Society Of Gynecologic Oncology Research Articles

Anti-cancer therapy and clinical trial considerations for gynecologic oncology patients during the COVID-19 pandemic crisis

ObjectivesThe COVID-19 pandemic has consumed considerable resources and has impacted the delivery of cancer care. Patients with cancer may have factors which place them at high risk for COVID 19 morbidity or mortality. Highly immunosuppressive chemotherapy regimens and possible exposure to COVID-19 during treatment may put patients at additional risk. The Society of Gynecologic Oncology convened an expert panel to address recommendations for best practices during this crisis to minimize risk to patients from deviations in cancer care and from COVID-19 morbidity. MethodsAn expert panel convened to develop initial consensus guidelines regarding anti-neoplastic therapy during the COVID-19 pandemic with respect to gynecologic cancer care and clinical trials. ResultsCOVID-19 poses special risks to patients who are older, have medical co-morbidities, and cancer. In addition, this pandemic will likely strain resources, making delivery of cancer care or conduct of clinical trials unpredictable. Recommendations are to limit visits and contact with health care facilities by using telemedicine when appropriate, and choosing regimens which require less frequent visits and which are less immunosuppressive. Deviations will occur in clinical trials as a result of limited resources, and it is important to understand regulatory obligations to trial sponsors as well as to the IRB to ensure that clinical trial and patient safety oversight are maintained. ConclusionsThe ongoing crisis will strain resources needed to deliver cancer care. When alterations to the delivery of care are mandated, efforts should be taken to minimize risks and maximize safety while approximating standard practice.

Clinical management of abnormal Pap tests: differences between US and Korean guidelines.

Cervical cancer has been the most common gynecological cancer in Korea but has become a preventable disease with regular screening and proper vaccination. If regular screening is provided, cervical cancer does not progress to more than carcinoma in situ, due to its comparatively long precancerous duration (years to decades). In 2012, the American Society for Colposcopy and Cervical Pathology published guidelines to aid clinicians in managing women with abnormal Papanicolaou (Pap) tests, and they soon became the standard in the United States. Not long thereafter, the Korean Society of Gynecologic Oncology and the Korean Society for Cytopathology published practical guidelines to reflect the specific situation in Korea. The detailed screening guidelines and management options in the case of abnormal Pap test results are sometimes the same and sometimes different in the United States and Korean guidelines. In this article, we summarize the differences between the United States and Korean guidelines in order to facilitate physicians’ proper management of abnormal Pap test results.

Take me to your leader: Reporting structures and equity in academic gynecologic oncology

ObjectiveGynecologic oncology includes increasing percentages of women. This study characterizes representation of faculty by gender and subspecialty in academic department leadership roles relevant to the specialty. MethodsThe American Association of Medical Colleges accredited schools of medicine were identified. Observational data was obtained through institutional websites in 2019. Results144 accredited medical schools contained a department of obstetrics and gynecology with a chair; 101 a gynecologic oncology division with a director; 98 a clinical cancer center with a director. Women were overrepresented in academic faculty roles compared to the US workforce (66 vs 57%, p < 0.01) but underrepresented in all leadership roles (p < 0.01). Departments with women chairs were more likely to have >50% women faculty (90.2 vs 9.8%, p < 0.01); and have larger faculties (80.4 vs 19.6% >20 faculty, p = 0.02). The cancer center director gender did not correlate to departmental characteristics. A surgically focused chair was also associated with >50% women faculty (85.7 vs 68.3%, p = 0.03); faculty size >20 (85.7 vs 61.4%, p < 0.01); and a woman gynecologic oncology division director (57.6 vs 29.4%, p < 0.01; 68.4 vs 31.7%, p < 0.01) and gynecologic oncology fellowship (50 vs 30.4%, p < 0.01; 59.1 vs 32%, p < 0.01). Gynecologic oncology leadership within cancer centers was below expected when incidence and mortality to leadership ratios were examined (p < 0.01, p < 0.01). ConclusionWithin academic medical schools, women remain under-represented in obstetrics and gynecology departmental and cancer center leadership. Potential benefits to gynecologic oncology divisions of inclusion women and surgically focused leadership were identified.

