Faculty Bibliography

OBJECTIVE:To evaluate the prevalence and risk factors for severe perioperative surgical morbidity among patients undergoing cesarean delivery. METHODS:This was a retrospective cross-sectional study of patients who underwent cesarean delivery in any California hospital between 2016 and 2021. Linked birth certificate and maternal discharge data identified cesarean delivery hospitalizations. We constructed a composite index for severe perioperative surgical morbidity, including intra-abdominal or pelvic visceral and vascular injuries, hysterectomy, pelvic or retroperitoneal hematoma, wound complications, ileus or bowel obstruction, acute peritonitis, and shock. Severe perioperative surgical morbidity prevalence was quantified overall and stratified by prelabor and intrapartum cesarean deliveries. We developed a multivariable Poisson log-linear regression model to identify independent risk factors for severe perioperative surgical morbidity. In secondary analyses, severe perioperative surgical morbidity prevalence and risk factors were assessed separately by prelabor and intrapartum cesarean delivery. RESULTS:Among 594,655 cesarean deliveries, 10,182 (171/10,000, 95% CI, 168-175) had severe perioperative surgical morbidity. The most common categorized morbidities were wound complications (59/10,000, 95% CI, 57-61); bladder, genitourinary, or pelvic injury (45/10,000, 95% CI, 43-47); ileus or bowel obstruction (33/10,000, 95% CI, 32-35); shock (15/10,000, 95% CI, 14-16); and intraoperative bowel injury (14/10,000, 95% CI, 13-15). Severe perioperative surgical morbidity prevalence was higher among patients undergoing intrapartum compared with prelabor cesarean delivery (203/10,000, 95% CI, 198-209 vs 146/10,000, 95% CI, 142-150). Patients with placenta accreta spectrum disorder had the highest severe perioperative surgical morbidity risk (adjusted risk ratio 15.3, 95% CI, 14.0-16.7). CONCLUSION/CONCLUSIONS:Nearly 1 in 60 patients who undergo cesarean delivery in California experienced severe perioperative surgical morbidity, with a higher prevalence occurring among intrapartum compared with prelabor cesarean deliveries. These findings underscore the need for systematic measurement and evaluation of surgical quality of care among patients undergoing cesarean delivery to identify opportunities for morbidity reduction.

PURPOSE/UNASSIGNED:The objective of this study was to identify temporal trends in intensity modulated radiation therapy (IMRT) use for patients with cervical cancer who received definitive chemoradiation. METHODS AND MATERIALS/UNASSIGNED:Patients diagnosed with stage IB2-IVA cervical cancer between 2004 and 2019 and treated with definitive chemoradiation were identified in the National Cancer Database. The primary outcome of interest was the use of IMRT versus 3-dimensional conformal radiation therapy (3DCRT) over time. Wilcoxon rank-sum tests, chi-square tests, and multivariable logistic regression were used to identify factors associated with the receipt of IMRT. RESULTS/UNASSIGNED:< .01). Clinical factors associated with increased IMRT use were stage III disease compared with stage I (odds ratio [OR], 1.3; CI, 1.0-1.5) and lymph node involvement (OR, 1.4; CI, 1.2-1.6). The demographic factors associated with increased IMRT receipt were treatment in the western US (OR, 1.5; CI, 1.2-1.8) and in the southern US (OR, 1.3; CI, 1.1-1.5) compared with the northeastern US, and living more than 50 miles from the treatment facility (OR, 1.2; CI, 1.0-1.5). Compared with White patients, Black patients (OR, 0.8; CI, 0.6-0.9) and patients receiving care at community hospitals compared with academic medical centers (OR, 0.7; CI, 0.6-0.7) were less likely to receive IMRT. CONCLUSIONS/UNASSIGNED:IMRT utilization for cervical cancer has increased over the last 15 years, especially for patients with advanced-stage disease or lymph node involvement. Understanding shifts in policy, demographic trends, and practice patterns may provide additional insight into the adoption of advanced technologies.

