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Abstract
Several recent advances in gynecologic cancer care have improved patient outcomes. These include national screening and vaccination programs for cervical cancer as well as neoadjuvant chemotherapy for ovarian cancer. Conversely, these advances have cumulatively reduced surgical opportunities for training creating a need to supplement existing training strategies with evidence-based adjuncts. Technologies such as virtual reality and augmented reality, if properly evaluated and validated, have transformative potential to support training. Given the changing landscape of surgical training in gynecologic oncology, we were keen to summarize the evidence underpinning current training in gynecologic oncology.
In this review, we undertook a literature search of Medline, Google, Google Scholar, Embase and Scopus to gather evidence on the current state of training in gynecologic oncology and to highlight existing evidence on the best methods to teach surgical skills. Drawing from the experiences of other surgical specialties we examined the use of training adjuncts such as cadaveric dissection, animation and 3D models as well as simulation training in surgical skills acquisition. Specifically, we looked at the use of training adjuncts in gynecologic oncology training as well as the evidence behind simulation training modalities such as low fidelity box trainers, virtual and augmented reality simulation in laparoscopic training. Finally, we provided context by looking at how training curriculums varied internationally.
Whereas some evidence to the reliability and validity of simulation training exists in other surgical specialties, our literature review did not find such evidence in gynecologic oncology. It is important that well conducted trials are used to ascertain the utility of simulation training modalities before integrating them into training curricula.
- Gynecologic Surgical Procedures
- Miscellaneous
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Introduction
Gynecologic oncologists are highly trained surgeons equipped with the knowledge and skills to manage gynecologic cancers. Skills and competencies required by a qualified gynecologic oncologist should be achieved through a formal subspecialty or fellowship training program within a standardized and quality assured training curriculum.
Several challenges exist in the training and acquisition of surgical skills by trainee gynecologic oncologists. These challenges have been exacerbated by recent positive advances in cancer care. Neoadjuvant chemotherapy and delayed debulking surgery has non-inferior survival and lesser morbidity than primary surgery for ovarian cancer.1 Increasing neoadjuvant chemotherapy use has reduced use of primary debulking surgery in ovarian cancer, resulting in fewer opportunities for training in surgical procedures such as bowel resection, diaphragmatic stripping and splenectomy.2 Successful screening and vaccination programs in high income countries have reduced cervical cancer incidence, resulting in fewer cervical cancers and correspondingly reduced need for Wertheim hysterectomies.3 4 Effective medical management for menorrhagia and benign gynecologic conditions have resulted in fewer hysterectomies being performed during general gynecology training.5 This has the potential to impact readiness for higher gynecologic oncology training among obstetrics and gynecology trainees. In addition, there are well documented challenges to the acquisition of traditional skills in complex open surgery imposed by limited surgical exposure, limited surgical case volume, as well as the introduction of minimally invasive surgery.6 7 Minimally invasive surgery, in addition to reducing training opportunities for open surgery, also presents a distinct, steep learning curve.8
Furthermore, existing concerns regarding gynecologic surgical training in the past decade and the resultant trainee-trainer dissatisfaction have been substantially aggravated by the disruption caused by the coronavirus (COVID-19) pandemic.9 Working hour restrictions in Europe, the United Kingdom (UK) and the United States of America (USA) alleviate trainee fatigue and reduce burnout but may also adversely impact surgical exposure.10 11
Coinciding with fewer surgical opportunities for trainees, the present-day trainee is also confronted by a requirement for greater skill complexity (eg, upper abdominal surgery, surgery for recurrence and a patient population with increasing frailty and comorbidities, including obesity). It is imperative, therefore, that we consider carefully how training curriculums and programs can be augmented and standardized to respond to the challenges of the modern-day cancer workload.