Diagnosis and Management of Adenocarcinoma in Situ: A Society of Gynecologic Oncology Evidence-Based Review and Recommendations.

This publication represents an extensive literature review with the goal of providing guidelines for the evaluation and management of cervical adenocarcinoma in situ (AIS). The authors drafted the guidelines on behalf of the Society of Gynecologic Oncology, and the guidelines have been reviewed and endorsed by the ASCCP. These guidelines harmonize with the ASCCP Risk-Based Management Consensus Guidelines and provide more specific guidance beyond that provided by the ASCCP guidelines. Examples of updates include recommendations to optimize the diagnostic excisional specimen, AIS management in the setting of positive compared with negative margins on the excisional specimen, surveillance and definitive management after fertility-sparing treatment, and management of AIS in pregnancy. The increasing incidence of AIS, its association with human papillomavirus-18 infection, challenges in diagnosis owing to frequent origin within the endocervical canal, and the possibility of skip lesions all make AIS a unique diagnosis whose management needs to be differentiated from the management of the more prevalent squamous cell dysplasia.

18: Adherence to recommended practices when performing a risk-reducing bilateral salpingo-oophorectomy

To determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy (RRBSO) as described by the American College of Obstetricians and Gynecologists and Society of Gynecologic Oncology. We sought to determine if adherence differed by type of training i.e., gynecologic oncologists versus benign gynecologists. Additionally, we aimed to determine the incidence of ovarian cancer diagnosed at the time of RRBSO in a large cohort of patients with a BRCA mutation. This descriptive, retrospective analysis was performed in an academic medical center. We examined the charts of 269 patients with a known BRCA mutation who underwent prophylactic RRBSO between July 2007 and September 2018. Surgery was performed either by a gynecologic oncologist or a benign gynecologist. Comparisons between groups were performed in the statistical analysis. Among 269 patients who underwent RRBSO, 220 were performed by gynecologic oncologists and 49 were performed by benign gynecologists. Washings were not performed in 5% of cases performed by gynecologic oncologists, and 37% of cases performed by benign gynecologists (p < 0.0001). Complete serial sectioning of the adnexa was not performed in 12% of cases performed by oncologists, and 13% of cases performed by benign gynecologists (p = 0.714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at time of surgery and met criteria for conversion to a staging procedure. Fifty-five percent of all patients also underwent concomitant hysterectomy. The incidence of ovarian cancer diagnosis at the time of RRBSO is low, and often not diagnosed at the time of surgery due to presence of only microscopic disease. For this reason, it may not be necessary for gynecologic oncologists to exclusively perform RRBSO procedures. However, this study also reveals that when this procedure is being performed by benign gynecologic surgeons, the recommended practices (washings and serial frozen section) are not routinely being followed. If benign gynecologic surgeons are to begin to routinely perform RRBSO, it is imperative to promote better adherence to these practices.

Vaginal Surgery Exposure in Gynecologic Oncology Fellowship

Vaginal Surgery Exposure in Gynecologic Oncology Fellowship

High-risk human papillomavirus testing as a primary screening for cervical cancer: position statement by the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology.

Based on emerging data and current knowledge regarding high-risk human papillomavirus (hrHPV) testing as a primary screening for cervical cancer, the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology support the following scientific facts:• Compared to cytology, hrHPV screening has higher sensitivity and detects more cases of high-grade cervical intraepithelial neoplasia.• Qualified hrHPV testing can be considered as an alternative primary screening for cervical cancer to the current cytology method.• The starting age of primary hrHPV screening should not be before 25 years because of possible overtreatment in this age, which has a high human papillomavirus (HPV) prevalence but rarely progresses to cancer. The screening interval should be no sooner than every 3 years and no longer than every 5 years.• Before the introduction of hrHPV screening in Korea, research into comparative effectiveness of primary hrHPV screening for cervical cancer should be conducted to determine the appropriate HPV assay, starting age, and screening interval.