OBJECTIVE:To develop, implement, and assess the utility of a standardized letter of evaluation (SLOE) for OBGYN residency applicants in the US. DESIGN/METHODS:OBGYN program directors (PDs) were surveyed over 2 consecutive years and asked to estimate the percentage of applicants submitting an SLOE and to indicate its helpfulness compared to traditional letters of recommendation. Sub-group analysis by program type was performed. In 2023, comments for improvement were collected and analyzed for themes using a large language model. SETTING/METHODS:OB/GYN residency programs in the United States. PARTICIPANTS/METHODS:OB/GYN PDs in the United States. RESULTS:The survey was completed by 254 of 293 (86.7%) of PDs in 2022 and 253/293 (86.3%) in 2023. From 2022 to 2023, there was no difference in the estimated percentage of applicants who submitted an SLOE to a program (median 50%-74%), though in 2023, university and combined university-community programs estimated receiving higher percentage of applicants submitting SLOEs compared to community and military programs (p < 0.001). Over the study period, the favorability of the SLOE improved, and feedback indicates a need for continued improvement in the SLOE process, including faculty development, standardization, and more honest assessment of applicants. CONCLUSIONS:An SLOE was submitted by most applicants to OBGYN residency programs. Iterative modification of the SLOE based on PD, applicant, and faculty advisor feedback is needed to assess its utility in the application process.

IMPORTANCE/UNASSIGNED:Screening by low-dose computed tomography can reduce lung cancer mortality among high-risk individuals, but many lung cancers occur among individuals with a smoking history who are not eligible for screening. OBJECTIVE/UNASSIGNED:To develop and validate the protein-based Integrative Analysis of Lung Cancer Risk and Etiology (INTEGRAL)-Risk model in individuals with a smoking history from the general population. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Cohorts in the Lung Cancer Cohort Consortium recruited research participants in the US, Europe, Asia, and Australia between 1985 and 2009, who were followed up for lung cancer and other health outcomes until 2021. Fourteen case cohorts of 3695 participants with a smoking history within the Lung Cancer Cohort Consortium, including 2305 randomly sampled participants and 1390 patients diagnosed with lung cancer within 3 years after blood sample collection, were designed. Plasma or serum samples from each participant were assayed using the INTEGRAL protein panel in 2022. The INTEGRAL-Risk model was trained using 7 predefined case cohorts (training set; n = 1951) to estimate absolute risk of being diagnosed with lung cancer based on age, smoking history, and 13 proteins. The validity of the INTEGRAL-Risk model was assessed in 7 independent case cohorts (testing set; n = 1744) at 1, 2, and 3 years after blood collection. EXPOSURE/UNASSIGNED:Absolute risk estimates from the protein-based INTEGRAL-Risk model. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the validity of the INTEGRAL-Risk model in the testing set with respect to discrimination (area under the curve [AUC]) and calibration (ratio of expected-to-observed cases [E/O]). RESULTS/UNASSIGNED:A total of 3695 participants were included, with 1951 participants (including 807 with lung cancer) in the training set and 1744 participants (including 583 with lung cancer) in the testing set. In the combined 14 training and testing sets, after application of statistical weights, 323 570 participants were represented (185 016 [57%] female; median [IQR] age, 60 [51-67] years). In the independent testing set, discrimination of the INTEGRAL-Risk model was highest at 1 year of follow-up and exceeded that of the questionnaire-based PLCOm2012 (Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial) model (INTEGRAL-Risk AUC of 0.88 [95% CI, 0.85-0.91] vs PLCOm2012 AUC of 0.79 [95% CI, 0.75-0.83]; P value for difference <.001). Using a risk threshold to achieve the same specificity as US Preventive Services Task Force (USPSTF) 2021 criteria, the INTEGRAL-Risk model captured 85% of lung cancer cases compared with 63% by USPSTF 2021 and 70% by PLCOm2012. Discrimination of the INTEGRAL-Risk model decreased with longer prediction horizons, with a 2-year AUC of 0.84 (95% CI, 0.81-0.86) and 3-year AUC of 0.81 (95% CI, 0.79-0.83). The model was well calibrated (E/O over 3 years, 0.87 [95% CI, 0.69-1.14]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Compared with questionnaire-based approaches, the protein-based INTEGRAL-Risk model improved short-term prediction of lung cancer in people with a smoking history. This model has potential to improve selection of high-risk individuals who are most likely to benefit from lung cancer screening.

