The Role of the Gynecologic Oncologist
In this video, Stephanie V. Blank, MD, and Warner K. Huh, MD, discuss the evolving role of the gynecologic oncologist, including the use of chemotherapy, benign surgery, and the management of patients with placenta accrete spectrum. They also discussed these topics during an interactive session at The Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women’s Cancer titled “The Future is Now: Determining the Fate of Gynecological Oncology.”
Additional Resource:
Blank SV, Huh WK, Bell M, et al. Doubling down on the future of gynecologic oncology: The SGO future of the profession summit report. Gynecol Oncol. 2023;171:76-82. doi:10.1016/j.ygyno.2023.02.008
Stephanie V. Blank, MD, is President and Director of Gynecologic Oncology at Mount Sinai Health System.
Warner K. Huh, MD, is Chair of the Department of Obstetrics and Gynecology at the University of Alabama at Birmingham School of Medicine (Birmingham, AL).
TRANSCRIPTION:
Dr Stephanie Blank:
Yes, hi. I'm Stephanie Blank, I'm the director of Gynecologic Oncology for the Mount Sinai Health System in New York, and I am the past president of the Society of Gynecologic Oncology.
Dr Warner Huh:
I'm Warner Huh. I'm the chair of the Department of OB-GYN at the University of Alabama here in Birmingham, Alabama, and the past present for SGO in 2020.
C360: Please provide an overview of the topics that you discussed during your session titled "The Future is Now: Determining the Fate of Gynecological Oncology" at SGO 2023.
Dr Stephanie Blank:
At this session, we first spoke about the changes as we had perceived them that have happened in our specialty. We spoke about the work that we had done in our task force. We came together and had a summit to do a SWOT analysis. We spoke about that SWOT analysis. We basically decided to focus on three topics. We spoke about chemotherapy, we spoke about benign surgery, and we spoke about the management of placenta accreta spectrum cases. Then, we had an open discussion. Those were the main things we spoke about.
Dr Warner Huh:
For the viewers and listeners who don't know what placenta accreta spectrum is, it's when the placenta becomes abnormally adherent to the wall of the uterus, usually in the setting of prior C-section, and removing that becomes a pretty problematic surgical situation. It's a big surgery with a huge amount of blood loss.
C360: What kind of feedback did you receive from the participants?
Dr Warner Huh:
Yeah, that's a good question, and I think Dr Blank would agree with me. We knew that this was going to generate a lot of discussion from the SGO attendees. We knew that it was already generating conversation because we published a white paper from our summit that was published before the annual meeting and we actually surveyed the membership to understand how they were practicing. A couple of things, I think one of which is that I think people recognize that there's an absolute need to reassess the field of gynecologic oncology and proactively understand what our value is, not just to oncology care, but also to women's healthcare. But I think people also grew to understand the complexity of the issues that we're talking about and that there are no easy fixes. It does require the broader participation and input of SGO members, gynecologic oncologists, and just general GYN cancer specialists to help us provide the care that women deserve, but also serve the other things that we provide in women's health.
Dr Stephanie Blank:
Some things were a little surprising to us. We found that our members did not feel that they really belonged in OB-GYN departments, interesting for an OB-GYN chairman to hear perhaps, and that they didn't feel valued by their departments. A lot of people felt that they were doing more benign, and more than half did not want to be doing more benign surgery, but nothing was overwhelmingly one way. There certainly was a lot of diversity of opinion in our group, which spoke to something that we had found in our discussion among our group at our summit, that there's not one way to be. I think it was almost like a mantra that we came up with at the end of our discussion, that we really need to think about everybody. It's not just the academician in the ivory tower, there are all different types of people with all different types of practices and ways they would like to be. We're not trying to have each person say what they want, we want to think about the whole profession of gynecologic oncology and what should a gynecologic oncologist be able to do.
C360: How do you predict the feedback could impact clinical practice and the future of the field?
Well, I think that, for example, we did see that a lot of our members think it's very important for a GYN oncologist to be able to give chemotherapy, that it's a very important part of how we see ourselves be able to give the quality of care that's important to us. We know that this is something that we really need to fight for. Dr Huh and I are going to work on putting together a business plan, putting together some data, and demonstrating the value of GYN oncologists being involved in this care. It basically helped us guide which direction we're going to go next with this project.
Dr Warner Huh:
Yeah, I think Dr Blank mentioned it. We knew this going in. The session validated this: that there isn't a singular definition of what a gynecologic oncologist is and there's market diversity in how that type of care is delivered across the United States. I think the one thing that I took away from the session that I may not have really thought about or prioritized is that joint cancer care is very much team-based now. 50 years ago, it was very much this model, "I can do it all." I think we have to step away and recognize that we can't do it all and we shouldn't do it all. We should do it as a team, but we should be an essential figure in that team and how do we leverage our expertise in such a way.
I don't know about you, Stephanie, but for me, the comment that was made, particularly with medical oncologists, made me really think about that. That is really the way we need to be looking at this. It doesn't mean that we're taken out of the equation, in some ways we're relying on the expertise of multiple people because it's gotten so much more complicated, there are so many more options and it's just not right to rely on just one person. It's a very archaic way of looking at oncology care.
Dr Stephanie Blank:
No, I couldn't agree more.
C360: Please describe the role of a GYN oncologist and how it has changed over time.
