Commentary

Knowing that I am a psychiatrist, my friends and colleagues recently started to ask me, “Am I losing my mind?” The symptoms underlying these concerned queries are remarkably similar: inability to concentrate, becoming easily frustrated, forgetting things, not being as productive as usual, being overly tired despite doing less, and feeling unusually irritable, among other vague somatic symptoms. This condition is to be distinguished from COVID-19 in the brain, which is the protean serious neuropsychiatric manifestations of infection with the virus ranging from strokes and seizures to encephalopathy and psychosis especially in severe cases of infection.¹

As federal health care professionals (HCPs), many of us are familiar with acute high stress medical situations, which the pandemic has expanded and intensified: In New York City during the surge, the US Department of Veterans Affairs (VA) intensive care physician pushing life-sustaining resources to their limits in a valiant effort to keep alive as many people as possible; the US Public Health Service HCP working miracles without adequate supplies or staff in underserved hard-hit areas of the country; or the US Department of Defense clinician deftly trying to contain outbreaks in contained spaces like ships.

Emerging data already show that HCPs and other first responders facing these repeated episodes of acute stress are experiencing increased depression and anxiety.² Research from prior pandemics suggests that this is only the beginning of a wave of negative mental health complications in HCPs.³

In the acute form of stress, the hypothalamic pituitary axis (HPA axis) is an evolutionary engine that coordinates multiple organ systems from lungs to liver to ensure efficient escape from primeval dinosaurs or more modern threats like viruses. Fueling that engine is the hormonal cascade that ends in excessive secretion of cortisol.

Chronic stress affects the body and brain in a different way than does acute stress. The problem is that this sympathetic nervous system surge is meant to power a sprint to survival not the marathon of uncertainty that COVID-19 has become. As long as the body stays in acute stress mode, the brain cannot downshift to the parasympathetic system that would usually moderate and regulate our neurobiologic circuits and neuropsychological processes. Like any other engine in overdrive, the stress gear erodes the machinery of our body and brain. Hence, the symptoms of psychophysical wear and tear—allostatic load—that most of us are experiencing.⁴

The subject of this column is the lower level of prolonged chronic stress. The mild and amorphous pertubations that can be described as “the brain in COVID-19.” It is a syndrome that affects even those who have never been infected with the actual virus. Though not usually life-threatening or disabling, it is unnerving and distressing as the queries from my colleagues and friends show. Their reports and my observations have led me to opine that “no one is okay” due to months of living under the strain of a pandemic.

The degree and scope of chronic stress that a person experiences caused by COVID-19 has to be contextualized and individualized. Those who have lost jobs, who are working while children are going to school online, who are caring for relatives, or who are in fear of losing their home face tremendous stress and challenges.⁵ Yet even those like me, whose biggest worry is a dog barking through important teleconference meetings, still undergo a milder form of near constant stress.

Consider that all of us have become strangers in an even stranger land. Masks have become an object of political controversy. In states where masking is mandatory, you must be mask vigilant every time you go out. In many areas of the country stores have limited hours, access, and supplies and any trip away from the house risks infection. Conversely, for those in a high-risk population, it may have been months since they have left home at all, and many sick, older, and vulnerable persons are suffering from isolation, loneliness, and boredom. The minor distractions and innocent pleasures that relieve day-to-day stress are no longer safe or available options, like eating out, attending shows, or taking trips.

Most of us are waiting for news of an effective available vaccine, some with yearning and others with dread. For George Gershwin, summertime meant that “the livin’ is easy,” but the summer of 2020 has been anything but easy and that takes its toll on the mind. Without adequate positive stimulation, attention wanders and memory fails to encode details, making even routine tasks more difficult; without meaningful social contact, emotions become sharp and ragged often hurting others. Most important, without periods in which we can relax, there is psychic exhaustion.⁶

At this point you may be thinking, “So, now that you told us we are all under chronic stress, are you going to tell us whether we can do anything about it?” There are many fantastic websites (including the VA) where experts far more qualified than I am offer excellent advice on coping with the pandemic.⁷ What I can provide is 5 reflections on managing the stress that I have used and that others with whom I shared them have found helpful.

