Gynecologic Oncology Education Program
Morning Work Rounds:
Interdisciplinary work rounds take place at 7:00 AM each morning except for Thursday mornings when there are OB/GYN department meetings. All GYN Oncology patients are cared for by this team. The team consists of the on-call faculty, clinical fellows, resident team (PGY-1, PGY-2, PGY-3), advanced practice provider (APP), and clinical pharmacist. Prior to these rounds, medical students and residents see and evaluate patients and write their progress notes. The on service fellow is expected to provide guidance to the other trainees and take primary responsibility for ICU patients and other complicated situations. The on service fellow leads rounds with the faculty member providing direct observation.
Saturday and Sunday Rounds:
On the weekend, the on call faculty, on call fellow, residents and medical student round together as a team. Prior to these rounds, medical students and residents see and evaluate patients and write their progress notes. The on service fellow is expected to provide guidance to the other trainees and take primary responsibility for ICU patients and other complicated situations. Detailed daily plans are developed for safe sign-out of each inpatient.
Specific off-service rotations were chosen based on both the clinical educational opportunities as well as the quality of the faculty in that specialty. Each of the rotations has a proven track record of excellence in house staff education. The specifics of the educational organization are left to the faculty in charge of the rotation for that specialty. However, the educational content and value have been reassessed on a regular basis to be certain that they are in line with the Guide to Learning in Gynecologic Oncology. The quality and amount of educational opportunities are also routinely evaluated. For the 2019-2020 academic year, the off service rotations are Palliative Medicine in May of the 2nd fellowship year, Radiation Oncology in November of the 3rd fellowship year, and Urologic Oncology/Plastic Surgery in February of the 3rd fellowship year.
Tuesday and Friday morning clinics are dedicated to seeing patients actively receiving chemotherapy for GYN cancers. The on call fellow is expected to attend these chemotherapy clinics every week of the year with rare exception (vacation, exenteration, rad hyst, etc.). The vast majority of patients under active treatment are seen in one of these two sessions. This multidisciplinary clinic allows for the consolidation of resources to best serve the needs of our patients. Cancer genetics, cancer psychology, social work, clinical research staff, oncology pharmacists and nutrition services are assigned to the clinic during this time. Faculty consists of gynecologic oncology faculty as well as a medical oncologist with special interest in gynecologic cancer, Dr. Howard Bailey. Dr. Bailey adds to the educational experience of trainees by his ability to put the chemotherapeutic agent in the context of many different disease sites. His long-standing interest in drug development and Phase I trials provides the trainees with excellent insight into the details of novel therapeutics.
The fellow is expected to evaluate the patient, determine treatment benefit and toxicity, and develop a plan. They then present to the faculty who sees and examines the patient. Once a treatment plan is determined, the fellow writes the chemotherapy orders under direct supervision of faculty. This clinic provides multiple opportunities to communicate with patients regarding disease progression, changing or stopping treatment, hospice care and end of life issues.
Individual Faculty clinics occur each weekday and include new, pre and postoperative, follow-up and urgent patients. Fellow duties are similar to that described above. After obtaining a history and basic physical exam, the patient is presented to the faculty. Patients are then be examined by the fellow and faculty in concert, including the pelvic exam, and a plan determined by the fellow. If approved by faculty, the fellow then completes the orders and documentation.
Aside from chemotherapy clinic as detailed above, each clinical fellow spends 1 week in clinic per month when there is no off-service rotation. The remainder of the time, the fellow(s) go to the operating room. If there is an off-service rotation, the clinical fellow on-service goes to the chemotherapy clinics but no additional clinic during that month.
The Gyn Onc Division has dedicated block time all day Monday, Tuesday, Wednesday and Friday, with a half a day on Thursday afternoon. In addition, UWHC has created an “oncology room” with time available each day of the week for semi-urgent cancer cases. This provides the service with adequate OR time during daytime hours of the week for its large case volume. Blocked gynecologic oncology “robot time” is also available. All cases, whether major or minor, complicated or simple, inpatient or ambulatory are performed under direct supervision of faculty. In straight-forward cases (simple hysterectomy, adnexal surgery), the resident usually performs the surgery with the direct assistance of either the faculty or the fellow. In more complicated procedures (advanced laparoscopy, radical surgery, bowel resection, etc) the fellow performs the surgery with the direct assistance of faculty. It is the faculty’s responsibility to ensure safety by providing graduated responsibility. The fellow is given immediate feedback as well as written evaluation on specifics of surgical technique such as tissue handling, use of assistants, ease of instrument use, and knowledge of the procedure.