The objective of this systematic review was to identify the evidence of testicular cancer risk for people with intersex conditions. This assessment is hoped to help refine risk stratification tools for assessing gonadal malignancy risk and guide the development of more robust evidence-based management strategies. The literature was searched in Ovid MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health using a search string developed by a multidisciplinary team. The protocol was registered at Prospective Register of Systematic Reviews as CRD42021231313. A total of 3608 articles were found. After selection, 301 publications were included (1215 individuals). The results identified significant evidence that pre-pubertal gonadectomy may be linked to lower rates of malignant gonadal changes for patients with partial gonadal dysgenesis, Turner's syndrome with Y-chromosome material, complete androgen insensitivity, partial androgen insensitivity, and patients with ovotestis/es. The evidence was not significant for patients with complete gonadal dysgenesis, Klinefelter syndrome, nor WT1-related syndromes. Specific cancer outcomes were unable to be assessed due to small sample sizes and thus it is unknown if clinically significant cancer outcomes are meaningfully altered by pre-pubertal gonadectomy. Importantly, the quality of data on the topic of gonadal malignancy in intersex patients with testicular tissue was determined to be poor overall. The quality was relatively more robust regarding the conditions of Complete Androgen Insensitivity, Klinefelter syndrome, and patients with ovotestis/es. More high-quality research is needed to draw specific conclusions on the risks and benefits of performing pre-pubertal gonadectomy for intersex patients. When counseling these patients, clinicians should be transparent regarding the paucity of data supporting pre-pubertal gonadectomy.

In the time since the last Clinical Practice Committee review of treatment of women with endometrial cancer in 2021, the field of gynecologic oncology has seen significant changes in endometrial cancer from understanding risk factors, addition of molecular staging, and expanded use of maintenance and targeted therapies. Despite these advances, the incidence of endometrial cancer as well as the deaths attributable to the disease continued to rise. Fortunately, since then, there has been progress in the treatment of patients with endometrial cancer, including increased utilization of molecular pathology, greater understanding of genetic predisposition, enhanced methods for lymph node assessment, a broader understanding of the efficacy of radiation and chemotherapy, and a more efficient approach to survivorship and surveillance. The purpose of this document is to present a comprehensive review of this progress. Manuscript development process: The authors reviewed the available evidence, contributed to the development of this manuscript, provided critical review of the guidelines, and finalized the manuscript recommendations. The review was also presented to and approved by the Society of Gynecologic Oncology (SGO) Clinical Practice Committee, Document Review Panel, and the Board of Directors prior to submission for publication. The recommendations for this manuscript were developed by a panel of gynecologic oncologists who were members of the SGO Clinical Practice Committee and subject matter experts. Panelists reviewed and considered evidence from current uterine cancer literature. The terminology used in these guidelines was adopted from the ASCCP management guidelines [1] using a two-part rating system to grade the strength of recommendation and quality of evidence. The rating for each recommendation is given in parentheses.