1. Set realistic expectations. We are in a different reality in which we may need to take on smaller tasks, pace our work and take more breaks and, most of all, give ourselves a break when we are not as functional as we were before the pandemic.

2. Get out in nature. Find a green space to walk or sit, spend time with companion animals, go for a hike or bicycle near water or mountains, or watch the birds in a forest. Nothing can help restore our perspective or calm frayed nerves like the socially distanced outdoors.

3. Reach out. Even though we cannot hug or even shake hands, we can still pick up the phone or mouse and check on someone who is down. All the great traditions of the world agree that the best way to lift our own spirits is to help others.

4. Be kind. This is among the most important responses. As the epigraph suggests, everyone is engaged in an often silent and secret struggle and deserves our compassion. This call for kindness should be extended to ourselves so that we can be patient and compassionate to others.

5. Have courage and hope. This may be the most important of all. Whether we are infected or are fearing/avoiding infection, COVID-19 makes us sick in body and brain. We must have faith that there is something—the mind, the spirit—beyond the purely physical that gives us courage to outlast COVID-19 and to have hope for a postpandemic future that though not the same as before may well be in some ways better

Knowing that I am a psychiatrist, my friends and colleagues recently started to ask me, “Am I losing my mind?” The symptoms underlying these concerned queries are remarkably similar: inability to concentrate, becoming easily frustrated, forgetting things, not being as productive as usual, being overly tired despite doing less, and feeling unusually irritable, among other vague somatic symptoms. This condition is to be distinguished from COVID-19 in the brain, which is the protean serious neuropsychiatric manifestations of infection with the virus ranging from strokes and seizures to encephalopathy and psychosis especially in severe cases of infection.¹

As federal health care professionals (HCPs), many of us are familiar with acute high stress medical situations, which the pandemic has expanded and intensified: In New York City during the surge, the US Department of Veterans Affairs (VA) intensive care physician pushing life-sustaining resources to their limits in a valiant effort to keep alive as many people as possible; the US Public Health Service HCP working miracles without adequate supplies or staff in underserved hard-hit areas of the country; or the US Department of Defense clinician deftly trying to contain outbreaks in contained spaces like ships.

Emerging data already show that HCPs and other first responders facing these repeated episodes of acute stress are experiencing increased depression and anxiety.² Research from prior pandemics suggests that this is only the beginning of a wave of negative mental health complications in HCPs.³

In the acute form of stress, the hypothalamic pituitary axis (HPA axis) is an evolutionary engine that coordinates multiple organ systems from lungs to liver to ensure efficient escape from primeval dinosaurs or more modern threats like viruses. Fueling that engine is the hormonal cascade that ends in excessive secretion of cortisol.

Chronic stress affects the body and brain in a different way than does acute stress. The problem is that this sympathetic nervous system surge is meant to power a sprint to survival not the marathon of uncertainty that COVID-19 has become. As long as the body stays in acute stress mode, the brain cannot downshift to the parasympathetic system that would usually moderate and regulate our neurobiologic circuits and neuropsychological processes. Like any other engine in overdrive, the stress gear erodes the machinery of our body and brain. Hence, the symptoms of psychophysical wear and tear—allostatic load—that most of us are experiencing.⁴

The subject of this column is the lower level of prolonged chronic stress. The mild and amorphous pertubations that can be described as “the brain in COVID-19.” It is a syndrome that affects even those who have never been infected with the actual virus. Though not usually life-threatening or disabling, it is unnerving and distressing as the queries from my colleagues and friends show. Their reports and my observations have led me to opine that “no one is okay” due to months of living under the strain of a pandemic.

The degree and scope of chronic stress that a person experiences caused by COVID-19 has to be contextualized and individualized. Those who have lost jobs, who are working while children are going to school online, who are caring for relatives, or who are in fear of losing their home face tremendous stress and challenges.⁵ Yet even those like me, whose biggest worry is a dog barking through important teleconference meetings, still undergo a milder form of near constant stress.

