Gynecologic Oncology Fellowship Training Research Articles

Perspectives of gynecologic oncology fellowship training and preparedness for practice

We aimed to examine the preparedness of recent gynecologic oncology fellowship graduates for independent practice.We conducted a web-based survey study using REDCap targeting Society of Gynecologic Oncology (SGO) members who graduated gynecologic oncology fellowship within the last six years. The survey included 52 items assessing fellowship training experiences, level of comfort in performing core gynecologic oncology surgical procedures and administering cancer-directed therapies. Questions also addressed factors driving participants’ selection of fellowship programs, educational experience, research and preparedness for independent practice. A total of 296 participants were invited to complete the survey. Response rate was 42% with n = 124 completed surveys included for analysis. The highest ranked factor for fellowship selection was fit with program 36% (n = 45). Upon completing fellowship, most were uncomfortable performing ureteral conduit formation 84% (n = 103), ureteroneocystostomy 77% (n = 94), exenteration 68% (n = 83), splenectomy 67% (n = 83) and lower anterior resection 41% (n = 51). Most were comfortable managing intraoperative complications 85% (n = 104) and standard cancer staging procedures (range: 61%–99%). Majority were comfortable providing cancer directed therapies with chemotherapy 99% (n = 123), immunotherapy 84% (n = 104), and poly ADP-ribose polymerase (PARP) inhibitors 97% (n = 120). Upon completing fellowship, 77% (n = 95) report having mentorship that met their expectations during fellowship and 94% (n = 116) felt they were ready for independent practice. Majority of fellowship graduates were prepared for independent practice and felt comfortable performing routine surgical procedures and cancer directed treatment. However, most are not comfortable with ultra-radical gynecologic oncology procedures. Maximizing surgical opportunities during fellowship training and acquiring early career mentorship may help.

Innovation in gynecologic oncology fellowship training: Rethinking the research year (1207)

Innovation in gynecologic oncology fellowship training: Rethinking the research year (1207)

Current perspectives of gynecologic oncology fellowship training and preparedness for practice

<h3>Objectives:</h3> The field of gynecologic oncology practice has evolved over decades, yet there is little known on how current fellowships are preparing gynecologic oncologists for practice in the era of these changes. Thus, we sought to investigate gynecologic oncology fellowship graduates' training experience and preparedness for practice following fellowship. <h3>Methods:</h3> This is a cross-sectional web-based survey study using REDCap, an electronic web-based application. We surveyed members of the Society of Gynecologic Oncology (SGO) who graduated from gynecologic oncology fellowship in 2015-2020. Email invitations to participate were sent with de-identified survey links. The survey included 51 questions assessing fellowship training experiences and level of comfort in performing core gynecologic oncology surgical procedures and administering cancer-directed therapies, including chemotherapy, immunotherapy, and PARP inhibitors. Additional questions addressed factors driving participants' selection of fellowship programs, education experience, research and preparedness for independent practice. Descriptive statistics were used for analyses. <h3>Results:</h3> A total of 297 SGO members were invited to participate, one was excluded due to a non-working email. The response rate was 43.9% (n=130) and n=123 completed surveys were included for final analysis. Over half (55.2% n=68) of responders were in their first 3 years of independent practice. The highest ranked factor for fellowship selection was fit with program (36.6% n=45) followed by surgical volume (29.3% n=36). Upon completing fellowship, most were uncomfortable performing radical surgeries in ureteral conduit formation (83.8% n=103), ureteroneocystostomy (76.4% n=94), exenteration (67.5%, n=83), splenectomy (66.7% n=83) and lower anterior bowel resection (41.5%, n=51). Most were comfortable managing intraoperative complications (84.5% n=104) and obstetrical hemorrhages (88.6% n=109), as well as standard open and minimally invasive staging (range: 61%-99.2%). More than half of those who did not have off-service surgical rotations in fellowship indicated they would have wanted rotations in surgical oncology (58% n=58), urology (57% n=59) and colorectal surgery (71.5% n=73) in fellowship training. Majority of respondents (91.1% n=112) used cancer-directed therapies in their current practice and were most uncomfortable managing immunotherapy side effects (30.1% n=37). Over a third (34.1% n=42) were somewhat or not confident that their fellowship thesis project will be suitable for oral boards defense and 22.8% (n=28) were unprepared to continue research in their career. Upon completing fellowship, 77.2% (n=95) report having mentorship that met their expectations during fellowship and 94.4% (n=116) overall were prepared for independent practice as gynecologic oncologists. <h3>Conclusions:</h3> Majority of recent gynecologic oncology fellowship graduates were prepared for independent practice and felt comfortable performing routine surgical procedures. However, most are not comfortable with radical gynecologic oncology surgeries; for this reason mentorship in early gynecologic oncology faculty development remains important. Many graduates also desired incorporating non-gynecologic oncology surgery service experience during fellowship, which could help supplement this discrepancy for less common procedures.

