BackTable OBGYN BackTable

In this episode, Drs. Mark Hoffman and Amy Park invite Drs. Rebecca Stone and Kara Long Roche to speak about opportunistic salpingectomy to prevent ovarian cancer, specifically serous carcinoma.

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SHOW NOTES

The episode begins discussing ovarian cancer as a whole and how it affects 1 in 78 women in their lifetime with high mortality rates, no screening tests, and hardly any symptoms before it becomes metastatic. Most ovarian cancers (80-90%) are epithelial, and of those, most are high grade serous carcinomas, which are very lethal.

Drs. Stone and Long Roche go on to explain how ovarian cancer is actually disseminated tubal cancer, and that there is data showing dysplasia in the fallopian tube before it turns into ovarian cancer. In fact, the fimbriated ends of the fallopian tube are very high in p53 mutations, and there is data showing a decreased risk of ovarian cancer with tubal ligation. As a result, salpingectomy can be used as primary prevention for ovarian cancer. They have been doing opportunistic salpingectomies on women already in the OR for hysterectomies, Cesarean sections, ovarian cystectomies, etc. They would like to expand it to women receiving abdominal or urologic surgeries, including hernia repairs or cholecystectomies, which would require education, training, and communication across multidisciplinary teams.

The physicians continue to discuss the impact of opportunistic salpingectomies, mentioning 2000 lives could be saved every year in addition to 0.5 billion health care dollars saved as a result. They compare it to the HPV vaccine with a number needed to treat around 1 in 300 to 1 in 500 and a risk reduction of 65% or greater.

Technically speaking, the physicians mentioned the difficulties of ensuring adequate fimbriae removal of the ovary without causing more harm; overall, data shows that if done correctly, this procedure does not result in early menopause or impaired ovarian function. They also stated there is no specific procedure code for opportunistic salpingectomy along with conflicting state laws on reimbursability for the procedure, which could affect data collection and implementation.

Finally, the episode ends with talk about the future of opportunistic salpingectomies. Data shows there is a decreased incidence of high grade serous ovarian carcinoma, but more data is needed on mortality effects. The physicians strive to educate providers and patients about the procedure while ensuring no woman becomes sterilized before she is ready. Their target population is women in their 40s who will be in the OR already, as they don’t see opportunistic salpingectomies becoming indicated for the general population soon.

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RESOURCES

Break Through Cancer Organization:
https://breakthroughcancer.org/

ACOG Guidelines:
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian-cancer-prevention

In this episode, Drs. Mark Hoffman and Amy Park invite Dr. Susan Khalil, a board-certified OB/GYN and fellowship-trained Minimally Invasive Gynecologic Surgeon at Mount Sinai in New York, to speak about the topic of second victim and fostering resilience in the field of Obstetrics and Gynecology.

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SHOW NOTES

Dr. Khalil’s efforts to improve quality and patient safety began almost a decade ago. When discussing how she is involved with quality and safety, Dr. Khalil describes her experiences with programs outside of her institution, such as Schwartz Rounds through the Schwartz Center for Compassionate Healthcare, as well as those within her institution, including those conducted by the Vice Chair for Wellness and the Chief Wellness Officer at Mount Sinai. Throughout these programs, Dr. Khalil explains that the common thread is the opportunity to discuss a negative patient outcome or a harmful situation within the workplace within a safe environment. In Dr. Khalil’s personal experience, these programs have covered topics such as improving communication in a multidisciplinary team.

The physicians then transition to discuss the topic of “second victim,” which Dr. Khalil describes as the caregiver who witnesses a patient undergoing a traumatic event and that caregiver’s personal trauma they are then left to cope with. She expresses that these situations often require mental health support, especially from a community that understands clinically what is happening and also has the resources to provide the caregiver with the support they need to return to work more resilient. Ultimately, Dr. Khalil believes that culture is the key to fostering a safe environment for physicians, as well as all other people involved in a patient’s care. Dr. Khalil encourages those who may not have access to these resources to consider online resources (e.g., the Schwartz Center) or to look to other institutions as a framework to tailor programs that may work within your own hospital or institution.

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RESOURCES

The Schwartz Center for Compassionate Healthcare:
https://www.theschwartzcenter.org/programs/schwartz-rounds/

Khalil S, Ascher-Walsh C. Advancing Patient Safety Science While Not Losing Focus of the Big Picture: Improving Patient Care. J Minim Invasive Gynecol. 2022 May;29(5):581-582. doi: 10.1016/j.jmig.2022.03.003. Epub 2022 Mar 11. PMID: 35283322.

Association of Academic Surgery Presidential Address by Dr. Carrie Cunningham Lubitz:
https://www.youtube.com/watch?v=JaNBH4UPHv4

In this episode, Dr. Leslie Appiah, who is fellowship-trained in Pediatric and Adolescent Gynecology and is the Director of the Fertility Preservation Program at the University of Colorado, discusses oncofertility and fertility preservation.

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Dr. Appiah begins the episode by defining oncofertility as a multidisciplinary field that improves fertility and reproductive health outcomes for patients with cancer diagnoses. She emphasizes the growth of the field, with the term “oncofertility” being coined in 2009 by Dr. Teresa Woodruff at Northwestern University. Now, 13 states have legislation that mandates insurance providers to cover fertility services for patients with and without cancer.

The primary patient population that may benefit includes patients with a cancer diagnosis, although additional populations who may benefit, including patients with Sickle Cell Anemia undergoing bone marrow transplant, systemic lupus erythematosus using alkylator therapies, transgender populations undergoing gender-affirming treatments, and patients born with genetic conditions that may result in infertility (e.g., Turner Syndrome). The main agents that are harmful to fertility include alkylator and radiation therapies.

