History of gynecologic oncology subspecialty

The impact of Black founding fathers on the specialty of gynecologic oncology

INTRODUCTION

The formative period of the specialty of gynecologic oncology was from 1968 to 1972 and became a board-certified specialty in 1973. During this formation there were no Black physicians participating in this process. We chronicle and document the incorporation of the first three board-certified Black physicians in the specialty of gynecologic oncology here for historical purposes.

METHODS

We highlight the hostile climate experienced by Black physicians before and during the formation of gynecologic oncology, review the acceptance and training of the first three Black physicians in the specialty and recognize their significant contributions to the field.

RESULTS

The biographies and the narrative of these men describe their impact and contribution to medicine. We chronicle the historic presence of the first board-certified Black gynecologic oncologists and pelvic surgeons in the United States.

CONCLUSION

These three men represent the Black Founding Fathers of gynecologic oncology. Their perseverance in the face of adversity and commitment to excellence have left an indelible impact on the institutions that they developed, the individuals that they trained, and the patients that they served.

Medicolegal, infrastructural, and financial aspects in gynecologic cancer surgery and their implications in decision making processes: Quo Vadis?

Surgical decision making is complex and involves a combination of analytic, intuitive, and cognitive processes. Medicolegal, infrastructural, and financial factors may influence these processes depending on the context and setting, but to what extent can they influence surgical decision making in gynecologic oncology? This scoping review evaluates existing literature related to medicolegal, infrastructural, and financial aspects of gynecologic cancer surgery and their implications in surgical decision making. Our objective was to summarize the findings and limitations of published research, identify gaps in the literature, and make recommendations for future research to inform policy.

Cross-sectional survey of surgical practices among gynecologic oncologists in the United States

OBJECTIVE

We sought to document current surgical practices among gynecologic oncologists in the United States.

METHODS

In March/April 2020, we conducted a cross-sectional survey among members of the Society of Gynecologic Oncology to identify gynecologic oncology practice trends in the United States. The survey collected demographic data and queried participants on types of surgical procedures performed and chemotherapy use. Univariant and multivariant analyses were used to evaluate the association between surgeon practice type, region of practice, working with gynecologic oncology fellows, time in practice, and dominant surgical modality of practice on performance of specific procedures.

RESULTS

Among 1199 gynecologic oncology surgeons who were emailed the survey, 724 completed the survey (60.4% response rate). Of these respondents, 170 (23.5%) were within 6 years of fellowship graduation, 368 (50.8%) identified as female; and 479 (66.2%) worked in an academic setting. Surgeons who worked with gynecologic oncology fellows were more likely to perform bowel surgery, upper abdominal surgery, complex upper abdominal surgery, and prescribe chemotherapy. Surgeons who were ≥ 13 years out from fellowship graduation were more likely to perform bowel surgery and complex abdominal surgery and less likely to prescribe chemotherapy and perform sentinel lymph node dissections (P < 0.05).

CONCLUSIONS

These findings highlight the variation in surgical procedures performed by gynecologic oncologists in the United States. These data support that there are practice variations that would benefit from further investigation.

Doubling down on the future of gynecologic oncology: The SGO future of the profession summit report

The original vision of the field of gynecologic oncology was to establish a multidisciplinary approach to the management of patients with gynecologic cancers. Fifty years later, scientific advances have markedly changed the overall practice of gynecologic oncology, but the profession continues to struggle to define its value-financial and otherwise. These issues were examined in full at the Society of Gynecologic Oncology (SGO) Future of the Profession Summit and the purpose of this document is to summarize the discussion, share the group's perceived strengths, weaknesses, opportunities, and threats (SWOT) for gynecologic oncologists, further educate members and others within the patient care team about the unique role of gynecologic oncologists, and plan future steps in the short- and long- term to preserve the subspecialty's critical mission of providing comprehensive, longitudinal care for people with gynecologic cancers.

Gynaecological Oncology in India: Past, Present and Future

Gynaecological cancers contribute to a substantial portion of the global cancer burden. Traditionally, these cancers have been treated by generalists, including gynaecologists and surgeons. However, owing to increasing sophistication and challenges in their management, a new sub-speciality of Gynaecologic Oncology, dedicated to these women's comprehensive care, has emerged in recent times. The emergence and evolution of this sub-speciality will facilitate a holistic approach to treating women suffering from gynaecological cancers, including tailored surgical techniques, fertility preservation, precision medicine, hormone modulators, targeted therapy and immunotherapy, which can be achieved within the framework of multidisciplinary management. Hence, we decided to write this synopsis to shed light on the evolution of this discipline in India and offer current and future perspectives.