Several solutions have been proposed to address these challenges in gynecologic oncology training including traditional methods, like cadaveric dissection and innovative technologies such as simulation training; virtual reality for laparoscopy and robotics training. Critically, it is not known whether these training methods translate to real life surgical competency or improved patient outcomes, and most have not been independently validated. As an exemplar for simulation training, Hays et al., in their meta-analysis explored the important characteristics associated with effective simulation training in the aviation industry and demonstrated that the use of flight simulators combined with aircraft training led to skills improvements in jet pilots compared with training with aircraft only. Training effectiveness was dependent on task type, as well as the amount and type of simulation training received.12
In this narrative review, we examine the evidence for various methods of acquiring the relevant surgical skills pertaining to gynecologic oncology, including laparoscopic simulation training within the sub-speciality and general gynecology. We also summarize key findings, deficiencies and highlight the need for research in this area to provide robust evidence by presenting examples from other surgical disciplines, for example, colorectal cancer surgery, that could be useful models for gynecologic oncology. Finally, we describe gynecologic oncology subspecialty training programs across high-, middle- and low-income countries. The latter aimed at providing context and aimed at providing context and highlighting disparities in training structure which will need to be addressed to create high quality but resource sensitive, adaptable gynecologic training curricula to tackle the global gynecologic cancer challenge.
Methods
We conducted a literature search of PubMed (Medline), Embase, Google, Google Scholar and Scopus to identify what evidence exists to underpin surgical training in gynecologic oncology, general gynecology and other surgical specialties. We also searched the above databases for literature around the structure of gynecologic training programs and curriculums globally across both low- and middle- income countries (LMIC) and high-income countries (HIC). We included recognized subspecialty training programs both under the remit of obstetrics and gynecology as well as general surgery and also included initiatives toward the acquisition of gynecologic oncology skills outside of a formal subspecialty program. We acknowledge there may be existing programs we have not included where we could not locate sufficient information to be included in this review. We reviewed evidence to augment surgical training from related specialties, for example, colorectal, hepato-biliary and upper abdominal surgery, that can be adapted to gynecologic cancer surgery.
We used search terms ‘surgical training’, ’train the trainer’, ’cadaveric dissection course’, ‘upper abdominal surgery’, ‘colorectal surgery’, ‘gynae-oncology’ (or related terms, that is, each cancer in turn), ‘trainees’ (or related terms) and proposed modes of teaching, including ‘training’, ‘augmented reality’, ‘virtual reality’, ‘simulation’, ‘haptics’ and ‘cadaveric dissection’. We have chosen not to include training using live animal models in this review as these methods are expensive, require infrastructure investment and are difficult to scale.
Current state of training
Our scoping search identified two key themes from the current state of gynecologic oncology training. The first theme highlighted in an experiential survey of European gynecologic oncology trainees related to dissatisfaction with clinical training while the second stressed the need for update and standardization of training programs.13 Gan et al., summarize results from a prospective web-based survey of gynecologic oncology trainees within the European Network of Young Gynaecologic Oncologists. Their results highlighted poor ratings in both training and experience in advanced laparoscopic surgical training and robotic surgical training, due to the paucity of centers offering these treatment modalities.14
Lack of exposure to radical surgeries has been reported within the UK and Europe, with trainee feedback highlighting the need for additional training in radical surgery.15 Roque et al., in the USA discussed the challenges affecting the rapidly changing field of gynecologic oncology as a surgical specialty, highlighting some of the advances in surgical approaches which have led to training deficiencies. They looked at challenges posed by the complexities of the American gynecologic training structure, such as the lack of standardization of training as well as a workforce demographic shift toward a growing number of female trainees. Trainees are generally seeking a better work-life balance including time away for family priorities.7 Several challenges currently in gynecologic oncology training have been experienced in other surgical specialties and it will be useful to draw from their experience in the early application of adjunctive strategies for training.
Evidence for surgical skills training
There are various training methods to suit a range of surgical approaches: cadaveric dissections, live animals and open simulators to guide open surgical approaches, box simulators to guide laparoscopic techniques and virtual and augmented reality to guide robotic approaches.16 17 It is worth discussing concepts around measuring surgical performance before exploring these modalities in detail.