Consider that all of us have become strangers in an even stranger land. Masks have become an object of political controversy. In states where masking is mandatory, you must be mask vigilant every time you go out. In many areas of the country stores have limited hours, access, and supplies and any trip away from the house risks infection. Conversely, for those in a high-risk population, it may have been months since they have left home at all, and many sick, older, and vulnerable persons are suffering from isolation, loneliness, and boredom. The minor distractions and innocent pleasures that relieve day-to-day stress are no longer safe or available options, like eating out, attending shows, or taking trips.

Most of us are waiting for news of an effective available vaccine, some with yearning and others with dread. For George Gershwin, summertime meant that “the livin’ is easy,” but the summer of 2020 has been anything but easy and that takes its toll on the mind. Without adequate positive stimulation, attention wanders and memory fails to encode details, making even routine tasks more difficult; without meaningful social contact, emotions become sharp and ragged often hurting others. Most important, without periods in which we can relax, there is psychic exhaustion.⁶

At this point you may be thinking, “So, now that you told us we are all under chronic stress, are you going to tell us whether we can do anything about it?” There are many fantastic websites (including the VA) where experts far more qualified than I am offer excellent advice on coping with the pandemic.⁷ What I can provide is 5 reflections on managing the stress that I have used and that others with whom I shared them have found helpful.

1. Set realistic expectations. We are in a different reality in which we may need to take on smaller tasks, pace our work and take more breaks and, most of all, give ourselves a break when we are not as functional as we were before the pandemic.

2. Get out in nature. Find a green space to walk or sit, spend time with companion animals, go for a hike or bicycle near water or mountains, or watch the birds in a forest. Nothing can help restore our perspective or calm frayed nerves like the socially distanced outdoors.

3. Reach out. Even though we cannot hug or even shake hands, we can still pick up the phone or mouse and check on someone who is down. All the great traditions of the world agree that the best way to lift our own spirits is to help others.

4. Be kind. This is among the most important responses. As the epigraph suggests, everyone is engaged in an often silent and secret struggle and deserves our compassion. This call for kindness should be extended to ourselves so that we can be patient and compassionate to others.

5. Have courage and hope. This may be the most important of all. Whether we are infected or are fearing/avoiding infection, COVID-19 makes us sick in body and brain. We must have faith that there is something—the mind, the spirit—beyond the purely physical that gives us courage to outlast COVID-19 and to have hope for a postpandemic future that though not the same as before may well be in some ways better

Knowing that I am a psychiatrist, my friends and colleagues recently started to ask me, “Am I losing my mind?” The symptoms underlying these concerned queries are remarkably similar: inability to concentrate, becoming easily frustrated, forgetting things, not being as productive as usual, being overly tired despite doing less, and feeling unusually irritable, among other vague somatic symptoms. This condition is to be distinguished from COVID-19 in the brain, which is the protean serious neuropsychiatric manifestations of infection with the virus ranging from strokes and seizures to encephalopathy and psychosis especially in severe cases of infection.¹

As federal health care professionals (HCPs), many of us are familiar with acute high stress medical situations, which the pandemic has expanded and intensified: In New York City during the surge, the US Department of Veterans Affairs (VA) intensive care physician pushing life-sustaining resources to their limits in a valiant effort to keep alive as many people as possible; the US Public Health Service HCP working miracles without adequate supplies or staff in underserved hard-hit areas of the country; or the US Department of Defense clinician deftly trying to contain outbreaks in contained spaces like ships.

Emerging data already show that HCPs and other first responders facing these repeated episodes of acute stress are experiencing increased depression and anxiety.² Research from prior pandemics suggests that this is only the beginning of a wave of negative mental health complications in HCPs.³

In the acute form of stress, the hypothalamic pituitary axis (HPA axis) is an evolutionary engine that coordinates multiple organ systems from lungs to liver to ensure efficient escape from primeval dinosaurs or more modern threats like viruses. Fueling that engine is the hormonal cascade that ends in excessive secretion of cortisol.