Underrepresented minority representation trends in gynecologic oncology fellowships in the United States

ObjectiveTo evaluate representation trends of historically underrepresented minority (URM) groups in gynecologic oncology fellowships in the United States using a nationwide database collected by the Accreditation Council for Graduate Medical Education (ACGME). MethodsData on self-reported ethnicity/race of filled residency positions was collected from ACGME Database Books across three academic years from 2016 to 2019. Primary chi-square analysis compared URM representation in gynecologic oncology to obstetrics and gynecology, other surgical specialties, and other medical specialties. Secondary analysis examined representation of two URM subgroups: 1) Asian/Pacific Islander, and 2) Hispanic, Black, Native American, Other (HBNO), across specialty groups. ResultsA total of 528 gynecologic oncology positions, 12,559 obstetrics and gynecology positions, 52,733 other surgical positions, and 240,690 other medical positions from ACGME accredited medical specialties were included in analysis. Primary comparative analysis showed a statistically significant lower proportion (P < 0.05) of URM trainees in gynecologic oncology in comparison to each of obstetrics and gynecology, other surgical fields, and other medical fields. Secondary analysis also demonstrated a significantly lower proportion (P < 0.05) of HBNO physicians in gynecologic oncology in comparison to obstetrics and gynecology, as well as all other medical and surgical specialties. ConclusionsThis study illustrates the disparities in URM representation, especially those who identify as HBNO, in gynecologic oncology fellowship training in comparison to obstetrics and gynecology as well as other medical and surgical fields. Improvements to the current recruitment and selection practices in gynecologic oncology fellowships in the United States are necessary in order to ensure a diverse and representative workforce.

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.

Twenty-year surgical trends in a gynecologic oncology fellowship training program: Implications for practice

ObjectiveTo assess whether there were any significant changes in surgical training volume over the past 20 years that might have ramifications toward preparedness for practice. MethodsWe used deidentified annual summaries of fellow case numbers for the academic years 1999 through 2018. Unpaired t-tests with Welch's correction were performed on all surgical categories for 10-year and 5-year periods. ResultsThe total number of hysterectomies performed each year did not change significantly. The percent of hysterectomies performed by minimally invasive surgery increased significantly starting in 2008. There was a significant decline in the number of radical hysterectomies conducted starting after 2004, which then remained stable. There was also a significant decline in the number of bowel resections/anastomoses performed by fellows on the gynecologic oncology services that occurred and stabilized during the same time frame. There were other significant trends associated with the introduction of minimally invasive techniques. ConclusionThe results of this study suggest the need to reevaluate fellowship training and/or the scope of surgical practice in gynecologic oncology.

Vulvar cancer and HIV at a teaching hospital in Ethiopia

Objective: In 2017, there was an estimated 350,000 women living with human immunodeficiency virus (HIV) in Ethiopia. Primary cancers including vulvar cancer are increased among HIV women, which is associated with the numbers of years of HIV infection and compliance with antiretroviral therapy (ART). In 2013, the Addis Ababa city cancer registry reported a vulvar cancer incidence of 1.4 per 100,000 women. In 2016, a gynecologic oncology clinical service was initiated with the start of the gynecologic oncology fellowship training program in Addis Abba at St. Paul’s Hospital Millennium Medical College (SPHMMC). Surgical and chemotherapy can be delivered at SPHMMC, but lack of radiation therapy, an average delay greater than 6 months, limits access to definitive radiation treatment for women with vulvar cancer. The aim of this study is to report early data on the trend of vulvar cancer.

Palliative Care Education in Gynecologic Oncology: a Survey of Gynecologic Oncologists and Gynecologic Oncology Fellows in Thailand.