Impact of surgical training techniques
Test reliability is the extent to which a modality can produce stable and consistent results. Using inbuilt tasks within virtual reality simulators, reliability can be tested by the trainee’s ability to complete various psychomotor tasks and Objective Structured Assessment of Technical Skills (OSATS) that measure surgical dexterity parameters, time taken to a complete task, and complication rates. However, these tasks have been shown to lack reproducibility of results when completed multiple times (test-retest reliability) as well as lacking consistency of results in a standard peer review process with different trainers (inter-rater reliability). Therefore, virtual reality validation for use as part of a standard curriculum must include a follow-up of the trainee’s learning curve and the use of two or more senior reviewers to establish aspects of the test reliability.18
Test validity is the ability of a measuring tool to measure what it claims to measure. When a test appears to measure what it purports to measure by using the right parameters, then it has content and face validity. The level of sophistication of modern high fidelity virtual simulators with integrated advanced virtual reality lens for orientation and haptic feedback allows for easy validation of the face and content validity. The test construct validity ensures a virtual reality tool actually assesses surgical competencies. The construct validity of laparoscopic simulations can help distinguish between surgeons of different competencies or skill levels.18 The construct validity reflects the subject’s ability to learn skills on the virtual reality simulator that translate to real-life surgical skills. Shore et al., showed that the use of comprehensive simulation training among obstetrics and gynecology trainees improved technical knowledge and performance in theater compared with conventional residency training.19 The predictive validity of laparoscopic simulation training is useful in determining which virtual reality skills best predict patient safety, clinical outcomes and clinical performance (blood loss, instrument path, and operating time).8 20 21
Adjuncts to skills training
Among the available training modalities in surgical training, there is a paucity of evidence regarding the most effective method. Currently, the master-apprentice or expert-guidance model is used to train surgeons in open surgery and is embedded in the development of surgical techniques and practice. There are various adjuncts to surgical training; modalities include cadaveric dissections, 3D printing and animation and simulation training of various fidelities. Simulator fidelity refers to how closely the simulator can replicate life experiences and this is broadly classified into low and high-fidelity trainers. High-fidelity simulators such as virtual and augmented reality are most commonly employed in procedural training.22 Augmented reality as opposed to virtual reality utilizes a real-world setting so users are controlling their presence in the real-world, as opposed to a fictional reality alone which usually lacks haptic feedback. Laparoscopic box trainers are a common example of low-fidelity simulators.
Cadaveric dissections are an established training adjunct which have been used in surgical specialties for surgical training and skills augmentation with varying but generally good results, depending on the type of specimen and degree of embalment.23 24 A prospective randomized controlled trial (RCT) from Turkey investigating educational tools for laparoscopic colorectal surgery showed that either the use of 3D animation and cadaveric videos 23, individually or in combination, was a superior educational tool at helping candidates in understanding rectal surgery, compared with surgical textbooks.23 A summary of these studies on cadaveric dissection as training adjunct can be found in Online supplemental appendix I.
Supplemental material
Animation and 3D techniques have also been reported in general surgical training literature. In an RCT comparing the educational role of 3D printed models with that of the conventional magnetic resonance imaging (MRI) films in the training of surgical residents, residents who trained on 3D models performed better compared with those who relied only on MRI images.25 This has potential use in pre-operative planning and represents an additional educational tool which is very relevant in the modern context where there is limited recourse to cadavers and animal models for training. There is also evidence from meta-analysis of systematic reviews looking at the role of video based coaching as a method of improving surgical training. In one study, 24 eligible RCTs were identified that showed that video based coaching increased the technical performance of surgical residents performing jejunojejunostomy, right colectomy, and laparoscopic cholecystectomies, even though significant study and intervention heterogeneity was noted due to a wide range of video based coaching techniques included.26 A summary of these studies on various adjuncts such as didactic as well as video based coaching and 3D models has been summarized in Online supplemental appendix II.
Supplemental material
Within minimally invasive surgery, several studies have been conducted in general surgical specialties to assess and validate the use of modalities such as box simulation and virtual reality trainers. A comprehensive systematic review, including 18 RCTs, by Humm et al., investigated the impact of virtual reality simulation training on operative performance in laparoscopic cholecystectomy. This study showed that virtual reality training, compared with no additional training, led to better junior trainee performance in performing a laparoscopic cholecystectomy measured by time to complete task and OSATS.27 A multicenter RCT among colorectal surgery trainees showed that surgical performance of trainee surgeons with different competencies in sigmoid colectomy was well differentiated using virtual reality simulators. Competency gained on the virtual simulator also translated to real-life surgical competency with significantly improved performance through repetition for time, movements, and path length for less experienced surgeons.28 A summary of these studies on various virtual and augmented reality simulation adjuncts and their role in surgical skills training has been summarized in Online supplemental appendix III.
