Creating work environments where people of all genders in gynecologic oncology can thrive: An SGO evidence-based review.

Equality, equity, and parity in the workplace are necessary to optimize patient care across all aspects of medicine. Gender-based inequities remain an obstacle to quality of care, including within the now majority women subspecialty of gynecologic oncology. The results of the 2020 SGO State of the Society Survey prompted this evidence-based review. Evidence related to relevant aspects of the clinical care model by which women with malignancies are cared for is summarized. Recommendations are made that include ways to create work environments where all members of a gynecologic oncology clinical care team, regardless of gender, can thrive. These recommendations aim to improve equality and equity within the specialty and, in doing so, elevate the care that our patients receive.

Equal care ensures equal survival for African-American women with cervical carcinoma.

BACKGROUND: [corrected] It was the purpose of this study to investigate whether race is an independent prognostic factor in the survival of patients with cervical carcinoma in a health care system with minimal racial bias, and few barriers to access to care. METHODS: Records for patients with a diagnosis of invasive cervical carcinoma from 1988 to 1999 were obtained from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data including race, age at diagnosis, histology, grade, stage, socioeconomic status, treatment modality, and survival also were obtained. Survival analysis was performed with Kaplan-Meier survival curves. RESULTS: One thousand five hundred fifty-three patients were obtained for review. Sixty-five percent of patients were Caucasian, and 35% were minorities. Of the minorities, 29% were African Americans (AAs). Mean age of diagnosis was similar among AAs and Caucasians, 44 and 42 years, respectively. There was no statistically significant difference between the distribution of age, stage, grade, or histology between Caucasians and AAs. Forty-six percent of patients were treated with surgery and 56% with radiation therapy, with no difference in type of treatment between the Caucasian and AA groups. Five- and 10-year survival rates for Caucasians and AAs were 75%, and 76%, and 64% 65% (P = 0.59), respectively. CONCLUSIONS: In an equal access, unbiased, nonracial environment, race is not an independent predictor of survival for patients with cervical carcinoma. This study has shown, for the first time to the authors' knowledge, that when they receive equal treatment for cervical carcinoma, AA women's survival can approach that of their nonminority counterparts (75% at 10 years).

Videoteleconferencing for administration of a multisite obstetrics and gynecology core clerkship.

Recent changes and trends in health care delivery have required medical schools to use multiple sites to obtain adequate patient exposure for their students. Decentralization of clinical undergraduate medical education may lead to a lack of continuity in curricula, evaluation, and feedback. We describe the use of interactive videoteleconferencing as a tool to link and improve a multi-site undergraduate core clerkship in obstetrics and gynecology. The Uniformed Services University of the Health Sciences, Bethesda, Maryland, currently utilizes five geographically separate sites for its 6-week core clerkship in obstetrics and gynecology. The site coordinators, clerkship director, and administrative personnel from the parent institution meet approximately 3 weeks after the completion of each core clerkship for live, real-time, and interactive broadcast to complete student evaluations, review curricula, and discuss problems with current students and other pertinent educational issues. Videoteleconferencing provides a mechanism to ensure consistency in curriculum and student evaluations and provides administrative support to distant sites. Furthermore, it enables site coordinators to keep the clerkship director abreast of students and clerkship issues.

A descriptive evaluation with follow-up of the clinical significance of atypical immature squamous metaplasia of the cervix.

OBJECTIVES: We set out to determine the clinical significance of atypical immature squamous metaplasia (AIM). METHODS: We performed in a military, hospital-based colposcopy clinic a descriptive, retrospective review of patients who had a diagnosis of AIM. Patients were examined at 3- to 4-month intervals for at least 1 year after a diagnosis of AIM was established. A gynecological pathologist reviewed all histological and cytological specimens. Initial histological or cytological specimens were tested for the presence of HPV DNA using in situ hybridization. RESULTS: High-risk HPV DNA types 16 or 18 were detected in 3% of patients with AIM. Concurrent cervical intraepithelial neoplasia 3 (CIN3) was noted in 3% of patients with AIM. One-third of patients with initially diagnosed AIM had complete resolution of this lesion after 1 year of follow-up. CONCLUSIONS: This descriptive, retrospective review shows that AIM does not appear to be associated with high-risk HPV DNA or with CIN3. In this limited study, a concurrent diagnosis of AIM likely does not influence the 1-year behavior of CIN. The degree of CIN should dictate treatment recommendations. A larger prospective trial is needed.

Effect of residency program merger on undergraduate medical student education in obstetrics and gynecology.