Gynae-Oncology Surgeons’ Preparedness to Undertake Colorectal Procedures during Cytoreductive Surgery for Ovarian Cancer: A Cross Sectional Survey

Cytoreductive surgery for advanced ovarian cancer commonly involves bowel resection. Although UK gynaecological oncologists are trained in bowel surgery, the degree to which they perform bowel surgery independently varies nationally. A recent joint policy statement from the British Gynaecological Cancer Society (BGCS) emphasises the need for formalised colorectal support. An anonymous, online survey was emailed to BGCS members to assess the status of multidisciplinary working between UK gynaecological oncology and colorectal/general surgical teams. A total of 46 members responded (8.2% response rate). There was a large variety in the involvement of colorectal/general surgical teams in preoperative planning. A total of 13% of respondents had no formalised agreement for intraoperative support, 72.1% of respondents independently performed rectal peritoneal stripping and 60.5% independently performed small bowel resection. This was reduced to 27.9% for right hemicolectomy with primary anastomosis and 16.3% for left hemicolectomy with primary anastomosis. Respondents often involved colorectal support for post-operative complications. The majority of UK gynaecological oncologists involve colorectal/general surgical teams in bowel procedures, more commonly for large bowel procedures compared to small bowel and for left colon compared to right colon procedures. A total of 16.3% of respondents independently performed all surveyed bowel procedures. Future research should examine training and experience within these groups to address this disparity.

Gynecologic oncologist impact on adjuvant chemotherapy care for stage II-IV ovarian cancer patients

OBJECTIVE

We aim to evaluate the impact gynecologic oncologists have on ovarian cancer adjuvant chemotherapy care from their role as surgeons recommending adjuvant chemotherapy care and their role as adjuvant chemotherapy providers while considering rural-urban differences.

METHODS

Multivariable adjusted logistic regressions and Cox proportional hazards models were developed using a population-based, retrospective cohort of stage II-IV and unknown stage ovarian cancer patients diagnosed in Iowa, Kansas, and Missouri in 2010-2012 whose medical records were abstracted in 2017-2018.

RESULTS

Gynecologic oncologist surgeons (versus other type of surgeon) were associated with increased odds of adjuvant chemotherapy initiation (adjusted odds ratio (OR) 2.18; 95% confidence interval (CI) 1.10-4.33) and having a gynecologic oncologist adjuvant chemotherapy provider (OR 10.0; 95% CI 4.58-21.8). Independent of type of surgeon, rural patients were less likely to have a gynecologic oncologist chemotherapy provider (OR 0.52; 95% CI 0.30-0.91). Gynecologic oncologist adjuvant chemotherapy providers (versus other providers) were associated with decreased surgery-to-chemotherapy time (rural: 6 days; urban: 8 days) and increased distance to chemotherapy (rural: 22 miles; urban: 11 miles). Rural women (versus urban) traveled 38 miles farther when their chemotherapy provider was a gynecologic oncologist and 27 miles farther when it was not.

CONCLUSION

Gynecologic oncologist surgeons may impact adjuvant chemotherapy initiation. Gynecologic oncologists serving as adjuvant chemotherapy providers were associated with some care benefits, such as reduced time from surgery-to-chemotherapy, and some care barriers, such as travel distance. The barriers and benefits of having a gynecologic oncologist involved in adjuvant chemotherapy care, including rural-urban differences, warrant further research in other populations.

Rural disparities in surgical care from gynecologic oncologists among Midwestern ovarian cancer patients

OBJECTIVE

Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care.

METHODS

We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18-89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010-2012 in Kansas, Missouri and Iowa by rurality.

RESULTS

Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24-0.58) and referral to a specialist (OR 0.37, 95% CI 0.23-0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26-1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm.

CONCLUSION

There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.

Gynecologic Oncology in the Department of Defense

Gynecologic oncology existed within the Department of Defense (DOD) prior to its recognition as a separate subspecialty of obstetrics and gynecology. Military gynecologic oncologists were among the founders of the specialty and continue a tradition of leadership and engagement within the field at the national and international level. The full range of gynecologic oncology services is located at the military's largest medical centers, acknowledging the team approach with multiple subspecialties necessary to provide the highest standard of modern gynecologic cancer care. Gynecologic oncologists within the military receive training on par or exceeding that of their civilian counterparts, and their education extends beyond traditional training to prepare them for the unique challenges within military medicine as well. The clinical offerings from these practitioners and their facilities are state of the art, and each offers the full spectrum of care inclusive of surgery and chemotherapy. Closely coupled with expert clinical care is medical education and comprehensive cancer research. The gynecologic oncology research conducted by the DOD spans the scientific spectrum from basic laboratory investigations, to translational and molecular analyses, to all phases of clinical trials. This discussion will examine gynecologic oncology services in the DOD inclusive of infrastructure, personnel and training, clinical care and outcomes, as well as research contributions.