Supplemental material
There is good evidence for a ‘Train the trainer’ program for colorectal surgery where laparoscopic surgery was introduced systematically through training the trainers, feedback, standardized assessment and incentivisation for laparoscopic surgery.29 The IMAGINE trial evaluates this approach in Australian gynecologists, using a surgical outreach training model whose results are awaited. Results of this trial, if positive, is likely to have a significant impact on training approaches within gynecologic oncology.30 In summary, there is a clear case for adapting and evaluating adjuncts and pedagogical research identified in other surgical disciplines to gynecologic oncology training.
Evidence for laparoscopy training in gynecologic oncology
There is some literature describing the evolution and use of laparoscopy among gynecologic oncology trainees in the USA. Frumovitz et al., in a series of longitudinal surveys of American gynecologic fellows demonstrated an increased utility and role of this modality in modern gynecologic cancer care.31 32 Laparoscopy forms the basis of minimally invasive surgery and lies at the intersection between open surgical techniques and the robotic assisted gynecologic procedures.
Even though laparoscopy is now widely employed in the field of gynecologic oncology, our scoping literature search did not find evidence on how best to train trainees in the acquisition of laparoscopic skills. There is however, some evidence regarding the validity and reliability of laparoscopy simulation training in general surgery and general gynecology which can be extrapolated to infer its potential usefulness in gynecologic oncology training.
An overview of the various simulation models shows that generally, simulation models are associated with shorter operative time and fewer intraoperative errors in vivo.8 17 There is considerable literature reviewing the evidence behind simulation based training, using common modalities such as laparoscopic box trainers, laparoscopic virtual reality simulator, animal models and lightly embalmed human cadavers.17 These support simulation training modalities and identify augmented reality with haptic feedback as the highest fidelity modality followed by virtual reality simulators.33 34 The Royal College of Obstetricians and Gynecologists training curriculum for benign gynecology now includes laparoscopic virtual simulation, while a number of gynecologic subspecialty training programs in the USA have already incorporated laparoscopic simulation training as a standard part of their curriculum.7 35
Avenues for further development of this subject include establishing the evidence for laparoscopic skills training in gynecologic oncology via RCTs and subsequent integration of simulation skills training into the training curriculum.20 It will be important to establish the evidence for the construct and predictive validity as well as the reliability of virtual simulation in gynecologic oncology training before integration into the training curriculum. This is due to the highly specialized nature of gynecologic oncology which may not guarantee direct inference from the evidence and experience in general gynecology and other surgical specialties.
Alternative modalities in training
Our literature search identified several training augmentation tools which have been reported as useful, both within the UK and internationally. The two most discussed modalities of gynecologic oncology surgical training include the use of cadaveric models and low-cost virtual reality simulation.
Cadaveric dissection
The use of human and animal cadaveric dissection for surgical training is a well-established training method. Porcine wet laboratory training in laparotomy, small bowel resection, splenectomy, hepatectomy, among other surgical procedures, has been shown to improve surgical proficiency.24 Feedback from the use of cadaveric models for training in highly complex procedures has further demonstrated its usefulness.36 Sideris et al., aimed to evaluate a new postgraduate training course for cytoreductive surgery for advanced ovarian/fallopian tube or primary peritoneal cancer using thiel-embalmed cadavers. This course had consultant surgeons with backgrounds in upper gastrointestinal, colorectal, hepatobiliary and urologic surgery as trainers. Feedback from trainees concluded that the use of surgical experts within a cadaveric training course was invaluable in enhancing gynecologic oncology surgical training, especially due to the multi-organ/system approach required within these procedures.37
Researchers from Istanbul described two cadaveric courses held in 2019, for vulva cancer surgery and abdominal gynecologic cancer surgery. Participant feedback described an improvement in surgical skills, technique development and understanding of topographic surgical anatomy.38 This supports the use of cadaveric dissection alongside clinical training. However, though widely used, this is expensive, limited in access and hard to scale.
Virtual reality simulation
In Zambia, low-cost virtual reality radical hysterectomy training was demonstrated to increase trainees’ confidence, enhance skill development and reinforce anatomical and clinical knowledge. Within this training, participants were trained to perform five sequential steps of a radical abdominal hysterectomy on a virtual reality platform constructed to scale, enabling manipulation with equivalent instruments and visual feedback, but no haptic feedback.39 These methods could reduce the time and cost needed to teach Wertheim’s surgical techniques to trainees and hence, could be arguably beneficial in both high-income and resource-limited settings. Larson et al., showed a 17–50% reduction in operative time with virtual reality training compared with traditional methods or no training, with greater proficiency achieved with more complex procedures.21
Indeed, the challenges related to providing adequate evidence-based training, through training adjuncts like simulation training, for gynecologic oncology trainees exists in the context of huge training disparities worldwide as well as within the same country. Some of these training methods will need adaptation to ensure that they are useful in high income countries as well as low- and middle-income countries. Hence, it is important to examine the evidence very broadly, but also with the knowledge of the disparities in training curricula and requirements in different health systems.