Chronic stress affects the body and brain in a different way than does acute stress. The problem is that this sympathetic nervous system surge is meant to power a sprint to survival not the marathon of uncertainty that COVID-19 has become. As long as the body stays in acute stress mode, the brain cannot downshift to the parasympathetic system that would usually moderate and regulate our neurobiologic circuits and neuropsychological processes. Like any other engine in overdrive, the stress gear erodes the machinery of our body and brain. Hence, the symptoms of psychophysical wear and tear—allostatic load—that most of us are experiencing.⁴

The subject of this column is the lower level of prolonged chronic stress. The mild and amorphous pertubations that can be described as “the brain in COVID-19.” It is a syndrome that affects even those who have never been infected with the actual virus. Though not usually life-threatening or disabling, it is unnerving and distressing as the queries from my colleagues and friends show. Their reports and my observations have led me to opine that “no one is okay” due to months of living under the strain of a pandemic.

The degree and scope of chronic stress that a person experiences caused by COVID-19 has to be contextualized and individualized. Those who have lost jobs, who are working while children are going to school online, who are caring for relatives, or who are in fear of losing their home face tremendous stress and challenges.⁵ Yet even those like me, whose biggest worry is a dog barking through important teleconference meetings, still undergo a milder form of near constant stress.

Consider that all of us have become strangers in an even stranger land. Masks have become an object of political controversy. In states where masking is mandatory, you must be mask vigilant every time you go out. In many areas of the country stores have limited hours, access, and supplies and any trip away from the house risks infection. Conversely, for those in a high-risk population, it may have been months since they have left home at all, and many sick, older, and vulnerable persons are suffering from isolation, loneliness, and boredom. The minor distractions and innocent pleasures that relieve day-to-day stress are no longer safe or available options, like eating out, attending shows, or taking trips.

Most of us are waiting for news of an effective available vaccine, some with yearning and others with dread. For George Gershwin, summertime meant that “the livin’ is easy,” but the summer of 2020 has been anything but easy and that takes its toll on the mind. Without adequate positive stimulation, attention wanders and memory fails to encode details, making even routine tasks more difficult; without meaningful social contact, emotions become sharp and ragged often hurting others. Most important, without periods in which we can relax, there is psychic exhaustion.⁶

At this point you may be thinking, “So, now that you told us we are all under chronic stress, are you going to tell us whether we can do anything about it?” There are many fantastic websites (including the VA) where experts far more qualified than I am offer excellent advice on coping with the pandemic.⁷ What I can provide is 5 reflections on managing the stress that I have used and that others with whom I shared them have found helpful.

1. Set realistic expectations. We are in a different reality in which we may need to take on smaller tasks, pace our work and take more breaks and, most of all, give ourselves a break when we are not as functional as we were before the pandemic.

2. Get out in nature. Find a green space to walk or sit, spend time with companion animals, go for a hike or bicycle near water or mountains, or watch the birds in a forest. Nothing can help restore our perspective or calm frayed nerves like the socially distanced outdoors.

3. Reach out. Even though we cannot hug or even shake hands, we can still pick up the phone or mouse and check on someone who is down. All the great traditions of the world agree that the best way to lift our own spirits is to help others.

4. Be kind. This is among the most important responses. As the epigraph suggests, everyone is engaged in an often silent and secret struggle and deserves our compassion. This call for kindness should be extended to ourselves so that we can be patient and compassionate to others.

5. Have courage and hope. This may be the most important of all. Whether we are infected or are fearing/avoiding infection, COVID-19 makes us sick in body and brain. We must have faith that there is something—the mind, the spirit—beyond the purely physical that gives us courage to outlast COVID-19 and to have hope for a postpandemic future that though not the same as before may well be in some ways better

When an ovarian mass is anticipated or known, following evaluation of a patient’s history and physician examination, imaging via transvaginal and often abdominal ultrasound is the very next step. This evaluation likely will include both gray-scale and color Doppler examination. The initial concern always must be to identify ovarian malignancy.