Rapid dissemination of practice-changing information: A longitudinal analysis of real-world rates of minimally invasive radical hysterectomy before and after presentation of the LACC trial

ObjectiveCharacterize change in rates of minimally invasive (MIS) radical hysterectomy after presentation of the LACC trial. MethodsLongitudinal analysis of data from Vizient® database for surgically treated patients with invasive cervical cancer from April 2017–March 2019. Covariates studied included patient demographic and obesity categories, dates of LACC trial presentation and publication, and hospital characteristics. Results2102 cervical cancer patients had surgery at 201 hospitals. Most were age 31–50 (51.2%), White (64.8%), and had public (49.2%) health insurance. Annual rates of MIS fell from 51.9% to 27.1% after the LACC trial presentation (RR 0.52, 95% CI 0.47, 0.58; p < 0.0001). Adjusting for within hospital correlation, the odds of MIS dropped by 13% per month (OR = 0.872 per month, 95% CI 0.852, 0.891; p < 0.001), without further change in rates of MIS after the peer-review publication (OR = 1.033 per month, 95% CI 0.897, 1.189; p = 0.65). Rates of MIS declined across all demographics (RR = 0.32–0.65; p < 0.01), except in morbidly obese women (RR = 0.90; p = 0.60). Applying mixed effects model, rates of MIS fell by 3% per month in morbidly obese women versus 18% per month if body mass index<40 kg/m2. NCCN member hospitals and hospitals with gynecologic oncology fellowship training programs significantly reduced rates of MIS radical hysterectomy faster, but not earlier, than other hospitals. ConclusionsRates of MIS radical hysterectomy fell dramatically and pervasively after the LACC trial presentation, despite ongoing substantive controversy. Practice pattern changes were not significant in morbidly obese women.

Hormone therapy (HT) in women with gynecologic cancers and in women at high risk for developing a gynecologic cancer: A Society of Gynecologic Oncology (SGO) clinical practice statement: This practice statement has been endorsed by The North American Menopause Society

•Treatment or prevention of gynecologic cancer often results in induced menopause significantly impacting quality of life. •Hormone therapy is underutilized in in these settings despite more severe symptoms with induced menopause. •The risk/benefit profile of HT is favorable in most EOC, early stage endometrial, and cervical cancer. •HT is not recommended in women with advanced EC, uterine sarcoma, endometrioid or low grade serous ovarian cancer. •Lynch syndrome patients and BRCA mutation carriers without history of breast cancer may also use HT to improve QOL.

Use of cannabinoids in cancer patients: A Society of Gynecologic Oncology (SGO) clinical practice statement

•Tetrahydrocannabinol (THC), cannabidiol (CBD) and cannabinol (CBN) affect the human endocannabinoid system. •Cannabinoids reduce chemotherapy induced nausea or vomiting (CINV) and neuropathic pain. •Each state has its own regulations for medical and recreational cannabis use. •Effects of cannabinoids on chemotherapy, immunotherapy, and tumor growth remain under investigation. •Providers should focus indications, alternatives, risks and benefits of medical cannabis use to make appropriate referrals.

Risk-reducing Bilateral Salpingo-oophorectomy: Assessing the Incidence of Occult Ovarian Cancer and Surgeon Adherence to Recommended Practices