Dr Warner Huh:
Again, for our audience who doesn't know this, what's truly unique about gynecologic oncologists is that not only are we surgically trained to do the various surgeries that we do related to GYN malignancies, but we keep that patient in general and manage them post-operatively after their surgery with things like chemotherapy. There's no other surgical discipline in the United States like that. Our predecessors have created this really awesome unique model of care that the patients love, they love having a singular oncologist that's guiding them through this path.
If you use the example of endometrial cancer, we do their surgeries and then we make the decision about whether or not they need chemotherapy, they're followed closely, or we've got to refer them to a radiation oncologist, but we're very much governing and captaining their care in many, many ways. To the point that I brought up earlier, this is good. The amount of advances that we've seen in GYN cancer over the last five or six years has literally quadrupled what we've seen in the last 20, and it's become a lot more challenging, but I think that a lot of GYN gynecologists want to be front and center in terms of managing these patients and making sure that they're on the right path and the right journey.
I think those are the changes, the changes that are that instead of one person, now they are multiple people, but I would argue that the gynecologic oncologist is very much front and center in terms of decision-making with the patient.
Dr Stephanie Blank:
Yeah, I think one thing that we were also speaking about is that gynecologic oncologists are increasingly being asked to do more and more benign surgery. It takes a lot of time to be able to offer the type of comprehensive longitudinal care that Dr Huh described, and so being asked to do a lot more benign surgery really takes away from the time that you can give to your other patients. That's one way that we are being pushed in a different direction than some of us might want. That's one way that our specialty has changed.
C360: What do you anticipate is the future of GYN oncology?
One thing that we just keep saying is that if we don't define our future, somebody else is going to do it for us. We keep saying this over and over again because it's so incredibly true. We are going to define our future. Now that we have come together and really agree that our focus is on our patients, we need to figure out the best way to allow us to continue to offer the type of care that we need to be able to offer. I think that's going to need us to be able to come up with tools for some of our members, ways that they can speak to their administration, their cancer centers, their departments, how they can define what their priorities are, because if GYN oncologists end up doing all the benign surgery in departments, all the hemorrhages in obstetrics, all the teaching, all the leadership, we're doing a lot, it's going to ultimately be negatively impacting our patients. That's why we all started this in the first place.
I'm not trying to end this negatively, because I think ultimately the end of this is going to be positive because we're going to take control of this situation in a good way, but we do have to take control over it.
Dr Warner Huh:
To expand that further, obviously the last several minutes we talked about just GYN oncology care. But I think what Dr Blank is definitely alluding to is the downstream impact on just women's health in general, particularly for the next generation. I have two concerns. One is that the added pressures that are placed on a gynecologic oncologist to take care of non-cancer patients, given the limited number of gynecological oncologists in the United States, I'm worried is going to affect the access for our cancer patients to be seen in a timely manner since we'll have competing priorities. That's one major concern.
The other concern I have is that we really do need to look proactively at whether patients who need traditional benign gynecologic care are being managed by the right person. That goes all the way back to training. I think that this has highlighted some potential gaps and needs assessments that are on the training side for women's health that I think our colleagues outside of gynecologic oncology are now really starting to appreciate. They certainly don't want gynecologic oncologists not to be able to see their cancer patients, but then the question that has to be asked is who's going to see those patients? Right now, there isn't a clear plan to do that. There's not only heightened awareness for the gynecologic oncology community but there's also heightened awareness for the entire OB/GYN community in proactively trying to figure out how to solve these problems for the future.
C360: What are the overall take-home messages from our conversation today and from the session at SGO 2023?
Dr Warner Huh:
When I started looking at these issues when I was SGO president pre-COVID, I think every profession should do a deep dive and understand what their place is in the medical profession. When you don't do it, things change and all of a sudden you lose control and you can no longer dictate how to lead and adapt with those changes. I think that's very much what we have done here. I think what has become a liability, but the hallmark of our profession is that we always put patients first and we rarely say no because we don't want patients to suffer, and we don't want them to draw the shorts straws. We always say yes, but that constant yes isn't sustainable.
I think that the reason why we held this session is to understand how we better align the needs of the profession with all the needs related to cancer care and women's healthcare. This is not the end, this is very much the beginning. I think that what we know, having talked to multiple groups, societies, and leaders in the profession, they acknowledge that this is just the beginning of the discussion basically.
Dr Stephanie Blank:
Yeah. We're going to get really old talking about this, Warner.
Dr Warner Huh:
Yeah, I think we're going to be talking about this well into our retirement, unfortunately.
Dr Stephanie Blank:
Yes.
Dr Warner Huh:
No, but that's okay.
Dr Stephanie Blank:
Yeah, I agree with that. There've been advances in our field. People are living longer. We have so many great new treatments, but this has changed the field so much. Actually, it was a great treat to be able to sit back and look at how things have changed and think about how they're going, but we're strategic planning for our profession. I think every profession should do this. I think that it's, again, just the beginning. Maybe in a couple of years, we'll come and do this again. We'll have another chat.
Dr Warner Huh:
Yeah, and one last comment. What's exciting for me is to see the current young generation that's entering the field, or fellows, really wrap their heads around this, because you can see them putting the dots together and say, "Okay, I get it," but there was a comment that was made from a fellow, they wanted to tell us that they're so inspired by their predecessors and how special this field is and they think that the field is actually in a great place, but they're thankful that there are people who are thinking about their future. I think that comment alone made this whole effort worth it for me, personally