SGO Issues Jan. 28, 2016
NCI centers call for increased HPV vaccinations
Medical malpractice explored at Winter Meeting
Palliative care in cervical cancer, part I | Lois Ramondetta, MD
Lady Ganga film continues movement to end cervical cancer
Cervical cancer website resources available
On Jan. 27, National Cancer Institute-funded cancer centers issued a joint statement calling for increased human papillomavirus (HPV) vaccination. The NCI statement cited statistics from the Centers for Disease Control and Prevention (CDC), which indicated that approximately 79 million people in the United States are currently infected with HPV, and 14 million new infections occur each year. The Society of Gynecologic Oncology, which represents the specialists who treat cervical cancer, strongly supports vaccination of both girls and boys against HPV, and offers resources to the general public at sgo.org/hpv.
Over 90 percent of surgeons are sued at some point in their career, yet the average physician has minimal training in the process until they actually experience their own case, says Jeffrey M. Fowler, MD, of The Ohio State University in Columbus, OH. Attendees of the 2016 SGO Winter Meeting will learn how medical malpractice might impact gynecologic oncologists in a session titled, “Clinical Practice Matters: Medical Malpractice and Other Issues.”
Dr. Fowler and Larry J. Copeland, MD, also of Ohio State, will co-moderate the session designed to help attendees develop a clear understanding of the medical malpractice process, areas of highest risk for litigation in gynecologic oncology, and ways to incorporate risk management strategies.
The session is new to the Winter Meeting, which traditionally attracts a large number of early career SGO members. The conference is Feb. 11-13 at the Resort at Squaw Creek in Lake Tahoe, CA.
“I do not think that most physicians receive any formal education on the medical malpractice process or risk management,” said Dr. Fowler. “There is evidence that once a case is initiated against them most doctors feel that they do not receive adequate support from their health system. Familiarity with the process in advance may alleviate some anxiety but also facilitate proper preparation of their defense.”
Dr. Fowler noted that while missed or delayed diagnosis of a malignancy is a major area in medical-legal liability, such situations usually occur prior to a patient seeing a gynecologic oncologist.
“The highest risk areas for gynecologic oncologists would be adverse events related to surgery, delayed diagnosis of a surgical complication and complications related to minimally invasive surgery,” he said.
“Management of rare tumors is also a potential risk area,” Dr. Copeland explained. “And litigation regarding the informed consent process also seems to be on the rise.”
Participants will also learn about becoming an expert witness in a medical malpractice trial.
“Probably the most common pathway to becoming an expert witness is after you have been in practice for five to ten years you may be invited to provide an expert opinion,” said Dr. Copeland. “If the counsel is confident you can deliver the message at trial then you may be engaged further. Responding to attorney interrogations is tricky and takes some practice to accurately reflect your opinions and not be painted into a corner based on a poor choice of words.”
Dr. Copeland added that senior members of the discipline may be invited to review cases more frequently than their younger colleagues, but that junior colleagues are not necessarily being “disloyal” to their colleagues if they act as a plaintiff expert.
“Being a good plaintiff expert, ironically, may actually help the defendant,” he said. “A bad plaintiff expert is a worst-case scenario. Sometimes a defense expert at trial overstates the defense position—causing harm to the defendant.”
One aspect of medical malpractice that will be brought up at the Practicing Wellness Special Interest Session at the SGO Annual Meeting in San Diego is its connection to poor physician well-being. Dr. Fowler explained how medical errors have been shown to have significant and long-lasting emotional impact on surgeons.
“Medical errors were significantly associated with low mental quality of life, depression and burnout,” said Dr. Fowler. “A higher level of burnout correlated with an increased risk for medical error. Those reporting medical errors also measured low for career satisfaction.”
Dr. Fowler added that both the frequency of malpractice lawsuits and the adverse associations with surgeons’ mental quality of life, burnout, career satisfaction, and suicidal ideation emphasize another occupational risk factor that can adversely impact surgeons.