This study aimed to determine the incidence of ovarian cancer diagnosed at the time of risk-reducing bilateral salpingo-oophorectomy in a large cohort of patients with a BRCA mutation. In addition, we aimed to determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy as described by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology. We sought to determine if adherence differed by the type of training (i.e., gynecologic oncologists vs benign gynecologists). Descriptive, retrospective analysis. Academic medical center. Two hundred sixty-nine patients with a known BRCA mutation. Prophylactic risk-reducing bilateral salpingo-oophorectomy performed either by a gynecologic oncologist or a benign gynecologist between July 2007 and September 2018. Among 269 patients who underwent risk-reducing bilateral salpingo-oophorectomies, 220 procedures were performed by gynecologic oncologists, and 49 were performed by benign gynecologists. Washings were not performed in 5% of the procedures performed by gynecologic oncologists and 37% of the procedures performed by benign gynecologists (p <.001). Complete serial sectioning of the adnexa was not performed in 12% of the procedures performed by oncologists, and 13% of the procedures performed by benign gynecologists (p = .714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at the time of surgery and met the criteria for conversion to a staging procedure. Because the incidence of ovarian cancer diagnosis at the time of risk-reducing bilateral salpingo-oophorectomy is low and is often not diagnosed at the time of surgery owing to the presence of only microscopic disease, it may not be necessary for gynecologic oncologists to exclusively perform these procedures. However, this study also revealed that when this procedure is performed by benign gynecologic surgeons, some of the recommended practices are not routinely followed. If general gynecologic surgeons are to routinely perform risk-reducing bilateral salpingo-oophorectomies, it is important to promote better adherence to these practices.

High-risk human papillomavirus testing as a primary screening for cervical cancer: position statement by the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology.

Based on emerging data and current knowledge regarding high-risk human papillomavirus (hrHPV) testing as a primary screening for cervical cancer, the Korean Society of Obstetrics and Gynecology and the Korean Society of Gynecologic Oncology support the following scientific facts:• Compared to cytology, hrHPV screening has higher sensitivity and detects more cases of high-grade cervical intraepithelial neoplasia.• Qualified hrHPV testing can be considered as an alternative primary screening for cervical cancer to the current cytology method.• The starting age of primary hrHPV screening should not be before 25 years because of possible overtreatment in this age, which has a high human papillomavirus (HPV) prevalence but rarely progresses to cancer. The screening interval should be no sooner than every 3 years and no longer than every 5 years.• Before the introduction of hrHPV screening in Korea, research into comparative effectiveness of primary hrHPV screening for cervical cancer should be conducted to determine the appropriate HPV assay, starting age, and screening interval.

The 6th Biennial Meeting of the Asian Society of Gynecologic Oncology, October 10th to 12th, 2019.

The 6th Biennial Meeting of the Asian Society of Gynecologic Oncology, October 10th to 12th, 2019.

Japan Society of Gynecologic Oncology 2018 guidelines for treatment of uterine body neoplasms.

The Fourth Edition of the Guidelines for Treatment of Uterine Body Neoplasm was published in 2018. These guidelines include 9 chapters: 1. Overview of the guidelines, 2. Initial treatment for endometrial cancer, 3. Postoperative adjuvant therapy for endometrial cancer, 4. Post-treatment surveillance for endometrial cancer, 5. Treatment for advanced or recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment of uterine carcinosarcoma and uterine sarcoma, 8. Treatment of trophoblastic disease, 9. Document collection; and nine algorithms: 1-3. Initial treatment of endometrial cancer, 4. Postoperative adjuvant treatment for endometrial cancer, 5. Treatment of recurrent endometrial cancer, 6. Fertility-sparing therapy, 7. Treatment for uterine carcinosarcoma, 8. Treatment for uterine sarcoma, 9. Treatment for choriocarcinoma. Each chapter includes overviews and clinical questions, and recommendations, objectives, explanation, and references are provided for each clinical question. This revision has no major changes compared to the 3rd edition, but does have some differences: 1) an explanation of the recommendation decision process and conflict of interest considerations have been added in the overview, 2) nurses, pharmacists and patients participated in creation of the guidelines, in addition to physicians, 3) the approach to evidence collection is listed at the end of the guidelines, and 4) for clinical questions that lack evidence or clinical validation, the opinion of the Guidelines Committee is given as a “Recommendations for tomorrow”.