Division of Responsibility:
During the times of year when two fellows are on service at the same time, they alternate as the fellow “on service.” This fellow is directly responsible for the inpatient service for the week. The OR cases will be divided between the fellows commensurate to level of training. During a month when two fellows are on service, each fellow will spend one week in clinic.
The vast majority of Fellowship education and responsibilities take place at UWHC. Currently, 95% of gynecologic cancer surgeries are performed at UWHC in conjunction with UWCCC. It is our expectation that there will not be a marked change in this distribution over time. However, we include Meriter Hospital in this application for the following reasons: 1) The Department of Ob/Gyn is based on the Meriter campus, including the administrative offices and conferences; 2) We do have a small surgical and consultative Gyn Oncology presence at their facility including routine endometrial cancer patients, low-risk adnexal masses, and generalist support for difficult benign cases. At this point, we do not plan to assign a fellow to Meriter. It is expected that the fellow may join the faculty for the occasional surgery/consult at Meriter. Educational organization will be the same as if the case had occurred at UWHC.
Attending staff are present for the substantive portions of all major and minor surgical procedures. Fellows have direct supervision and hands-on training in the operating room. Our expectation is that fellows be involved in all aspects of patient management. At the heart of gynecologic oncology training is the development of specialized technical skill and surgical judgment necessary to manage patients with gynecologic malignancies. Focused instruction and technical training in the operating room is best learned directly from experienced practitioners. Fellows benefit from consistent supervision and are not left to learn these skills independently.
These didactic sessions occur weekly from 0730-0830 on Wednesday. These change to 0700-0800 when the Cancer Center Grand Rounds covers a topic of interest. The sessions are attended by Gynecologic Oncology faculty as well as fellows. These are specifically designed for gynecologic oncology fellow education. Background reading materials are distributed ahead of time. The choice of topics has been developed to ensure adequate review of all portions of The American Board of Obstetrics and Gynecology Guide to Learning in Gynecologic Oncology. These topics are covered over a 1.5 year period to ensure that each fellow has the opportunity to be involved with each topic twice. The general framework for disease site related topics is a formal review of the relevant chapter from either Principles and Practice of Gynecologic Oncology by Barakat et al., or Gynecologic Oncology by Berek and Hacker followed by review of sentinel articles in each disease site. When appropriate, faculty from other disciplines such as Medical Oncology, Surgical Oncology, Radiation Oncology, and Pathology cover topics relevant to their discipline.
UW Paul P. Carbone Comprehensive Cancer Center Grand Rounds
This conference held weekly on Wednesday mornings at 0800 is dedicated to topics related to both clinical and basic/translational research of cancer. It is attended by physicians and researchers in the cancer center. Faculty and fellows decide in advance which topics are of interest and move our Wednesday morning didactic 30 minutes earlier to allow attendance at both educational opportunities.
UW Department of OB/GYN Grand Rounds (Thursday 0800/weekly)
This conference is held weekly from September through May and invites a broad range of speakers from both within and outside the UW to speak on all topics of Obstetrics and Gynecology. Gynecologic Oncology faculty is responsible for approximately 2-4 topics per year.
UW Department of OB/GYN Morbidity & Mortality (Thursday 0700/3 per month)
This conference is held 3 out of 4 weeks of each month and reviews reportable events from all UW OB/GYN services as well as interesting cases.
Scientific Writing Workshops
This workshop is held twice annually. It offers a two-day Manuscript Writing section and a two-day Grant Writing section. The course is conducted to meet individual, institutional and national needs to enhance training programs for clinical investigators. It utilizes lectures, discussions, computer demonstrations and writing exercises to teach knowledge and skills necessary to be successful in manuscript ant grant writing. All three current fellows have participated in this course.
Short Course in Clinical Research
It utilizes lectures, discussions, computer demonstrations and writing exercises to teach knowledge and skills necessary to be successful in manuscript ant grant writing.
