The relative importance of surgical training and laboratory research in a gynecologic oncology fellowship

Impact of Sentinel Node Approach in Gynecologic Cancer on Training Needs

STUDY OBJECTIVE

We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions.

DESIGN

Retrospective multi-institution cohort (Canadian Task Force classification II-2).

SETTING

Three tertiary cancer referral cancer centers.

PATIENTS

Patients with endometrial and vulvar cancer undergoing lymph node evaluation.

INTERVENTIONS

Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment.

MEASUREMENTS AND MAIN RESULTS

Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins.

CONCLUSIONS

Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.

Evaluation of Association Between Gynecologic Oncology Fellowship Length and a Career in Academic Medicine

The purpose of this study is to determine the association between gynecologic oncology fellowship training factors, including fellowship length, and a career in academic medicine. A survey was sent to all 980 gynecologic oncologists identified via the SGO membership directory. The survey questions focused on demographics, fellowship training, practice- type, and research involvement. Demographics of the study population and survey responses were reported using frequencies and percentages. Chi-squared tests were used to test for associations between selected survey responses and length of fellowship. The authors received 410 (42 %) responses. Most respondents (60 %) graduated from a 3-year fellowship, while 27 and 13 % attended 2- and 4-year fellowships, respectively. Practice descriptions included academic/university (52 %), community/private practice (21 %), private practice with academic appointment (20 %), and other (7 %). A majority (64 %) reported current involvement in research as a principal investigator (PI); however, 54 % reported spending 10 % or less of their time in research-related activities. Approximately half reported that their fellowship research experience contributed to their current practice. Graduates of 3- and 4-year fellowships had similar rates of employment in academic/university settings (58 and 52 %, respectively). Graduates of 4-year fellowships were more likely to hold an advanced degree and 11 or more publications at completion of fellowship. A majority of graduates of a gynecologic oncology fellowship practice in an academic/university setting and are involved in research. Fellowship length does not correlate with a current academic medicine appointment. Graduates of 4-year fellowships are more likely to hold additional advanced degrees and more publications.

Determining the Role of a National Objective Assessment of Surgical Skills in Gynecological Oncology: An e-Delphi Methodology

Objective

The aim of this study is to determine a national consensus on the role of an objective assessment of technical surgical skills in gynecological oncology (GO).

Methods

After approval was obtained from Society of Gynecologic Oncology of Canada, A panel of 20 GO leaders was assembled, representing all GO fellowship programs, and was asked to participate in an anonymous group and respond to an online 49-item questionnaire using a modified Delphi methodology.

Results

Ninety-five percent (n = 19) of those invited to participate did so. Seventeen of the panelists (89.5%) believed there was no sufficiently standardized technical skills assessment for GO fellows, whereas 18 responders (95%) believed that fellows should be objectively assessed on more than 1 occasion during their training. Consensus was predefined as Cronbach α greater than 0.8. The panel agreed on what procedures should be objectively assessed with a Cronbach α of 0.967. An overall Cronbach α of 0.993 was achieved after a single Delphi round.

Conclusions

We achieved consensus on the possible components and logistics of a skills assessment process among a group of highly experienced GO trainers in Canada. This study provides the basis for further investigation and debate on the potential value, necessity, and feasibility of an assessment of advanced surgical and nonsurgical skills of GO trainees.

Surgical fellowship training in Canada: what is its current status and is improvement required?

This paper examines current issues concerning surgical fellowship training in Canada. Other than information from a few studies of fellowship training in North America, there are scant data on this subject in the literature. Little is known about the demographic characteristics of those who pursue fellowship training in Canada, what the experiences and expectations are of fellows and their supervisors with respect to the strengths and weaknesses of this level of training, or how this level of education fits in with Canadian undergraduate and postgraduate medical training. We summarize current knowledge about fellowship training in Canada as it pertains to demographic characteristics, finances, work hours, residency training, preparation for clinical and research work and satisfaction with training. Most information on surgical fellowship training comes from the United States. As such, we used information from American studies to supplement the Canadian data. Because a surgical fellowship experience in Canada may be different from that in the United States, we propose that Canadian surgical fellows and their supervisors should be surveyed to gain an understanding of such information. This knowledge could be used to improve surgical fellowship training in Canada.

Ovarian cancer debulking surgery: a survey of practice in Australia and New Zealand

INTRODUCTION

The purpose of our study was to survey all practicing gynecological oncologists in Australia and New Zealand to determine their definition of optimal debulking, their current surgical techniques used to achieve optimal debulking, and their reasons for using or not using such techniques.

METHODS

In October 2007, an email survey was distributed to all 42 practicing gynecological oncologists in Australia and New Zealand. Information obtained included practice patterns, as well as surgical expertise, techniques, and rationale with respect to primary debulking surgery for advanced epithelial ovarian cancer.