OBJECTIVE: To evaluate the effect of residency program merger on third-year medical student clerkships using student evaluations of their experiences and standardized subject examination scores. METHODS: End-of-clerkship ratings from student evaluations and National Board of Medical Examiners standardized subject examination scores in obstetrics and gynecology were used from clerkship sites where three separate military residency programs in obstetrics and gynecology recently merged into two new programs. Mean student evaluation scores and subject examination scores for the year preceding and the year following the merger were compared. RESULTS: The mean differences in medical student evaluation scores before and after merger of the residency programs were 0.1 (Mann-Whitney rank sum, P = .1), -0.1 (Mann-Whitney rank sum, P = .8), and 0.2 (Mann-Whitney rank sum, P = .3). The mean differences for subject examination scores before and after merger of the residency programs were -3.5 (95% confidence interval [CI] -33.2, 26.2; paired t test), -30.1 (95% CI -58.9, -1.4; paired t test), and -35.3 (95% CI -74.8, 4.3; paired t test). CONCLUSION: Merger of residency programs in obstetrics and gynecology does not appear to have a deleterious effect on medical students' satisfaction with the clerkship or their performance on standardized subject examinations at our institution.

Development and use of military-unique standardized gynecology patients in military undergraduate medical education.

Performance-based testing using standardized patients is becoming increasingly popular as a means to assess the clinical competence of medical students. Medical students entering postgraduate training in military treatment facilities have the additional responsibility of military readiness. The increasing number of women in the active armed forces and the diverse missions encountered by the military today necessitate inclusion of military-unique standardized gynecologic patients and scenarios into curricula. We developed a military-unique standardized gynecology patient and scenario and an objective structured clinical examination to evaluate medical students' skills in data gathering and synthesis, development of differential diagnoses, problem solving, and working through military-unique issues of the patient scenario. Integration of an objective structured clinical examination of military-unique gynecology standardized patient scenarios into the obstetrics and gynecology curriculum at the Uniformed Services University of the Health Sciences can lead to successful assessment of student clinical skills and provide a means of ongoing military readiness training.

Primary peritoneal psammocarcinoma: A case presenting with an upper abdominal mass and elevated CA-125.

Primary peritoneal serous adenocarcinoma with predominating psammoma bodies, psammocarcinoma, is a very rare tumor with only seven cases documented in the English literature. Pathological classification of this entity was established in 1990 and clinical behavior of this tumor is uncertain. Based on limited data these tumors appear to behave similarly to low malignant potential tumors of the ovary. This case describes a 59-year-old woman who underwent exploratory laparotomy for a large upper abdominal cystic mass. Findings included a large tumor mass involving the gastrocolic omentum and dense small bowel adhesions. The patient had normal ovaries and was debulked to no macroscopic disease. Final pathologic diagnosis confirmed a stage IIIC primary peritoneal psammocarcinoma. The patient has received no adjunctive therapy and is without evidence of disease 2 years after surgery. Primary peritoneal psammocarcinoma is a neoplasm which can mimic serous adenocarcinoma of the ovary. In contrast, primary peritoneal psammocarcinoma appears to behave in an indolent fashion. Primary surgical debulking should be attempted, while the utility of postoperative chemotherapy remains unknown.

A survey of military residencies regarding 4th-year medical school clerkships.

OBJECTIVE: To determine the value of 4th-year medical student clerkships assessed by military obstetric and gynecologic program directors and residents. METHODS: A questionnaire was sent to all Department of Defense obstetric and gynecologic residency program directors and residents. All of the program directors and 124 of 194 (64%) residents responded, reporting the value of 4th-year medical student clerkships for students entering their programs. Descriptive statistics are reported. RESULTS: Primary care clerkships were valued most highly by program directors who valued obstetric and gynecologic clerkships at their program sites or audition electives higher than those done at other sites. Residents most highly valued obstetric and gynecologic and intensive care clerkships. Most surgical subspecialties were believed to be of minimal or no value. CONCLUSION: For students entering their programs, military program directors placed the highest value on primary care clerkships. Program directors also highly valued obstetric and gynecologic clerkships at their programs, whereas residents considered obstetric and gynecologic and intensive care clerkships to be most helpful.

Development and use of military-unique standardized gynecology patients for military residents in obstetrics and gynecology training programs.

Focused military curricula and readiness training are often inadequate for military resident physicians. We developed a standardized gynecologic military-unique patient scenario and examination to assess obstetrics and gynecology residents' clinical and operational problem-solving abilities. Integration of military-unique gynecologic standardized patients, clinical scenarios, and objective structured clinical examinations into obstetrics and gynecology curricula is a novel approach for realistic medical readiness training for resident physicians. This tool can become a cornerstone in the ongoing development of needed military-unique curricula.

Prospects for human papillomavirus vaccine development: emerging HPV vaccines.

This review concentrates on recent advances in human papillomavirus vaccine development. Strategies for prophylactic HPV subunit vaccines utilizing recombinantly synthesized, immunogenic virus-like particles are discussed. Therapeutic strategies focusing on the induction of cell-mediated immunity and gene manipulation for the treatment of established HPV-associated disease are also reviewed.

Prospects for human papillomavirus vaccine development: emerging HPV vaccines.

This review concentrates on recent advances in human papillomavirus vaccine development. Strategies for prophylactic HPV subunit vaccines utilizing recombinantly synthesized, immunogenic virus-like particles are discussed. Therapeutic strategies focusing on the induction of cell-mediated immunity and gene manipulation for the treatment of established HPV-associated disease are also reviewed.