Global overview of gynecologic oncology training programs
The need for formal gynecologic oncology training programs has come to the forefront in many low- and middle-income countries due to a rising burden of gynecologic cancers in these settings. Among the cohort of these countries with gynecologic oncology training, we recognize notable differences in training infrastructure. There are multiple challenges such as the lack of local human resource and infrastructure which hamper the establishment of a modern gynecologic oncology subspecialty training which is comprehensive and of comparable international standards of academia and professionalism.40 41
In many low- and middle-income countries, gynecologic oncology training programs have been achieved through effective collaborative work between local and international partners. There are mainly two types of gynecologic training in this cohort of countries; formal subspecialization, accredited locally, nationally or internationally through foreign universities or entities such as the International Gynecologic Cancer Society (IGCS)40–42 as well as special training in the acquisition of gynecologic oncology skills outside formal subspecialty training of a formal subspecialty program. Gynecologic cancer care is within the remit of general surgeons who have different skillsets in some countries, such as Brazil. This is relevant within the current debate regarding the scope of surgical training in gynecologic oncology.41 Gynecologic cancer in the hands of general surgeons may reflect an underdevelopment of gynecologic oncology as a subspecialty in these settings and this has implications for continuity care and the stewardship of holistic care.
United Kingdom
Gynecologic oncology training in the UK is an established program of 2- or 3 year duration pending evidence of research exemption at time of application. It is a national, Royal College of Obstetricians and Gynecologists structured training program with entry based on years of training criteria and an interview process. An online logbook of surgical and non-surgical competencies is required to be maintained. There is no exit exam; however, there is an annual progress review conducted in the form of a panel which evaluates workplace-based assessments such as Objective Structured Assessment of Technical Skills, Case-Based Discussions, and a mini-Clinical Evaluation Exercise. Research criteria for completion of training includes a higher degree (Doctor of Medicine (MD) or PhD), two first-author original research publications or an advanced professional module in clinical research.43
The Royal College of Obstetricians and Gynecologists subspecialty training program in gynecological oncology supports the majority of training within the UK. However, a small number of UK centers are also European Society of Gynecological Oncology (ESGO) accredited centers. ESGO provides an alternative structured training curriculum which has been adopted by the majority of Europe with over 163 accredited centers across the UK, Europe and the USA.44
Europe
ESGO has formulated a standardized training curriculum for trainees, which has included a minimum number of surgical procedures directly related to a gynecologic cancer diagnosis. All objectives and educational requirements within the ESGO curriculum have been created through the Delphi method (iterative expert analysis of popular opinions and salient points via questionnaires), with a strong focus on trainee involvement. To obtain accreditation, the trainee must complete all qualitative and quantitative objectives and sit a written exit exam.44
United States
Gynecologic oncology fellowship programs are certified by the Accreditation Council for Graduate Medical Education. The program enables individuals to demonstrate proficiency in a diverse spectrum of surgical procedures, as outlined by the American Board of Obstetrics and Gynecology. On completion, the trainee is eligible to take the American Board of Obstetrics & Gynecology oral and written examinations for Board Certification in gynecologic oncology.45
Australia
The Certification in Gynecological Oncology Subspecialty Committee in Australia has the authority to oversee the training and accreditation policies for the attainment of the gynecologic oncology subspecialty. This includes a 3 year scheme with compulsory rotations, reports, work-based assessments, a prospectively approved research project, multi-source feedback and a written examination. All these training requirements must be met, with certification by the Royal Australian and New Zealand College of Obstetricians and Gynecologists board.46
International Gynecologic Cancer Society
In December 2016, the International Gynecologic Cancer Society (IGCS) introduced the gynecologic oncology global curriculum and mentorship program, a 2 year program created for countries in low- and middle-income settings without formal gynecologic oncology training to augment education and training.