The physicians then transition to discuss fertility preservation, and Dr. Appiah highlights that it is the responsibility of medical providers to offer counseling for every patient who is at risk for infertility. She then describes types of fertility preservation, including sperm banking, testicular tissue preservation, egg freezing, and ovarian tissue cryopreservation. Dr. Appiah then shares 3 different procedures that are used for ovarian tissue cryopreservation, the most common approach begin a laparoscopic procedure to retrieve one ovary, which is then preserved and later transplanted back into the pelvic peritoneum once the patient has completed cancer therapies and is ready to start a family.

The episode concludes with Dr. Appiah shares future directions in the field of oncofertility, which includes streamlining the process for male patients, ensuring every state is able to allow fertility preservation services that are covered by insurance providers, optimizing the process of transplanting ovarian tissue, and utilizing ovarian tissues for hormone replacement.

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RESOURCES

ReproTech, Fertility Preservation:
https://www.reprotech.com/fertility-preservation-network/

Oncofertility Consortium:
https://oncofertility.msu.edu/about/

Alliance for Fertility Preservation, Fertility Scout:
https://www.allianceforfertilitypreservation.org/about-fertility-scout/

In this episode, Dr. Camille Clare, the Chair of the Department of Obstetrics and Gynecology at SUNY Downstate College of Medicine, joins Drs. Mark Hoffman and Amy Park to discuss social determinants of health in the field of OB/GYN.

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SHOW NOTES

Dr. Clare identifies social determinants of health as factors that prevent patients from accessing healthcare multiple times. She describes examples as housing (e.g., safe environments to live and raise families, school district locations), access to transportation, and occupation. The physicians discuss the impact of social determinants of health in the field of OB/GYN, involving how certain conditions (i.e., rates of preterm birth, infertility, and cancer) present. The group also acknowledges the concept of “political determinants of health,” which involves policies that lead to certain health outcomes, such as redlining and how it has contributed to food insecurity and many other negative effects.

The physicians also discuss how groups are addressing the downstream effects of health inequities. Dr. Clare is personally involved in lobbying and encourages those around her to advocate at the local, state, and federal levels to improve policy. In addition, Dr. Clare utilizes social media as a way to promote health equity and empower students/trainees to make positive impacts on their communities.

The episode ends with Dr. Clare expressing current improvements among the medical community when it comes to addressing social determinants of health and health inequities. Ultimately, Dr. Clare is grateful that the medical community is now more open to discuss difficult conversations that focus on improving patient care. She has also appreciated the active effort to make the medical school recruitment process more inclusive in order to diversify the future physician workforce.

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RESOURCES

Dr. Camille A Clare:
@cclareMDMPH (https://twitter.com/cclareMDMPH)

Claire Cain Miller, Sarah Kliff, Larry Buchanan. “Childbirth Is Deadlier for Black Families Even When They’re Rich, Expansive Study Finds” The New York Times. https://www.nytimes.com/interactive/2023/02/12/upshot/child-maternal-mortality-rich-poor.html

In this episode, Dr. Elliot Richards, a true physician-scientist and Director of Research in the Department of Reproductive Endocrinology and Infertility at the Cleveland Clinic, shares about his experience and studies regarding uterine transplant.

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Dr. Richards describes uterine transplant in the modern era as truly “patient-driven” and due to “patient-demand.” He begins the episode by detailing the history of uterine transplant, which was initially attempted in the 1930s, even before the first successful renal transplant 20 years later. More recently, successful uterine transplants were first conducted in Saudi Arabia, Sweden, Turkey, and now in a few United States institutions (e.g. Cleveland Clinic, University of Alabama at Birmingham, University of Pennsylvania, and Baylor).

He then addresses arguments or concerns against uterine transplant. Ultimately, Dr. Richards encourages listeners to identify infertility as a disease and one that warrants treatment, prompting the use of uterine transplant.

The physicians then discuss the process of uterine transplant. In current trials, the majority of patients are people with a diagnosis of mullein agenesis. Dr. Richards highlights that this population does not reflect the actual population that suffers from absolute uterine factor infertility (AUFI) and that he hopes that access to the procedure will expand for a more diverse patient population. He then describes the types of uterine donors (e.g., directed donor, non-director donor, deceased donor model, etc.) that are utilized by different institutions; the surgical process of the transplant itself; immunosuppression and pregnancy; as well as fertilization via IVF.

The episode ends with Dr. Richards discussing success rates by citing his prior studies, which includes a 74% 1-year graft survival and 83% live birth rate among those with a viable graft at 1 year. Specifically within the Cleveland Clinic study population, one patient delivered the first second baby last September. Future directions regarding uterine transplant include better understanding the costs of the procedure, shortage of available donors, identifying the true demand, leveraging minimally invasive surgical techniques, and fallopian tube preservation.

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RESOURCES

“The Danish Girl” 2015 film directed by Tim Hooper

“Uterus Transplant Animation Recipient” by Cleveland Clinic - ​​https://www.youtube.com/watch?v=13DwQ0HbuXc

“Cleveland Clinic Delivers Second Baby from Uterus Transplant” by Cleveland Clinic - https://www.youtube.com/watch?v=XJuedpL14AQ

Lefkowitz A, Edwards M, Balayla J. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transpl Int. 2012 Apr;25(4):439-47.

Johannesson L, Richards E, Reddy V, Walter J, Olthoff K, Quintini C, Tzakis A, Latif N, Porrett P, O'Neill K, Testa G. The First 5 Years of Uterus Transplant in the US: A Report From the United States Uterus Transplant Consortium. JAMA Surg. 2022 Sep 1;157(9):790-797.

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine.

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SHOW NOTES

First, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance.

Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well.

Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly.

Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence.

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RESOURCES

Knock Knock Hi Podcast
https://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053

First Descents
https://firstdescents.org/