Identifying Gaps and Inconsistencies in Urogynecologic Surgical Training of Obstetrics and Gynecology Residents

OBJECTIVE

This study aims to determine the expectations of Obstetrics and Gynecology (ObGyn) residency and Female Pelvic Medicine & Reconstructive Surgery (FPMRS) fellowship program directors (FPDs) for the independent performance of urogynecologic procedures during residency and to compare these expectations with the Council on Resident Education in Obstetrics and Gynecology (CREOG) educational objectives.

MATERIALS AND METHODS

Two parallel, anonymous surveys were distributed simultaneously to all directors of accredited ObGyn residency and FPMRS fellowship programs in the United States. Respondents provided their own professional and program demographic information and indicated whether they expected their residents to independently perform 27 selected urogynecologic procedures.

RESULTS

Among residency program directors (RPDs) and FPDs, the online survey response rate was 24.8% (n = 59) and 51.9% (n = 27), respectively. More RPDs expected residents to perform prolapse procedures with mesh, including laparoscopic sacrocolpopexy, all apical suspensions, mesh excisions, and cystotomy repairs, than FPDs. In addition, RPDs expected mastery of most urogynecologic procedures by the Post Graduate Year 3 level, whereas most FPDs did not expect independent performance of these procedures during residency at all. There were notable differences between RPDs' expectations and CREOG objectives regarding several surgical procedures. Whereas CREOG recommends independent performance of anterior and posterior repair, vaginal suspension, vaginal hysterectomy, and transobturator slings, a significant number of RPDs did not report expecting mastery of these procedures during residency. Approximately 30% of RPDs expected residents to perform open sacrocolpopexy and vesicovaginal fistula repair, whereas CREOG recommends only the understanding of these, without procedural mastery.

CONCLUSIONS

Although community needs vary by region and setting, CREOG objectives serve as the standard for resident surgical education. This study highlights the discordance between these objectives and ObGyn RDPs' reported expectations for resident performance as well as those held by FPMRS FPDs, the outcome of which reflects a misalignment in graduate medical education between RPDs and FPDs, thus hindering a clear standard for resident surgical competencies.

Evaluation of a New Oncogynecologic Training Program

Objective

The first cohort of Turkish fellows has begun to graduate from a newly accredited training program on gynecologic oncology. This study aimed to investigate the value of experience on the confidence of these fellows to perform surgical procedures.

Methods

We assessed the characteristics of 32 fellows, including the perceived adequacy of their fellowship training, the facilities of the clinics at which they were trained, and their levels of exposure and confidence in performing a total of 44 procedures. Exposure levels were performing, assisting with, observing, or no exposure. Confidence was assessed by asking whether they could perform each procedure. Correlation analysis was used to determine the link between exposure levels and confidence.

Results

The confidence of fellows to perform a surgical procedure increased with exposure to that procedure (r = 0.820, P < 0.001). Performing, assisting with, and observing a procedure created a sense of confidence in 97.2%, 54.1%, and 31.1% of fellows. The majority of fellows (>75%) had performed type 2 hysterectomy, total omentectomy, and pelvic and para-aortic lymphadenectomy. None of the fellows had ever performed a trachelectomy.

Conclusions

Efforts should be made in accredited systems for gynecologic oncology surgical training to provide more opportunities for trainees to perform surgical procedures, rather than assisting with and observing them.

The need for more workshops in laparoscopic surgery and surgical anatomy for European gynaecological oncology trainees: a survey by the European Network of Young Gynaecological Oncologists

OBJECTIVE

The objective of this study was to highlight the relative preference of European gynecologic oncology trainees for workshops that could support and supplement their training needs.

METHODS

A Web-based survey was sent to 900 trainees on the European Network of Young Gynaecological Oncologists database in November 2011. Respondents were asked to rate a 13-item questionnaire (using a 1- to 5-point Likert scale) on workshop topics they felt would most benefit their training requirements. Free text space for additional topics was also provided. Descriptive analysis was used to describe the mean scores reported for different items. A complete linkage hierarchical cluster analysis with Dendron plot was used to assess any clustering of data, and Cronbach α was used to assess the internal reliability of the questionnaire.

RESULTS

One hundred ninety trainees from 37 countries responded to the survey, giving a 21% response rate. The 3 most important topics reported were laparoscopic surgery; surgical anatomy, and imaging techniques in gynecologic oncology. The Dendron plot indicated 4 different clusters of workshops (research related skills, supportive ancillary skills, related nonsurgical subspecialties, and core surgical skills) reflecting different competencies trainees need to meet. There was no significant association between individual country of training and workshop preference. The mean duration of the workshop preferred by 71% of respondents was 2 days. Cronbach α of the 13-item questionnaire was 0.78, which suggests good internal consistency/reliability.

CONCLUSIONS

This report for the first time highlights the relative importance and significance European trainees attach to some of their training needs in gynecologic oncology. Laparoscopic surgery, surgical anatomy, and imaging appear to be the 3 areas of greatest need. The European Society of Gynaecological Oncology, other national specialist societies, and institutions should direct additional training efforts at these areas.