Contact

Mamta Rohra
Senior Program Assistant
Department of Obstetrics & Gynaecology
E-mail: mamta.rohra@vch.ca

Medical Expert/Clinical Decision-Maker

Definition

Gynecologic Oncologists possess a defined body of knowledge and procedural skills which are used to collect and interpret data, make appropriate clinical decisions, and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date, ethical, and cost-effective clinical practice and effective communication in partnership with patients, other health care providers, and the community. The role of medical expert/clinical decision-maker is central to the function of gynecologic oncologists and draws on the competencies included in the roles of scholar, communicator, health advocate, manager, collaborator, and professional.

1.1 General Objectives

The fully-trained gynecologic oncologist must demonstrate:

  • diagnostic and therapeutic skills for effective and ethical patient care
  • the ability to access and apply relevant evidence-based medicine to clinical practice
  • effective consultation services with respect to patient care, education, media relations and legal opinions
  • recognition of personal limitations of expertise, including the need for appropriate patient referral and continuing medical education

1.2 Specific Objectives

In order to achieve these objectives, the fellow must demonstrate both knowledge (cognitive skill) and technical ability in the approach to problems in the practice of gynecologic oncology.

1.2.1 Cognitive Skills

The fully-trained gynecologic oncologist will possess knowledge of the following clinical conditions or problems encountered commonly in the practice of obstetrics and gynecology. This list should be considered in its totality, and not be considered as comprehensive for all disorders in the practice of this specialty.

1.2.1.1 An extensive level of knowledge is required for the following:

The pathophysiology, investigation, diagnosis, and/or management of pre-malignant and malignant diseases of the vulva, vagina, cervix, uterus, fallopian tube, ovary, and trophoblast, including:

  • known risk factors for pre-malignant and malignant gynaecologic conditions
  • Tumor immunology, host defense mechanisms and biologic therapy
  • Genetics of cancer including mechanisms of human gene mutations, oncogenes, tumor suppressor genes, apoptosis, mismatch repair genes and telomeres
  • Genetic studies in human cancers including breast, colorectal, endometrial and ovarian cancer
  • the current guidelines and indications for screening for cervical, endometrial and ovarian cancer, and an understanding of the reliability of current screening methods.
  • the classification, staging, and natural history of all genital tract cancers
  • appropriate use of simple and radical surgery, including node sampling, and debulking surgery in the management of gynaecologic malignancies, and the indications for appropriate referral for more extensive surgery, radiation, and systemic therapy
  • the principles of colposcopy, including its limitations and the indications for referral for colposcopic assessment.
  • the principles and complications of chemotherapy and radiotherapy for gynecologic malignancies, including an understanding of the indications for consultation with appropriate specialists
  • the principles of palliative medicine for incurable gynecologic disease, including the social, ethical and legal implications of the various options
  • the concept of quality of life and its role in the management of oncology patients

Preoperative and Postoperative Care

  • perioperative risk factors and their assessment
  • the principles and appropriate use of nutritional support
  • the principles of wound healing
  • the principles and appropriate use of narcotics and NSAIDs for postoperative pain control
  • the management of postoperative medical and surgical complications, including indications for consultation with other specialties and/or the use of invasive hemodynamic monitoring and ventilatory support

Medical Oncology

  • Discuss the chemotherapy treatment of common gynecologic cancers
  • List the short and long-term side effects of the commonly used chemotherapeutic agents.
  • Be able to discuss with patients the rational for treatment programs, the disease prognosis and the quality of life of patients both on and post chemotherapy.
  • Discuss the treatment of recurrent disease, rational for drug choices, prognosis, response rates etc.
  • Be able to discuss with patients the role of palliative care: palliative surgery and symptom management in the face of incurable disease.
1.2.1.2 A working level of knowledge is required for the following:

Non-Gynecologic Conditions

The pathophysiology, investigation, diagnosis, and/or management of:

  • colorectal disease, including diverticular disease, colon and rectal cancer, inflammatory bowel disease, and appendicitis
  • bladder malignancy, including the approach to microscopic hematuria
  • breast conditions, including benign breast disease, breast cancer screening, and the effect of breast cancer and its therapies on the reproductive system
  • medical disorders that may have an effect on or be affected by the female reproductive system, including hypothalamic and pituitary disease, thyroid disease, osteoporosis, diabetes, cardiovascular disease, renal disease, and transplantation