The fellows will devote an entire year to conducting research. The primary goal of this endeavor will be to provide the fellows with the necessary skills and a knowledge base that may help them conduct independent research in the future. Approximately 2300 sq ft of laboratory space in the Clinical Sciences Center building is currently devoted to conduct Gynecologic Oncology research with plans underway for a major rehaul of the majority of the existing laboratory space.
During the first two months of the program (while on clinical gyn onc service), the fellows meet research mentors to discuss potential research projects. For the research component the fellows can choose topics that are basic science oriented, translational or with a clear focus on clinical and population sciences projects. Once the research topics have been decided, the fellows devote 1 hour per week while on the clinical service obtaining approvals from the Institutional Review Board or the Animal Care and Use Committee. The fellows are assisted by the Clinical Research Associates in obtaining these approvals. It is expected that the approvals will be well initiated before the fellows initiate their research year. During the research year the fellows are mentored by physicians and basic scientists. The fellows meet with their primary mentor (Mentor Committee Chair) once every week. The fellows also present their research findings at weekly laboratory meetings. During the research year the fellows learn basic and advanced laboratory techniques and extensively review the literature to understand the fundamental and state-of-the-art concepts in gynecologic oncology.
Our clinical and basic science faculty are committed to providing a rich laboratory and research experience for our fellows. Time for research endeavors is guarded with vigor and with explicit intent that clinical duties will not detract or distract. On rare occasions, surgical procedures and unusually instructive cases are carried out when the clinical fellows are unable to participate. From time to time, the research fellow is called upon to partake in these cases where the potential for clinical and surgical learning is unique or extraordinarily substantive. Infrequently, the research fellow is asked to help share the burden of clinical responsibilities in the event of illness or absence of clinical fellows—such occurrences are exceedingly rare. The research fellow participates in the weekend call schedule with a responsibility of every third weekend on call from Friday night until Monday morning. Other than morning rounds and emergencies, this call is taken from home. Regardless of circumstances on the clinical service, the research fellow spends over 90% of the research year protected from clinical tasks.
Laboratory Research in the Gynecologic Oncology Division
The Division of Gynecologic Oncology has a productive basic and translational research program led by Manish S. Patankar, Ph.D. The primary Gynecologic Oncology laboratory is conveniently located at the University of Wisconsin Hospital and Clinics (UWHC) which also houses the Division of Gynecologic Oncology. This 1200 sq. ft. wet lab facility is primarily utlizied by Dr. Patankar and will be completely refurbished and updated with modern laboratory facilities. Construction is expected to start in November 2010. Additional 1000 sq. ft. of wet laboratory space has now been made available to Dr. Patankar by the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center. This additional laboratory space is also located at the University of Wisconsin Hospital and Clinics (UWHC). The Division of Gynecologic Oncology therefore has a total of 2300 sq. ft of wet laboratory space available to conduct basic and translational research.
Several projects are currently underway in the laboratories of Dr. Patankar. Brief descriptions and highlights of these projects are provided below.
Dr. Patankar works on several joint projects. The most prominent among these is developing a novel diagnostic test based on the monitoring of the mucin MUC16 (the ovarian tumor marker CA125 is located in this mucin molecule) on specific immune cells. This project has been funded by various intramural funding sources and Dr. Patankar is the PI's on a R21 grant recently awarded by the National Cancer Institute. Dr. Patankar are also co-inventors on a patent application on this topic that has now been filed with the United States Patent Office through the Wisconsin Alumni Research Foundation (WARF).
In addition, Dr. Patankar are also investigating the biology of MUC16 in the progression of ovarian tumors with the ultimate goal of developing novel therapeutic strategies against this cancer. These studies are being conducted in collaboration with Drs. Ira Pastan and Mitchell Ho (National Cancer Institute, Bethesda, MD), and James C. Paulson (Scripps Research Institute, La Jolla, CA). In collaboration with Neoclone Biotechnology (Madison WI) Dr. Patankar have recently completed a National Institutes of Health Phase I Small Business Technology Transfer (STTR) grant to develop novel therapeutic antibodies against MUC16 that can be used to target ovarian tumors.
