Dr. Rose Provides Insight into Gynecologic Oncology

Session 213

Dr. Stephen Rose is an academic gynecologic oncologist who, as someone who recovered from cancer himself, found his passion for helping women. If you want to know more about the field, check out the Society of Gynecologic Oncology.

For more podcast resources to help you with your medical school journey and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:16] Interest in Gynecologic Oncology

Stephen did a rotation as a fourth-year medical student on the gynecologic oncology service at Indiana University where he was a medical student. He worked with some great GYN oncologists there and got to see the full spectrum of GYN oncology. Stephen was drawn to the breadth of the surgery and the way they cared for patients with chemotherapy and end-of-life issues.

He chose OB-GYN because he felt a better connection to the women population when he was in medical school. He wanted to spend my life taking care of women but he initially hadn’t given much thought to the cancer aspect of that yet.

'There's a different breadth of surgery that a GYN oncologist performs compared to a regular gynecologist.' Click To Tweet

Moreover, a lot of OB-GYN physicians deliver care to women who are, by and large, healthy women and having children at a very wonderful time in their lives. It’s a stark contrast in gynecologic oncology because these are women faced with the most significant health crisis of their lives, and sometimes, ultimately what would take their lives. And so, Hunter felt very connected to that.

Stephen had cancer called Hodgkin’s lymphoma when he was a third-year resident. It was right before he did their Gynecologic Oncology rotation as a resident. And so, the mix of those two things together cemented his desire to go on and work in cancer medicine at that point.

[06:07] The Biggest Myths or Misconceptions About Gynecologic Oncology

Stephen says that one of the biggest myths people hear is that it must be really sad to deal with cancer patients. But a lot of the women they’re taking care of are actually cured of their cancers, which is a very rewarding experience. You get to form relationships with people over time who are doing well.

'People forget that the majority of gynecologic oncologists practice or endometrial cancer patients. And endometrial cancer, by and large, is a very curable disease.'Click To Tweet

For the patients who, unfortunately, aren’t as lucky with the diagnosis or prognosis, it’s no different than any other cancer physician or doctor that deals with patients with a terminal illness. And so, having a healthy perspective helps.

Stephen adds that one of the nice things, which is also one of the hard things, is that you get to know people really well. They don’t only operate under patients, but that they administer chemotherapy as well. And so, you’ll have a relationship with someone with a terminal illness, sometimes all the way up to 10 years before that illness might take their life. And so, you get to know these women really well. That’s the beauty of it. But it’s also the heartbreak of it to a certain extent.

You get to know them really well and they become a part of your life. But you just have to take the lessons you learned from it with you and realize that it’s okay to be sad when a patient passes away.

[08:41] Traits that Lead to Becoming a Good Gynecologic Oncologist

Stephen says you have to like surgery because, at its heart, it’s a surgical subspecialty of OB/GYN. You have to be technical, and enjoy the surgical aspect of medical care.

Persistence is also key because a lot of what they do take a long time. That’s at least seven years of training before you’re finished. So you have to be able to come in every day and put in the hard work to get through that.

[09:41] Types of Patients

Most of their patients have been referred because they either have a diagnosis of cancer or have a suspicion they have gynecologic cancer. For example, endometrial cancer patients usually already have a biopsy that shows they have endometrial cancer and they get referred in.

For example, ovarian cancer patients will be sent because of a CT scan or an ultrasound finding that has a concern for cancer. Those will be patients they will see and operate on. They talk about the risks of cancer versus a benign mass, for instance.

In a typical clinic, you’ll have a full-day seeing new patients, and sometimes, people will give chemotherapy in their own clinic.

At Stephen’s practice, they have a different model where they have a very specific clinic where all of their chemotherapy patients come to the staff. Then they do a couple of days in the operating room.

Some of the surgeries they perform are laparoscopic minimally invasive. They use a lot of robotic techniques for hysterectomies and sentinel lymph node detection for endometrial cancer. They do a lot of open surgery for ovarian cancer as well as laparotomies with the removal of the ovaries and lymph nodes. Oftentimes, they do debulking surgeries where they get rid of the bulk of cancer in the abdomen. Those might entail bowel resections, maybe colostomy or ileostomy. They also do splenectomies as well as diaphragm resections.

[12:33] Taking Calls & Life Outside of the Hospital

Most of them in medical school take overnight calls or 24-hour calls. But the call for GYN oncologists they do at their hospital is four days in a row, Monday through Thursday, and then Friday through Sunday. This setup gives them some continuity to the care they’re providing to the patients in the hospital. And so, they can routinely be on call for a period of three or four days in a row.

In a private practice setting, things are a little bit different as the call demands are a little bit higher. Whereas in an academic setting, a lot of those calls from the floor go into residents and fellows.

Moreover, Stephen points out that one of the interesting things about OB/GYN is that so much of that work happens at night. Babies don’t really follow any routine for when they’re going to be born.

But the GYN oncologists follow a different cadence as the days are fairly long, but your nights are mostly free. You might put in 10 to 12 hour days, but your evenings are, by and large, free, and you’re not up at two in the morning doing deliveries every third or fourth night. So it’s a different cadence to the work, but Stephen thinks it lends itself a bit better to have a life outside of the hospital.

[15:30] The Training Path

After doing four years of OB/GYN residency, you do either a three or four-year fellowship in GYN oncology. Most fellowships are three years, and usually, there’s a one-year rotation of research and then two years of clinical work.