OBJECTIVE:To evaluate the association between severe perioperative surgical morbidity with cesarean delivery and postpartum readmission. METHODS:This was a retrospective cross-sectional study using linked birth certificate and maternal discharge data for patients who underwent cesarean delivery in any California hospital between October 2015 and October 2021. Severe perioperative surgical morbidity is an index characterized by severe surgical complications occurring during hospitalization for cesarean delivery, identified using International Classification of Diseases, Tenth Revision diagnosis and procedure codes for severe surgical complications. The primary outcome was all-cause postpartum readmission within 42 days after hospital discharge. Readmission rates were quantified for patients with and without severe perioperative surgical morbidity, and generalized estimating equations were used to estimate adjusted relative risks (aRRs), adjusted risk differences (aRD), and 95% CIs, accounting for patient- and hospital-level factors. In secondary analysis, the association was assessed separately for prelabor and intrapartum cesarean deliveries. RESULTS:The study population included women who had undergone 703,079 cesarean deliveries. The readmission rate was higher among those with severe perioperative surgical morbidity compared with those without severe perioperative surgical morbidity (469.4/10,000 [95% CI, 428.0-511.0] vs 165.3/10,000 [95% CI, 162.3-168.3]). Severe perioperative surgical morbidity was associated with a twofold increased risk of readmission (aRR 2.22; 95% CI, 2.00-2.46). The aRD for patients with severe perioperative surgical morbidity was an excess of two readmissions (2.5; 95% CI, 2.1-3.0/100 cesarean deliveries) compared with patients without severe perioperative surgical morbidity. Wound infection was the most common diagnosis at readmission among patients with severe perioperative surgical morbidity (77/10,000; 95% CI, 60.5-95.3). The risk of readmission was similar among patients with severe perioperative surgical morbidity and without severe perioperative surgical morbidity who underwent intrapartum cesarean delivery (aRR 2.35; 95% CI, 2.09-2.65) and prelabor cesarean delivery (aRR 2.03; 95% CI, 1.72-2.40). CONCLUSION/CONCLUSIONS:Nearly 1 in 20 patients undergoing cesarean delivery who experience severe perioperative surgical morbidity undergoes postpartum readmission, with a twofold increased readmission risk at 42 days after discharge. Patients with severe perioperative surgical morbidity may benefit from targeted follow-up to reduce postpartum admission.

OBJECTIVES/UNASSIGNED:To evaluate prevalence of sugar dating among undergraduate students and assess the demographics and motivations of sugar babies. PARTICIPANTS/UNASSIGNED:This study included 1582 undergraduate students 18 years or older in an urban, private university in the U.S. (82 sugar participants and 1500 controls). METHODS/UNASSIGNED:From October 2019 to May 2020, a cross-sectional, online survey asked participants about sugar dating experiences, substance use history, and childhood traumas. RESULTS/UNASSIGNED:Prevalence of sugar dating was 5.2%. Sugar babies were 2 to 5 times more likely to have experienced childhood trauma defined by the 10 item ACE questionnaire. Sugar babies were more likely to have financial support (loans, scholarships, Federal Pell grants, work-study), use illegal drugs, and have greater daily alcohol consumption. CONCLUSIONS/UNASSIGNED:Many sugar babies have experienced vulnerabilities (financial need, childhood traumas) that could heighten their risk of exploitation by sugar sponsors. Future studies should explore the dynamics of sugar relationships among undergraduate students and the risks accompanying these relationships.

OBJECTIVE:The aim of this study was to evaluate the incidence of congenital anomalies in dichorionic-diamniotic twins conceived with in-vitro fertilization (IVF) versus unassisted conception pregnancies in a large geographically diverse population. DESIGN/METHODS:This is a secondary analysis of data from a retrospective cohort study of twin pregnancies seen at 17 centers between 12/2011-2/2020. SUBJECTS/METHODS:This study included dichorionic-diamniotic twins conceived unassisted, or by in-vitro fertilization. EXPOSURE/METHODS:The exposure group is dichorionic-diamniotic twins conceived with IVF. MAIN OUTCOME MEASURE/METHODS:The primary outcome was presence of a congenital anomaly. Neonates with an abnormal newborn exam were evaluated for having a major or minor congenital anomaly and the major anomalies were further classified by organ system (cardiac, renal/genitourinary, gastrointestinal, and musculoskeletal). RESULTS:Of the 968 dichorionic-diamniotic twin pregnancies included, 521 (53.8%) were conceived with IVF and 447 (46.2%) were conceived unassisted. Congenital anomalies were found in 70 pregnancies (7.23%). Of those, 37 were found in pregnancies conceived by IVF (52.9%) versus 33 unassisted conception pregnancies (47.1) (p=0.87). There were no significant differences between IVF and unassisted conception pregnancies for major anomalies (p=0.65) or minor anomalies (p=0.94). CONCLUSION/CONCLUSIONS:In this large cohort of twin pregnancies, there is no significant difference in the incidence of anomalies for dichorionic-diamniotic twin pregnancies conceived by IVF versus unassisted conception pregnancies.