The organization leveraged existing infrastructure and collaborations to create a harmonized program for subspecialty training in the management of gynecologic cancer in low- and middle-income countries through the twinning of training institutions in developing and developed countries. Existing relationships and infrastructures such as virtual multidisciplinary teams are used to deliver virtual training alongside hands-on training, ongoing matrices and evaluation, and a final examination with a certificate of completion of training. Fellows keep a logbook through RedCap which can be regularly reviewed by local and international faculty. The Global Curriculum and mentoring scheme has centers in the Bahamas, Ethiopia, Fiji, Guatemala, Jamaica, Kenya, Mozambique, Uganda and Zambia.42
Gynecologic oncology programs in Africa
South Africa
The gynecologic oncology subspecialty training program in South Africa started in 2008. It is a 2 year program with the knowledge-based component assessed through an exit examination and clinical competency assessed through a logbook system. The program has a formal research requirement in the form of completion of a research project.47 The program is accredited by the Health Professions Council of South Africa, Medical and Dental Professions Board.48
Kenya
The training program curriculum in Kenya was developed through the Canadian Society of Gynaecologic Cancer with Moi University responsible for the accreditation of the training program. In 2017, this program became one of the pilot sites for the IGCS training initiative and was subsequently absorbed into the IGCS global curriculum.40
Ghana
Ghana has a long-standing residency program in obstetrics and gynecology established in 1989 between the University of Michigan and the Teaching Hospitals of Ghana. It is off the foundations of this residency program that subsequent training in gynecologic oncology and other gynecologic subspecialties was established. Their 4 year program in gynecologic oncology has specific entry requirements with a comprehensive syllabus covering every aspect of medical and surgical oncology including radiation therapy and pathology. Clinical assessment is through quarterly assessment of the trainee’s logbook while a knowledge exam is through the two-part Fellow of West African College of Surgeons (FWACS) examination. The is also a research requirement. The program is accredited by the Ghana College of Physicians and Surgeons (GCPS) and benefits from modest support from the University of Michigan which has a long-standing relationship with the Ghana College of Physicians and Surgeons.41 49
Ethiopia
The maiden program at the Black Lions Hospital in 2013 was a 3 year program. This was followed by the program at St Paul’s Hospital Millennium Medical College in 2015, both under the accreditation of the University of Addis Ababa and subsequently also accredited by the Association of Gynecological Oncology, Germany.41 Both programs have now been absorbed into the IGCS Global Curriculum and Mentoring scheme as one of its pilot sites.42
Central America, Oceania and Latin America
The first initiative toward providing specialized care for women in Central America was the Central America Gynecologic Oncology Education Program. This training program was designed to reinforce aspects of gynecological oncology training among residents in obstetrics and gynecology in Central America as opposed to a formal subspecialisation program. The Central America Gynecologic Oncology Education Program was developed through a collaboration with the IGCS and American College of Obstetricians & Gynecologist and interested residency programs in Central America. It was initially launched in Guatemala in 2009 but has since expanded to include Honduras, El Salvador, Nicaragua, Panama and Costa Rica.41
In Latin America, like most other low- and middle-income settings, care for women with cancers is being provided by general obstetricians and gynecologists with a limited number of formal training programs for the gynecologic oncologist.50 Brazil offers training in surgical oncology, following which trainees are able to manage other cancers as well as those in women.41
Indian subcontinent
India
India has an established 3 year subspecialty training program with specific entry criteria. Progress is monitored by the trainee’s local institution, with local mentors responsible for training. There is an exit exam which assesses the knowledge based aspect of training.51
Pakistan
Gynecologic oncology as an independent subspecialty is a relatively new program in Pakistan. So far it has been included as part of surgical oncology training, which is an established course.52
A separate gynecologic oncology fellowship is currently being offered as a 2 year fellowship with an entry requirement of 4 years of work experience in obstetrics and gynecology and a basic post- graduate qualification; this is being offered by the Aga Khan University. Entry is based on an interview.53
Nepal
Nepal does not have any formal gynecologic oncology training programs. As there is a strong need for trained gynecological oncologists to provide care, there is a 2 year Global Curriculum and mentorship program designed by IGCS to provide support and training until a program can be established.42
Bangladesh
There is a fellowship program of up to 3 years which candidates are eligible for following completion of basic postgraduate qualifications, with the requirement of an exit exam as well as thesis submission if opting to complete the academic portion of the curriculum (1 year).54
Sri Lanka