These four-year fellowships usually offer an advanced degree for that extra year, whether it’s a master’s in clinical research or some other degree. Typically, they’re a bit heavier on the research end.

[16:27] Overcoming the Negative Bias Against DOs

Stephen says that gynecologic oncology fellowship is historically pretty difficult to get into. They have roughly 100 applications for only one spot every year in their program at the University of Wisconsin. There are 62 fellowships now. When he started in 2006, there were only about 37 fellowships in the country.

Stephen adds that a good amount of research on your CV is really helpful. One of the things that tend to separate good GYN oncology applicants is whether they’ve done some research during their residency or undergraduate training. Some sort of inquiry into gynecologic cancer can separate you a little bit. They also look at things like medical school performance, as well as board scores, and extracurricular things.

'Coming from a DO school certainly isn't going to count you out by any stretch. But you do have to make sure you have the other areas shored up in order to be competitive.'Click To Tweet

[18:24] Message to the Future OB/GYN

Stephen explains they struggle the most with access. Over time, they get referred more and more patients. But when he first started as a GYN ecologist, they had a hard time, sometimes with people operating on ovarian masses that were very likely cancer. Then they would be sent to them with a half-completed surgery.

'The pendulum has swung a little bit further in the other direction at this point where most OB/GYN are reluctant to operate on anyone with even a slight concern for cancer in the ovary.'Click To Tweet

That being said, there has been a shift in that most OB/GYNs are now reluctant to operate on patients with even a slight concern for cancer. This has created an access issue for cancer patients being able to get into their GYN oncology appointments.

Therefore, he advises future primary care physicians to look to the risk of this mass being cancer. Whether it’s something that could be done locally, or does it really need to be done in an academic center.

Stephen clarifies it’s not the fault of the OB/GYNs but it’s just the way that the systems and the way that medicine has flowed in the last 10 to 15 years.

[20:12] Other Specialties They Work the Closest With

GYN oncologists work closely with colorectal surgery. Oftentimes, their cancers will be linked in some ways. For example, colon cancer can sometimes grow into pelvic structures like the ovary or the uterus. So they’re asked to come and help remove those organs during colon cancer surgery, and vice versa.

The other group of surgeons they work routinely with is plastic surgery. They do larger surgeries that need flaps, whether it be from the chrysalis or rectus abdominis. And they’ll come in and help with those to fill defects in the pelvis at times. They also work closely with medical oncology.

[21:31] What He Wished He Knew Before Going into the Field

Stephen recalls one of his mentors told him that the acuity of the patients and their medical needs never get any easier. The patients just kept being sicker over time. And that’s the piece that can, at times, begin to worry down a little bit.

Their patients are very ill, whether from cancer or from other sources. A lot of their patients are diabetic and obese and have high blood pressure, congestive heart failure, or kidney disease. And so, they see a lot of medical illness and a lot of pretty sick patients.

“Over time, it's a pretty hard edge to live on. So you have to be comfortable taking care of those medical illnesses as well as being a surgeon.”Click To Tweet

When asked about he handles the issue of obesity when more and more people are now talking about body positivity, Stephen explains that over time, you learn the techniques of being able to talk to patients without making them feel bad about being obese. That being said, it’s a fine line to walk.

[25:31] The Most and Least Like Things

Stephen is proud to say that the patients they serve are some of the best patients anywhere. By and large, women are the glue that keeps most families together. They are the mothers and the grandmothers, and people tend to rally around the matriarch of the family. And they get to see that day in and day out.

The women themselves are so courageous, gracious, and so thankful for the care that they provide them. And so, it’s an honor to serve them. Hence, the number one thing for Stephen is being able to serve that population in the way they have over the years.

The second thing he loves is operating, being able to care for women in that way and getting rid of these cancers, and allowing women the ability to heal from them.

On the flip side, the hardest part for him is when you have patients, you’ve made these connections with, are struggling with recurrences. Then they have to turn that corner towards palliation of cancer, and that is always difficult.

[27:29] Major Changes Coming into the Field

'Robotics was a big change in the last 15 years and allowed so many more surgeries to be done minimally invasively.'Click To Tweet

One of the biggest advances in ovarian cancer treatment has been PARP inhibitors, allowing patients to live longer than they were living before these drugs became available.

As to where the field is going, they’re learning more about the genetic signatures of these tumors. It’s going to help them treat people in better and better ways. So there’s just an incredible opportunity in the next 20 years.

They’re looking to find something better than actually just removing the organs. Especially removing ovaries, because there are so many health implications to taking women’s ovaries out at pre-menopausal ages. They have made some definite ground by taking out fallopian tubes instead of ovaries. They’ve figured out that most ovarian cancers actually start in the distal end of the fallopian tube.

And so, salpingectomy as a means to reduce the risk of ovary cancer has really taken off in the last few years and allowed women to keep their ovaries and their hormones.

They are finding more and more mutations that increase the patient’s risks of having ovarian or breast cancer, or even endometrial cancer in some cases. And so, prophylactic surgery will always be a part of that. But with these new mutations, Stephen hopes they will be able to find new medications that can take the place of prophylactic surgery.

[30:29] Final Words of Wisdom

If he had to do it all over again, Stephen says he would still have chosen the same field. Finally, for the students thinking about gynecologic oncology surgery in the future, reach out to your local gynecologic oncologist with your interest. It’s always great to get a head start.

Reach out early and let them get to know you. At their institution, if they know someone’s interested, they make sure they include them in any research studies that would be appropriate for them and try to mentor them along to help them get there if they want to.