Patients with heavily pretreated, platinum-resistant ovarian cancer showed promising responses with a triplet regimen consisting of COM701, BMS-986207, and nivolumab. 

Triplet Regimen of COM701, BMS-986207, and Nivolumab Shows Antitumor Activity in Platinum-Resistant Ovarian Cancer 

Kimberly A. Spickes, CNP, details the adverse events she sees with combination lenvatinib and pembrolizumab treatment for recurrent endometrial cancer.

Adverse Events Seen With Combination Lenvatinib and Pembrolizumab for Recurrent Endometrial Cancer

Kimberly Halla, NP, describes the standards for monitoring patients on therapy for recurrent endometrial cancer, including how often patients are seen in-person.

Gynecologic Cancers