Experience with opportunistic salpingectomy during vaginal hysterectomy for uterine prolapsus

Objective: The aim of this study was to evaluate the trend in uptake of salpingectomy at the time of vaginal hysterectomy after the Clinical Practice Statement of Society for Gynecologic Oncology and to assess the risk of operative/postoperative complications associated with salpingectomy during vaginal hysterectomy.&#x0D; Material and Methods: Patients who underwent vaginal hysterectomy or vaginal hysterectomy with salpingectomy for uterine prolapsus between January 2010 and January 2018 were analysed. We divided the patients into two groups to see the change in the rate of opportunistic salpingectomy after a systemwide practice recommendation was issued. Group 1 consist of patients who were operated between 2010-2014, before recommendation of the Society of Gynecologic Oncology that favour salpingectomy and Group 2 consist of patients operated after that.&#x0D; Results: From January 2010 to January 2018, a total of 1224 vaginal hysterectomies were performed. A total of 808 patients under 60 years old were included in the study. There was no difference in operating time, the median estimated blood loss, intraoperative complication and postoperative complication by the performance of salpingectomy (P&gt;0.05). When we examine the changes in the rate of salpingectomy year by year, from 2014, the salpingectomy rates increased, being 4 % in 2013, 7 % in 2015, and 8 % in 2017 onward.&#x0D; Conclusion: We report an increase in the rate of salpingectomy during vaginal hysterectomies from 3 % to 7.2 % after the recommendation of the Society of Gynecologic Oncology that favour salpingectomy but this increase is not as great as the increase during laparoscopic or abdominal hysterectomies.

Improving Value-Based Care Education in a Fellowship by Incorporating ACGME Competencies.

Most value-based care educational interventions teach knowledge of cost but fail to recognize the interrelatedness of the Accreditation Council for Graduate Medical Education (ACGME) competencies of medical knowledge, patient care, practice-based learning and improvement, and systems-based practice. We analyzed the impact on clinical decision-making of an educational curriculum that incorporated the spectrum of ACGME competencies. Five didactic sessions for a gynecologic oncology fellowship were modified to incorporate cost- and value-based care considerations for each clinical topic addressed. After discussion, the group of fellows identified 1 high-value and 5 low-value practices to target for improvement. The fellows then undertook a chart audit of clinical decisions occurring for patients seen in the outpatient clinics. The frequency of low- and high-value practices was compared before and after the educational intervention. A total of 126 patients with a cervical cancer diagnosis were seen by participants in the outpatient setting during the entire observation period. After the intervention, the occurrence of 3 identified low-value practices was reduced by 13% to 33%, demonstrating modest effect sizes (effect size ϕ = 0.2-0.3). One high-value practice (smoking cessation counseling) increased 100% after a fellow-initiated quality improvement project was undertaken. Two low-value practices, including routine surveillance imaging, remained unchanged. Overlaying value-based concepts in didactic conference teaching resulted in measurable changes in decision-making behavior. Engaging learners in a subsequent, focused quality practice review served as a vital part of their educational experience and allowed us to assess learner competency in its practical application.

Guideline No. 390-Classification and Management of Endometrial Hyperplasia.

The aim of this guideline is to aid primary care physicians and gynaecologists in the initial evaluation of women with suspected endometrial hyperplasia, to recommend the use of the 2014 World Health Organization classification for endometrial hyperplasia by all health care providers, and to guide the optimal treatment of women diagnosed with endometrial hyperplasia. Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. Adult women (18 years and older) presenting with suspected or confirmed endometrial hyperplasia. The discussion relates to the medical therapy as well as surgical treatment options for women with and without atypical endometrial hyperplasia. For this guideline, relevant studies were searched in PubMed, Cochrane Wiley, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials, human subjects, and published since 2000: (endometrial hyperplasia, endometrial intraepithelial neoplasia, endometrial sampling, endometrial curettage, diagnosis) AND (treatment, progestin therapy, surgery, LNG-IUS, aromatase inhibitors, metformin ), AND (obesity). The search was performed in April 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2152, and 82 studies were included in this review. The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. The interpretation of strong and weak recommendations was also included. The Summary of Findings is available upon request. It is expected that this guideline will benefit women with endometrial hyperplasia. This should guide patient informed consent before both medical and surgical management of this condition. Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. RECOMMENDATIONS.