Sri Lanka has a well-established curriculum for gynecologic oncology training. Candidates are eligible following completion of their postgraduate qualifications. There is no entrance examination, entry being based on their performance at their Doctor of Medicine/Master of Science examination. The program is for a duration of 3 years with 2 years of local training and 1 year of overseas training followed by an exit assessment to become board certified in gynecologic oncology.55
South-East Asia
There are 24 gynecologic oncology training centers spread out over Indonesia, Malaysia, Singapore, and Thailand; however, the level of training differs across all centers based on local factors.41
Singapore
Singapore offers a 12 month fellowship open to all candidates, including international ones, pending an application and interview process. There is a well-established curriculum with assessments at regular intervals but no exit examination.41
Indonesia
There is a recently established subspecialty training program in the form of a 2 year fellowship offered to gynecologists in Indonesia. Entry is based on a screening process with an exit examination at the end of the fellowship.56
Malaysia
Gynecologic oncology is now an established structured training program of 3 years in Malaysia with an entry criterion and an exit certification. Trainees have the option to spend a portion of their training overseas.57
Thailand
Thailand has a 2 year structured subspecialty training curriculum for candidates who have completed their core residency training in obstetrics and gynecology. Entry is based on a competitive interview with an exit examination comprizing a written and oral examination to be certified as a Gynecological Oncologist.58
One common characteristic noted throughout the review of training programs is that there is no standardization on the objective assessment of surgical competencies at entry or at the end of gynecologic oncology training or fellowships. Although trainees may be assessed based on performance at an exit examination, oral vivas or satisfactory evidence of completion of course requirements based on logbook and review panel recommendations; it is not evident from the curricula that there are standardized or objective approaches to assess surgical competencies at the end of the curriculum.
Finally, it is worth noting that the aforementioned challenges in training may also represent the evolution of gynecologic oncology as a specialty. This may warrant a change in training requirements as well as a change in training strategies as the job description of the modern gynecologic oncologist evolves. Training programs will need to accommodate a trend toward greater centralization with higher volume centers offering treatment for gynecologic cancer. Even within high volume centers, there may be teams that specialize in ovarian cancer surgery or teams that specialize in robotic surgery. In some settings, there may be a shift toward team working with other specialities such as colorectal surgeons, which will influence the requirements for training.
Conclusion
Our review finds there is no standardization of skills assessment or optimal best practice for how to train trainees to operate in gynecologic oncology surgical procedures. There are a wide range of training programs in gynecologic oncology across the world reflecting the needs of the individual healthcare systems. Several potential solutions exist including cadaveric dissection, simulation training, use of virtual reality and 3D model printing. However, these solutions have yet to be thoroughly validated and high quality evidence is lacking for any of these ‘trainee focused’ interventions, particularly in gynecologic oncology surgery. Similar underlying issues with the transfer of surgical skills in trainees in other surgical specialities exist and ongoing research is noted. Most of this work has been done in general surgery and will need to be adapted to gynecologic oncology trainees who usually receive training in obstetrics and gynecology prior to gynecologic oncology training. Robust evaluations of these are needed as future research priorities.
Currently, the evidence to support any interventions is generally of low quality and none have evaluated transfer to clinical environments or sustained impact on skills. Any intervention that improves surgical skills also needs to demonstrate translation to real-world performance and have a meaningful impact on clinical outcomes (reduced operative times, greater independence in operating, no excess morbidity). Validation of these methods before their systematic and formal introduction into training curricula is warranted.
Consensus to agree on surrogate endpoints and how these can be measured in a standardized way will be critical to adoption into routine training. Basket trials evaluating training interventions conducted to an agreed protocol across multiple countries, including trainees and trainers from diverse skill sets and countries of differing income categories, are critical to generate high quality evidence on augmenting surgical training in gynecologic oncology. This will ensure that future gynecologic oncologists are best placed to deliver the safest possible surgical outcomes and improved cancer care for patients.
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References
Supplementary materials
Supplementary Data
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Footnotes
B-LK and NB are joint first authors.
Twitter @ben_kemah, @sundar_sudha
Contributors SS conceptualised the paper, selected search terms, supervised the searches, reviewed drafts and edited the manuscript. B-LK, NB and AP performed searches, extracted information and wrote the paper. RS reviewed the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.