The main purpose of this study was to survey the education and training of certified gynecologic oncologists and fellows in Thailand. A secondary objective was to study the problems in fellowship training regarding palliative care for gynecologic cancer patients. A descriptive study was conducted by sending a questionnaire regarding palliative care education to all certified gynecologic oncologists and gynecologic oncology fellows in Thailand. The contents of the survey included fellowship training experience, caring for the dying, patient preparation, attitudes and respondent characteristics. Statistics were analyzed by percentage, mean and standard deviation and chi-square. One hundred seventy completed questionnaires were returned; the response rate was 66%. Most certified gynecologic oncologists and fellows in gynecologic oncology have a positive attitude towards palliative care education, and agree that "psychological distress can result in severe physical suffering". It was found that the curriculum of gynecologic oncology fellowship training equally emphasizes three aspects, namely managing post-operative complications, managing a patient at the end of life and managing a patient with gynecologic oncology. As for experiential training during the fellowship of gynecologic oncology, education regarding breaking bad news, discussion about goals of care and procedures for symptoms control were mostly on-the-job training without explicit teaching. In addition, only 42.9% of respondents were explicitly taught the coping skill for managing their own stress when caring for palliative patients during fellowship training. Most of respondents rated their clinical competency for palliative care in the "moderately well prepared" level, and the lowest score of the competency was the issue of spiritual care. Almost all certified gynecologic oncologists and fellows in gynecologic oncology have a positive attitude towards learning and teaching in palliative care. In this study, some issues were identified for improving palliative care education such as proper training under the supervision of a mentor, teaching how to deal with work stress, competency in spiritual care and attitudes on responsibility for bereavement care.

Make New Friends But Keep the Old: Minimally Invasive Surgery Training in Gynecologic Oncology Fellowship Programs.

To evaluate the role of minimally invasive surgery (MIS) in gynecologic oncology fellowship training and fellows' predictions of their use of MIS in their future practice. All fellows-in-training in American Board of Obstetrics and Gynecology-approved training programs were surveyed in 2012 through an online or mailed-paper survey. Data were analyzed and compared to results of a similar 2007 survey. Of 172 fellows, 69 (40%) responded. Ninety-nine percent of respondents (n = 68) indicated that MIS was either very important or important in gynecologic oncology, a proportion essentially unchanged from 2007 (100%). Compared to 2007, greater proportions of fellows considered laparoscopic radical hysterectomy and node dissection for cervical cancer (87% vs 54%; P < 0.0001) and trachelectomy and staging for cervical cancer (83% vs 32%; P < 0.0001) appropriate for MIS. Of the respondents, 92% believed that maximum or some emphasis should be placed on robotic-assisted surgery and 89% on traditional laparoscopy during fellowship training. Ten percent rated their fellowship training in laparoendoscopic single-site surgery as very poor; 44% said that the question was not applicable. Most respondents (60%) in 2012 performed at least 11 procedures per month, whereas most respondents (45%) in 2007 performed 6 to 10 procedures per month (P = 0.005). All respondents at institutions where robotic surgery was used were allowed to operate at the robotic console, and 63% of respondents reported that in robotic-assisted surgery cases when a fellow sat at the robot, the fellow performed more than 50% of the case at the console. These findings indicate that MIS in gynecologic oncology is here to stay. Fellowship programs should develop a systematic approach to training in MIS and in individual MIS platforms as they become more prevalent. Fellowship programs should also develop and apply an objective assessment of minimum proficiency in MIS to ensure that programs are adequately preparing trainees.

Gynecologic Oncologist as surgical consultant: Intraoperative consultations during general gynecologic surgery as an important focus of gynecologic oncology training

ObjectiveThe aim of this study is to explore the previously unexamined role of the Gynecologic Oncologist as an intraoperative consultant during general gynecologic surgery. MethodsDemographic and clinical data were collected on 98 major gynecologic surgeries that included both a general Gynecologist and a Gynecologic Oncologist between October 2010 and August 2014. Data were analyzed using XLSTAT-Prov2014.2.02. ResultsOf 794 major gynecologic surgeries, 98 (12.3%) cases that involved an intraoperative consultation were identified. There were 36 (37%) planned consults and 62 (63%) unplanned consults. Significantly more planned consults were during laparoscopy (100% v 58%; p<0.01) and significantly more unplanned consults were during laparotomy (42% v 0%; p<0.01). The majority of planned consults were for surgical training (86%) and the most common reasons for unplanned consults were adhesions (40%), bowel injury (19%), inability to identify ureter (19%), and cancer (11%). The most common interventions performed during unplanned consults were identification of anatomy (55%), lysis of adhesions (42%), and retroperitoneal dissection (27%). Average surgeon years in practice were significantly lower for unplanned consults (9 v 15; p<0.01). A total of 25 major adverse events occurred in 15 cases with the majority occurring in cases with unplanned consults (23% v 3%; p<0.01). After controlling for laparotomy, unplanned consultation was not significantly associated with major events (OR=6.67, 95%CI 0.69–64.39; p=0.10). ConclusionsGynecologic Oncologists play a pivotal role in the support of generalist colleagues during pelvic surgery. In this series, Gynecologic Oncologists were consulted frequently for complex major benign surgeries. It is important to incorporate the skills required of an intraoperative consultant into Gynecologic Oncology fellowship training.