As Cervical Cancer Awareness Month comes to a close, I find myself more tormented and frustrated about the status of health care in the United States when I see a woman who has been diagnosed with, treated for, or dying from cervical cancer than I do with any other gynecologic cancer. Delivering bad news is never easy, but telling someone that they have cancer is especially difficult when we know it could have been prevented.
I work in an environment where most patients are uninsured and without continuous access to health services, so I care for many women with advanced cervical cancer and many more women with recurrent or incurable cervical cancer.
In attempting to care for and treat women with incurable cervical cancer, the issue of futile care and palliative solutions seems so much more palpable to me. Pain, for instance, is much more common in women with recurrent cervical cancer than with other gynecologic cancers. Combining these severe pain symptoms with low health literacy and excessive social stressors, we are left with one of many tragic triads within the scope of life of women with cervical cancer.
Adding bevacizumab to standard treatment, regardless of the controversy, has given some hope to those experiencing recurrence and increased the previous improvement of 3 months Overall Survival (OS) to as much as 5 months. In my experience, there have been cases where adding bevacizumab initially appears to melt away the tumor and give a false sense of optimism to both the physician and patient. Eventually, gynecologic oncologists treating incurable cervical cancer need to determine what level of care or treatment should be offered after standard therapy has been given knowing that the response rates are slim to none.
Some people have posed the question why palliative care for cervical cancer patients is different from ovarian cancer. Cervical cancer settings are different for many reasons. We recently looked at symptoms at time of referral to palliative care and found more than half of patients with advanced cervical cancer were significantly burdened with pain, anorexia, a poor feeling of well-being, fatigue, insomnia, and constipation at the time of palliative care referral. The burden of disease for the majority of these patients always seems so much greater.
For many of these cervical cancer patients, the level of health literacy seems lower (e.g., they did not avail themselves of screening tests) or maybe the stressors that kept them from getting regular screening tests (denial, fatalism, fear or family burden) in many cases seem more severe. Research has shown that women with cervical cancer often come from a lower socioeconomic background and therefore may feel the pressure of out-of-pocket costs to a greater extent than other gynecologic patients.
Does any of this matter as we make decisions with and sometimes “for” patients about how they spend the rest of their lives? If a patient says, “Whatever you say, Doc,” do we take this information into account? Do we tell them that there is always one more chemotherapy agent, or do we tell them that we have no proof that their life will be extended or of better quality with additional treatment?
Or do we tell our patients about the Temel paper, which states in part, “Palliative care, with its focus on management of symptoms, psychosocial support, and assistance with decision making, has the potential to improve the quality of care and reduce the use of medical services.”
Do we always ask the patient and ourselves, “What is your goal for the rest of your life?
Lois M. Ramondetta, MD, is a Professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center, Houston, TX, and Chief, Division of Gynecologic Oncology, Lyndon B. Johnson General Hospital, Harris Health System, Houston, TX. Part II of her blog post on palliative care in cervical cancer will appear next month in SGO Issues.
The documentary film Lady Ganga follows the story of Michele Baldwin, who was 45 years old when she was diagnosed with terminal cervical cancer. Before her death, the single mother traveled to India to break a world paddle boarding record on the Ganges River and increase awareness about cervical cancer. Lady Ganga was produced by Lumiere Media, which released Someone You Love: The HPV Epidemic last year, and is part of a worldwide movement to stop this preventable disease through HPV vaccinations and cervical cancer screening.
January is cervical cancer awareness month, and the Society of Gynecologic Oncology and the Foundation for Women’s Cancer have a number of online resources that clinicians can share with their patients. SGO’s cervical cancer page includes general information about cervical cancer, clinical practice guidelines; SGO position statements and related Choosing Wisely resources on cervical cancer screening. Through the FWC website, patients can learn more about screening and prevention, diagnosis and treatment, and additional information in Spanish. Last year SGO also produced a short video on the importance of HPV vaccination for boys and girls.