Another established collaboration between Dr. Patankar and Dr. Paul Sondel (Department of Human Oncology, University of Wisconsin-Madison) is on understanding and enhancing the therapeutic potential of the immunocytokine huKS-IL2 in the treatment of ovarian tumors.
In addition to their collaborative research, Dr. Patankar have also developed and established several independent research projects. Dr. Patankar has developed projects on electrophysiology of ovarian cancer (in collaboration with Dr. Bikash Pattnaik, Department of Pediatrics and Opthalmology), microfluidic cell cultures to study tumor cell immune cell interactions (in collaboration with Dr. Dave Beebe, Department of Bioengineering), developing nanoparticles that lyse ovarian tumor cells by hyperthermia (in collaboration with Dr. Ralph Albrecht, Animal Sciences), and monitoring ovarian tumor growth by novel magnetic resonance imaging techniques (in collaboration with Drs. Sean Fain and Ian Rowland, Department of Medical Physics and Dr. Hirak Basu, University of Wisconsin Paul P. Carbone Comprehensive Cancer Center).
The Division of Gynecologic Oncology also has a strong record in mentoring fellows and graduate student research. Dr. Patankar has been the principle advisor for one PhD and three Masters level graduate students. Dr. Jennifer Gubbels gradauted with a PhD in Spring 2009 and is currently tenure-track Assistant Professor at Augustana College, South Dakota. Masters students graduating from the Patankar laboratory are Elizabeth Dille (currently a PhD student at the University of Kansas), Cara Raphael (currently a second year medical student at Medical College of Virginia, Richmond, VA), and Dr. David Engle (currently second year Gynecologic Oncology Fellow at the University of Iowa). Dr. Patankar is currently serving as the principal advisor for Dr. Chanel Tyler who recently completed her fellowship in maternal Fetal Medicine and is a junior faculty member in the Department of Obstetrics and Gynecology. Dr. Mian Shahzad, who began his Fellowship in Gynecologic Oncology in July 2010 also will receive his PhD from the Endocrinology Reproductive Physiology graduate program at the University of Wisconsin-Madison and Dr. Patankar will serve as his principal advisor. In Fall 2010, Mr. Nick Claussen will also initiated his PhD studies under Dr. Patankar's mentorship.
Dr. Patankar are also jointly mentoring Dr. Arvinder Kapur, a Assistant Scientist in their research group. Dr. Kapur contributes to research conducted by both the PI’s and is also developing her own individual research projects in Gynecologic Oncology. Dr. Kapur is also responsible for providing hands-on training and day-to-day guidance to the Gynecologic Oncology Fellows in their laboratory-based research projects.
Departmental Research Administration and Structure
The Department of Ob/Gyn employs a Research Administrator to oversee all research endeavors in the department. This person acts as a resource for extramural funding opportunities, budgeting, and compliance issues. In addition, the Department has a strong group of Clinical Research Associates (CRAs) to aid in conducting clinical trial research. Three of these CRAs are assigned to the Gynecologic Oncology Division. Their expertise, hard-work and enthusiasm have led to outstanding clinical trial management and data quality. They assist on IRB application and maintenance, grant submission and manuscript preparation. The Gynecologic Oncology Group (GOG) trials are administered through this office as well as audits of our GOG affiliate institutions.
The Department is also fortunate in having a separate Research Division. This structure provides multiple levels of support for the non-clinician researchers in the department, regardless of which clinical division an individual researcher works most closely. It also helps provide strong, NIH funded research throughout the Department, and allows for the clinicians to maximize their interaction and work with laboratory personnel. The Department supports basic translational and clinical research projects via development funds.
Two full-time information technologists are employed by the Department. They have been vital to establishing and maintaining modern research tools for the Division. Appropriate computer software and web access are made readily available to fellows to aid in research through this resource.
Minimally Invasive and Fertility-Sparing Surgery
The Division of Gynecologic Oncology strives to minimize surgical morbidity by providing appropriate, innovative, minimally invasive options. Prospectively researching such techniques, along with following and reporting outcomes are critical elements to insuring patient safety. Although there exists a core group of laparoscopic/robotic surgeons in the Division (dedicated to minimally invasive surgical innovation and education), all six members perform minimally invasive surgery. Four of the six faculty regularly perform laparoscopic and robotic assisted pelvic and para-aortic lymphadenectomy. Our Division actively enrolled patients on the GOG Lap 2 trial—the 6th most of any GOG institution.