Villoglandular adenocarcinoma of the cervix: a report of three cases and review of the literature.

Villoglandular adenocarcinoma of the cervix is a distinct histologic type of cervical cancer. Fewer than 60 cases have been reported in the literature. Previous reports suggest that, due to the highly favorable prognosis of this rare histologic type of cervical cancer, conservative surgical therapy with cervical conization or extrafascial hysterectomy alone may be undertaken. In this series, three cases of villoglandular adenocarcinoma of the cervix are described. Preoperatively in each case, the cancer was confined to the cervix and histologic well-differentiated villoglandular adenocarcinoma of the cervix was confirmed. Extended hysterectomy was performed in all cases. In one case, residual invasive endocervical adenocarcinoma was noted. Careful review of the histologic characteristics of these tumors is needed when deciding if these patients can be managed with conservative therapy.

The occurrence of endometrial adenocarcinoma in a patient with basal cell nevus syndrome.

Basal cell nevus syndrome is rare multisystem disorder. Its genital implications in female patients is thought to be limited to ovarian fibroma. This article describes endometrial adenocarcinoma in association with basal cell nevus syndrome in a 37-year-old female with multiple basal cell carcinomas, mandibular and maxillary bone cysts, right ovarian fibroma, and scoliosis. Histopathologic examination of her endometrial biopsy, performed for irregular uterine bleeding, revealed endometrial hyperplasia. Her bleeding failed to respond to progestin therapy, and a repeat endometrial biopsy revealed a well differentiated endometrial adenocarcinoma. Health-care providers are encouraged to refer these patients to gynecologists. Regular gynecologic examination as well as appropriate evaluation of abnormal menstrual bleeding should be emphasized.

Recurrent granulosa cell tumor of the ovary 37 years after initial diagnosis: a case report and review of the literature.

Granulosa cell tumors of the ovary (GCTs) are uncommon neoplasms that are characterized by late recurrence and high survival rates. A case of recurrent GCT presenting 37 years after initial diagnosis is reported with a review of the literature. This case illustrates an example of a very late recurrence and emphasizes the importance of the extended follow-up required for these patients.

Prospects for a vaccine against human papillomavirus.

OBJECTIVE: To summarize existing data regarding the feasibility of developing strategies for prophylactic and therapeutic vaccination against human papillomavirus (HPV) infection. DATA SOURCES: We used the Medline data base and reference lists of articles to identify English-language papers that evaluate strategies for prophylactic and therapeutic vaccination against HPV infection. METHODS OF STUDY SELECTION: Our search uncovered several reports of systems that produce recombinant HPV major capsid proteins as antigens for biochemical, molecular, and immunologic studies and investigations that evaluate cell-mediated immune responses to HPV-induced, tumor-associated peptides. DATA EXTRACTION AND SYNTHESIS: Recombinant HPV major capsid proteins, which self-assemble into virus-like particles, are produced in quantity, mimic the conformation of native virions, react with neutralizing antibodies, and are type-specific. Human papillomavirus early viral peptides induce cytotoxic T lymphocyte responses that retard tumor progression and protect against tumor development after challenge in animal models. CONCLUSIONS: Recombinant papillomavirus virus-like particles are highly antigenic, protective in animal models, lack potentially carcinogenic viral DNA, and are, therefore, ideal candidates for a prophylactic vaccine against HPV infection. Immunization with HPV tumor peptides may be beneficial in tumor prevention, regression, and rejection. Vaccines against HPV infection can be important in reducing the incidence of cervical dysplasia and carcinoma worldwide, particularly in developing countries.

Human papillomaviruses: their clinical significance in the management of cervical carcinoma.

Studies have shown a strong association between certain human papillomaviruses and the development of cervical carcinoma and its precursor lesions. The oncogenic potential of papillomaviruses has been clearly demonstrated in both laboratory animals and cultured cells. Recent advances in our understanding of viral pathogenesis have provided insights into the natural history of papillomavirus infection and subsequent development of neoplasia. A more thorough understanding of the molecular mechanisms responsible for viral oncogenesis will facilitate the development of novel preventive and therapeutic strategies to prevent and treat papillomavirus-associated cervical neoplasias. Strategies under current investigation are focusing on the induction of effective humoral and cell-mediated immunity, the expression of HPV gene products, and cofactors that interact with HPV gene products to affect cell transformation. As a result of these investigative efforts, prophylactic HPV capsid vaccines and other gene therapies may soon become clinically available.

Spontaneous preoperative internal jugular and subclavian vein thrombosis associated with an early-stage synchronous ovarian/endometrial malignancy.

A case of preoperative spontaneous internal jugular/subclavian vein thrombosis documented with magnetic resonance imaging associated with a synchronous stage II ovarian/stage I endometrial malignancy is presented. This unusual deep venous thrombosis site is classically associated with trauma, infection, head and neck malignancies, or central venous catheterization and is rarely associated with distant malignancies. Neck pain and swelling in a gynecologic oncology patient should prompt consideration of this diagnosis.