Adoption of enhanced recovery after laparotomy in gynecologic oncology

IntroductionEnhanced recovery after surgery (ERAS) pathways combine a comprehensive set of peri-operative practices that have been demonstrated to hasten patient post-operative recovery. We aimed to evaluate the adoption of ERAS...

Factors influencing residents’ interest in gynecologic oncology fellowship

ObjectivesTo identify the role of mentorship and other factors associated with obstetrics and gynecology (OB/GYN) resident interest in pursuing a fellowship in gynecologic oncology. MethodsA survey link was emailed to U.S. OB/GYN residency program coordinators to disperse to current residents. The 80-item survey asked about plans to pursue fellowship and influencing factors. Participants were stratified based on decision to pursue a fellowship in gynecologic oncology. Student’s t-test and Mann-Whitney tests were applied. ResultsAmong 236 surveyed residents, 32 (13.6%) were planning to pursue a fellowship in gynecologic oncology. There were no demographic differences favoring the choice of gynecologic oncology; however, trainees at academic programs were more likely to aspire to the subspecialty (p = 0.01). Residents interested in gynecologic oncology had marginally more mentors than others (p = 0.06), were more likely to have a gynecologic oncology mentor (p < 0.01), and were more likely to have cited mentorship as a reason for their career aspirations (p = 0.01). These residents were also less likely to report obvious burnout among faculty and fellows in their department (p < 0.01 and p = 0.01, respectively). ConclusionsStrong mentor relationships and the display of job satisfaction and work-life balance influence OB/GYN residents’ interest in gynecologic oncology fellowships. Programs should consider formal mentorship programs for residents, with priority on matching by subspecialty. The value of fellow and faculty efforts in mentorship should be recognized, and appropriate time should be protected for these relationships, along with efforts to support fellows and faculty at risk for burnout.

Survey of US gynecologic oncologists finds that approximately 64% have experienced sexual harassment.

A survey conducted among the physician members of the Society of Gynecologic Oncology found that approximately 64% of respondents experienced some form of sexual harassment during training or practice. The numbers were higher among women (71%) compared with men (51%). The abstract, presented at the 2019 American Society of Clinical Oncology meeting, held May 31 to June 4, 2019, in Chicago, also found that only 17% of women and 10% of men reported the incidents to officials and that female practitioners were more likely than their male counterparts to say that gender affected their career advancement (34% vs 10%) and salary prospects (42% vs 6%). According to lead author Marina Stasenko, MD, of Memorial Sloan Kettering Cancer Center in New York City, the research is aimed at increasing awareness of sexual harassment and gender inequalities among female physicians, whose numbers are increasing in medicine. The anonymous survey, which was conducted in 2018, was modeled in part on a similar survey that the Association of American Medical Colleges has conducted since 2012. It was sent to all 1566 US-based physician members of the Society of Gynecologic Oncology. In total, there were 402 respondents, including 255 women and 147 men. The survey measured a range of types of sexual harassment, such as being subjected to sexist remarks (58% of women in training and 51% of women in practice said they had experienced this compared with 28% of men in training and 24% of men in practice), being denied opportunities for training (26% of women in training and 33% of women in practice reported this vs 17% of men in training and 19% of men in practice), unwanted sexual advances (30% of women in training and 23% of women in practice and 27% of men in training and 28% of men in practice experienced this), and being asked to exchange sexual favors for academic positions (4% of women and 2% of men in both training and practice reported this). Some respondents also said they had received lower evaluations or academic positions as a result of harassment (31% in women and 14% in men). Among the reasons participants gave for not reporting the incidents were believing they were not important enough (40%), assuming that nothing would be done about it (37%), or being afraid of retaliation (34%). Dr. Stasenko said she hopes the survey will lead to more discussions regarding sexual harassment in medicine, as well as interventions to improve the situation.