Radiotherapy

  • basic principles of gynecologic radiotherapy including the physical and chemical nature of radiotherapy
  • biological effects of radiation including an understanding of radio-sensitivity and radio-curability.
  • An understanding of the effects of radiation on the fetus
  • A working knowledge of external beam radiation, brachytherapy and interstitial therapy and their clinical indications

1.2.2 Technical Skills

The fully-trained Gynecologic Oncologist must possess a wide variety of technical skills. The following is a detailed list of procedural and surgical skills. This list should be considered in its totality, and not be considered as exhaustive for all disorders in specialty practice.

1.2.2.1 Diagnostic Procedures and Techniques

The Gynecologic Oncologist in practice will utilize a number of diagnostic procedures and techniques. The fully trained fellow will demonstrate an understanding of the indications, risks and benefits, limitations and role of the following investigative techniques specific to practice, and will be competent in their interpretation.

Cytology and Histopathology – the physician will be competent and performing the following investigations and interpreting the results

  • cervical cytology
  • vulvar and vaginal biopsy
  • colposcopy with directed cervical biopsy (including LETZ/LEEP)
  • cervical polypectomy
  • endocervical curettage
  • endometrial biopsy

The fellow will also be able to identify the gross and microscopic characteristics of vulvar dermatoses, genital tract neoplasias (benign, premalignant, and malignant), and trophoblastic and placental disease.

1.2.2.2 Therapeutic Technologies

The fully trained fellow will have an extensive knowledge of the physics and technological application of the following therapeutic modalities, including the risks, benefits, and complications of these approaches.

  • electrocautery
  • cryotherapy
  • lasers
  • external beam and intracavitary radiotherapy
1.2.2.3 Surgical Skills

The categorized list also reflects the level of technical skill competency for each surgical procedure expected after completion of a fellowship program.

a. Surgical Procedures List A

The fully trained fellow must be competent to independently perform the following procedures in List A. He/she should be able to manage a patient prior to, during and after all of the following procedures. The fellow must be able to discuss with the patient the risks, benefits, and complications of these surgical treatments, as well as any available non-surgical treatment alternatives and the consequences of the absence of surgical treatment.

Open Gynecologic Procedures

  • total abdominal hysterectomy
  • radical abdominal hysterectomy
  • pelvic lymph node dissection
  • para-aortic lymph node dissection
  • pelvic exenteration anterior, posterior and total
  • infracolic omentectomy
  • repair of wound dehiscence
  • ureterolysis
  • enterotomy and cystotomy repair
  • small bowel resection and anastomosis
  • low anterior resection and anastomosis
  • abdominal-perineal resection
  • colostomy – end and loop
  • hypogastric artery ligation

Vaginal Gynecologic Procedures

  • cervical conization
  • vaginal hysterectomy
  • vaginectomy
  • trachelectomy
  • radical vaginal hysterectomy

Other Procedures

  • abdominal paracentesis
  • thoracentesis
  • laparoscopic pelvic sentinel node biopsy and lymphadenectomy
  • radical vulvectomy
  • simple vulvectomy
  • inguinal femoral sentinel node biopsy and lymphadenectomy
  • appendectomy
  • hernia repair
  • line insertion for invasive monitoring or administration of intravenous nutrition
  • laser vaporization of premalignant lesions of the lower genital tract
  • loop electrical excisional procedure (LEEP) or large loop excision of the transformation zone (LLETZ)
b. Surgical Procedures List B

The following procedures in List B are those that the fully trained fellow will understand and be able to perform, though he/she may not have actually acquired sufficient skill in residency to independently perform them. The fellow will be able to explain the indications for each of these procedures, as well as the perioperative management and complications.

  • Urinary diversion with ileo-conduit and with continent conduits
  • Split thickness skin grafting
  • Myocutaneous flap reconstruction of neovagina
  • Myocutaneous flap reconstruction of vulvar defects