RESULTS

There was an 81% response rate. Fifty-eight percent of respondents considered optimal debulking to be residual disease less than 10 mm, 21% considered it to be less than 5 mm, and 18% considered it to be no visible disease. Sixty-five percent were able to achieve optimal debulking in their patients, as measured by their own criteria. Patient factors considered to be most frequent barriers to optimal debulking were medical comorbidities (91%) and older patient population (59%). Disease findings which most often precluded optimal debulking were disease involving the base of the mesentery (94%), confluent diaphragmatic disease (74%), and large volume, confluent peritoneal disease (50%). A variety of procedures were used by either gynecological oncologists or their colleagues, but more than 50% would never perform resection of diaphragmatic disease, resection of parenchymal liver metastases, or ablation with cavitron ultrasonic surgical aspirator or argon beam. The most common reasons for not performing ultraradical procedures were concerns regarding benefit (39%), concerns regarding morbidity (24%), and lack of personal expertise (24%).

CONCLUSIONS

Most gynecological oncologists use a variety of surgical techniques to achieve optimal debulking. However, patient factors as well as concerns regarding benefit and lack of expertise were reasons cited for not performing ultraradical surgery.

Review of subspeciality training in obstetrics and gynaecology

Subspeciality training in obstetrics and gynaecology in the United Kingdom was introduced more than 25 years ago following a report published by a working party of the Royal College of Obstetricians and Gynaecologists (RCOG) in 1982. There are now over 400 accredited subspecialists and over 150 approved subspeciality training programmes. It is timely to consider whether there are sufficient or too many subspeciality training programmes and whether some of the training resource should be directed towards delivery of advanced training skills modules (ATSMs). It is 5 years since the establishment of the Postgraduate Medical Education and Training Board (PMETB), which has responsibility for all postgraduate medical education and training, which includes the subspecialities. This has changed the way that new centres are approved and training programmes monitored and assessed. The RCOG has the expertise and experience to ensure that programmes deliver high-quality training to develop doctors for the future who will become leaders in their field. Changes to the curriculum and methods of assessment of trainees need to be integrated into the structures developed by PMETB.

Prognostic factors for complete debulking in advanced ovarian cancer and its impact on survival. An exploratory analysis of a prospectively randomized phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR)

BACKGROUND

No residual tumor as result of primary surgery in advanced ovarian cancer is known as one of the most important prognostic factors.

PURPOSE

To evaluate the impact of different prognostic factors for surgical outcome and to evaluate the impact of surgical outcome on survival.

METHODS

Surgical data as well as survival data were documented throughout the multi-center prospective randomized phase III trial (OVAR-3) of the AGO-OVAR and were used for this exploratory analysis. In this study 798 patients with FIGO IIB-IV were first operated then randomized and homogenously treated with cisplatin/paclitaxel or carboplatin/paclitaxel. Only patients with complete surgical data (n=761) entered this analysis.

RESULTS

Multivariable logistic regression analysis showed a significant decrease of probability for complete debulking without any macroscopic residual tumor for higher pre-operative tumor load (OR 0.32; 95% CI 0.17-0.61), higher FIGO stage (OR 0.22; 95% CI 0.13-0.39), worse performance status (OR 0.57; 95% CI 0.38-0.86), advanced age (OR 0.78; 95% CI 0.65-0.94) and presence of peritoneal carcinomatosis (OR 0.17; 95% CI 0.10-0.28). Surgery in centers with surgeons who performed comprehensive surgical debulking including retroperitoneal lymphadenectomy and peritoneal stripping was associated with higher rates of complete debulking compared to surgery in other centers (32.8% vs. 22.9%, p=0.007). This resulted in a markedly improved overall survival (p=0.045). This effect was held true after adjustment for prognostic factors (HR 0.77, 95% CI 0.63-0.94, p=0.012).

CONCLUSION

Post-operative residual tumor is one of the most important independent prognostic factor for survival. Our results suggest an advantage for aggressive primary surgery and complete debulking. This surgical goal was achieved more often in experienced centers.

Impact of age on outcome in patients with advanced ovarian cancer treated within a prospectively randomized phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR)

OBJECTIVE

Ovarian cancer exhibits the highest mortality rate among gynecologic cancer and survival rates vary considerably by age. Therefore, we investigated impact of age on outcome in advanced ovarian cancer.

METHODS

We performed a subgroup-analysis concerning influence of age classified according to three categories: younger patients (YP; <50 years) vs. middle-aged patients (MP; 50-65 years) vs. elderly patients (EP; >65 years). 686 patients with FIGO IIB-IV were treated within a prospectively randomized phase III study (AGO-OVAR 3) comparing cisplatin-paclitaxel vs. carboplatin-paclitaxel. This subgroup-analysis consisted of patients with homogeneous histology and complete surgical data.

RESULTS

YP had statistically more often achieved no residual tumor after primary surgery than MP and EP (P < 0.0001) resulting in improved median overall survival: 60.7, 41.3, and 33.2 months for YP, MP, and EP, respectively. The survival advantage of YP compared to EP remained significant even in completely debulked patients. Multivariable analysis revealed age being an independent prognostic factor.

CONCLUSION

Reduced surgical radicality, that means both less optimal debulking and also less radical surgery, contributes to poorer outcome in elderly patients with advanced ovarian cancer. However, age-specific surgical approaches did only partially explain age-dependent outcome. Therefore, generalization of study results to all patient age groups might be limited and further studies should focus specifically on treatment in elderly patients.