In order to learn radical laparoscopic cervix cancer surgery, the Department supported Dr. Kushner to complete an apprenticeship at the Université Laval in Québec, Canada, under the instruction of Drs. Michel Roy and Marie Plante. The University of Wisconsin soon became one of the first centers in the United States to offer these options for patients. We performed the region’s first laparoscopic radical vaginal hysterectomy, laparoscopic sentinel lymph node mapping, and laparoscopic-assisted radical vaginal trachelectomy.
The Division continues to embrace innovation. We were instrumental in the organization and introduction of robotic surgery at the University of Wisconsin Hospital. We now have four robotic-trained faculty and are regularly performing both endometrial cancer staging and radical cervical cancer procedures with the robot. We follow our outcomes closely, and regularly report at national meetings on innovative robotic techniques, such as robotic-assisted radical vaginal trachelectomy or total robotic radical trachelectomy.
A multitude of research opportunities exist related to endoscopy. We have reported a prospective trial of laparoscopic sentinel lymph node mapping in cervical cancer and have performed a similar study in patients with endometrial cancer. We also have published on specific tools and curriculum for endoscopic education. This topic is of critical importance to Gyn Onc Fellowship, given the variance in resident education along with the complicated nature of the radical procedures being taught.
Our division has a robust quality of life research program. Dr. David Kushner serves on the quality of life committee for the GOG, and has been instrumental in leading the newly formed national network to advance sexual health in female cancer survivors. Lori Seaborne, PA-C, has also played a pivotal role in this endeavor, and is a nationally recognized sexual health educator and frequently lectures on this topic. We have completed a sexual health study on female cancer survivors that was presented nationally and recently published, and recently studied a vibrating wand intervention trial for women recovering from side effects of treatment.
Dr. Rose’s research has a broad quality of life reach. He recently published the first report of the role of humor in the lives of women with recurrent ovarian cancer, and is currently planning a trial with first year fellow Ryan Spencer on a humorous intervention during chemotherapy for women with gynecologic cancer. He and Dr. Spencer’s trial of a mindfulness program intervention while undergoing chemotherapy is currently in the accrual stage.
Dr. Ahmed Al-Niaimi’s research interests are in surgical quality. He presented a plenary session on his work on surgical site infection rates at the 2012 SGO, and is currently working on a comprehensive gynecologic oncology database that will incorporate morbidity as well as quality of life measures on our patients. He is a nationally recognized surgical quality leader and will join with Dr. Robert Bristow in upcoming surgical debulking courses as an instructor.
We are fortunate to have over 95% of our clinical and research activity centralized at the UWHC. The academic offices of the faculty and fellows are located on the 6th floor of the H module. The clinical trials office and half of the gynecologic oncology laboratories conveniently reside in this same space. The remainder of the dedicated gynecologic oncology laboratory space is just one floor down on the 5th floor of the J module.
The inpatient gynecology unit is down the hall from the academic offices on the 6th floor of the F module with the Gyn Oncology Clinic located two floors directly below (4th floor, F module). The chemotherapy administration area for the entire cancer center is on the second floor of the same building. The remainder of major shared clinical areas at UWHC (ICU, OR, ER) is located centrally in the hospital for easy access. The Health Science Learning Center (housing the School of Medicine and Public Health, the Ebling Library for Heath Sciences and an array of meeting facilities) is attached by a bridge to UWHC on the 1st floor.
The Department of Ob/Gyn, and particularly the Gynecologic Oncology Division, enjoys a long-term outstanding relationship with the other surgical specialties. The shared mission is to provide the best quality of care for women treated for gynecologic malignancies. To that end, the Division has been performing a wide-array of upper abdominal, gastrointestinal, reconstructive, and urologic surgeries for decades at a high level of proficiency. Nonetheless, consultation is requested for more complicated surgical and medical issues related to such procedures. Patients benefit from the expertise that these subspecialty services can provide. The fellows will also benefit greatly from the history of collegiality, as they are welcomed on these high-volume surgical services to enhance their educational opportunities.