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

BackgroundThe increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons. MethodsA prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared. ResultsTimes were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p<0.001), BSO 7% to 75% (p=0.005), right PLND 4% to 44% (p<0.001), left PLND 0% to 56% (p<0.001), and VCC 59% to 82% (p=0.024). Console times (min) were similar for SH (60 vs. 63, p=0.73), BSO (48 vs. 43, p=0.55), and VCC (20 vs. 22, p=0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p=0.04, left 23 vs. 27, p=0.02). Nodal counts were not significantly different (right 7 vs. 8, p=0.17 or left 7 vs. 7, p=0.87). ConclusionsRobotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

Robotic surgery in gynecologic oncology fellowship programs in the USA: a survey of fellows and fellowship directors

In order to understand how robotic surgery impacts gynecologic oncology fellowship training and surgical practices, a survey of fellows and fellowship directors was conducted. Questionnaires designed to determine the prevalence, application, and acceptance of robotics were sent to fellows and fellowship directors in approved U.S. programs. Of the respondents, 95% have a robot at their institution and 95% utilize it. Most responding fellowship directors (70%) reported that fellow education is enhanced by robotic surgery. Most fellows (65%) who responded feel comfortable using the robot, and 94% plan on performing robotic surgery upon completion of fellowship training. This survey demonstrates that robotic surgery is utilized in the majority of responding gynecologic oncology fellowship programs for a wide array of indications. Fellowship directors and fellows-in-training generally have a favorable view of this evolving technology. Based on these responses, robotic surgery will play an increasingly important role in the future.

Surgical education and training program development for gynecologic oncology: American perspective

The purpose of this paper is to provide information about gynecologic oncology fellowship training and guidance in program development. The characteristics necessary for a physician to develop into a successful gynecologic oncologist include an extensive fund of knowledge related to the subspecialty, strong interpersonal skills, the ability to practice within the complex systems required for management of gynecologic cancer patients, surgical expertise, and the clinical ability to provide comprehensive oncologic care for these women. In order for a trainee to acquire these skills, a gynecologic oncology training program must accept only highly qualified individuals as fellows, have a dedicated core faculty, practice in a supportive environment that has appropriate facilities, and provide adequate clinical material. The gynecologic oncology training program must be organized with an emphasis on education of the fellows. Part of the educational program is formal (lectures, assigned reading, basic skill sets, etc.). Training in clinical and surgical skills is a day-to-day process that occurs during the course of patient care. One requirement of The American Board of Obstetrics and Gynecology (ABOG) is that the fellow spends 12 months of protected time doing research. Fellows are also required to take 2 courses, one in biostatistics and one in cancer biology. A thesis of publishable quality is also required. All programs must perform ongoing quality assurance and reassessment of potential areas for improvement. ABOG is responsible for the accreditation and ongoing monitoring of the fellowship programs.

Effect of robotic surgery on a Gynecologic Oncology Fellowship Training Program

Effect of robotic surgery on a Gynecologic Oncology Fellowship Training Program

Effect of Robotic Surgery on a Gynecologic Oncology Fellowship Training Program

Effect of Robotic Surgery on a Gynecologic Oncology Fellowship Training Program

A case-controlled study of total laparoscopic radical hysterectomy with pelvic lymphadenectomy versus radical abdominal hysterectomy in a fellowship training program

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29-78 years). The mean pelvic lymph node count was 31 (range, 10-61) in the TLRH group versus 21.8 (range, 8-42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100-600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200-464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2-11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program

Study objective Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. Design Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children’s Hospital for locally advanced cervical cancer between June 2002 and June 2005. Setting Gynecologic oncology fellowship training program at a University-County Hospital Patients Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. Interventions Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. Measurements and main results A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. Conclusions It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.

36: Feasibility of Laparoscopic Extraperitoneal Surgical Staging for Locally Advanced Cervical Carcinoma in a Gynecologic Oncology Fellowship Training Program

36: Feasibility of Laparoscopic Extraperitoneal Surgical Staging for Locally Advanced Cervical Carcinoma in a Gynecologic Oncology Fellowship Training Program