Despite morphological scoring systems as well as the use of Doppler ultrasonography, there remains a lack of agreement and acceptance. In a 2008 multicenter study, Timmerman and colleagues evaluated 1,066 patients with 1,233 persistent adnexal tumors via transvaginal grayscale and Doppler ultrasound; 73% were benign tumors, and 27% were malignant tumors. Information on 42 gray-scale ultrasound variables and 6 Doppler variables was collected and evaluated to determine which variables had the highest positive predictive value for a malignant tumor and for a benign mass (Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365).

Five simple rules were selected that best predict malignancy (M-rules), as follows:

• Irregular solid tumor.
• Ascites.
• At least four papillary projections.
• Irregular multilocular-solid tumor with a greatest diameter greater than or equal to 10 cm.
• Very high color content on Doppler exam.

The following five simple rules suggested that a mass is benign (B-rules):

• Unilocular cyst.
• Largest solid component less than 7 mm.
• Acoustic shadows.
• Smooth multilocular tumor less than 10 cm.
• No detectable blood flow with Doppler exam.

Unfortunately, despite a sensitivity of 93% and specificity of 90%, and a positive and negative predictive value of 80% and 97%, these 10 simple rules were applicable to only 76% of tumors.

To assist those of us who are not gynecologic oncologists and who are often faced with having to determine whether surgery is recommended, I have elicited the expertise of Jubilee Brown, MD, professor and associate director of gynecologic oncology at the Levine Cancer Institute, Carolinas HealthCare System, in Charlotte, N.C., and the current president of the AAGL, to lead us in a review of evaluating an ovarian mass.
 

Dr. Miller is professor of obstetrics & gynecology in the department of clinical sciences, Rosalind Franklin University, North Chicago, Ill., and director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, both in Illinois. Email him at [email protected].

When an ovarian mass is anticipated or known, following evaluation of a patient’s history and physician examination, imaging via transvaginal and often abdominal ultrasound is the very next step. This evaluation likely will include both gray-scale and color Doppler examination. The initial concern always must be to identify ovarian malignancy.

Despite morphological scoring systems as well as the use of Doppler ultrasonography, there remains a lack of agreement and acceptance. In a 2008 multicenter study, Timmerman and colleagues evaluated 1,066 patients with 1,233 persistent adnexal tumors via transvaginal grayscale and Doppler ultrasound; 73% were benign tumors, and 27% were malignant tumors. Information on 42 gray-scale ultrasound variables and 6 Doppler variables was collected and evaluated to determine which variables had the highest positive predictive value for a malignant tumor and for a benign mass (Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365).

Five simple rules were selected that best predict malignancy (M-rules), as follows:

• Irregular solid tumor.
• Ascites.
• At least four papillary projections.
• Irregular multilocular-solid tumor with a greatest diameter greater than or equal to 10 cm.
• Very high color content on Doppler exam.

The following five simple rules suggested that a mass is benign (B-rules):

• Unilocular cyst.
• Largest solid component less than 7 mm.
• Acoustic shadows.
• Smooth multilocular tumor less than 10 cm.
• No detectable blood flow with Doppler exam.

Unfortunately, despite a sensitivity of 93% and specificity of 90%, and a positive and negative predictive value of 80% and 97%, these 10 simple rules were applicable to only 76% of tumors.

To assist those of us who are not gynecologic oncologists and who are often faced with having to determine whether surgery is recommended, I have elicited the expertise of Jubilee Brown, MD, professor and associate director of gynecologic oncology at the Levine Cancer Institute, Carolinas HealthCare System, in Charlotte, N.C., and the current president of the AAGL, to lead us in a review of evaluating an ovarian mass.
 

Dr. Miller is professor of obstetrics & gynecology in the department of clinical sciences, Rosalind Franklin University, North Chicago, Ill., and director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, both in Illinois. Email him at [email protected].

When an ovarian mass is anticipated or known, following evaluation of a patient’s history and physician examination, imaging via transvaginal and often abdominal ultrasound is the very next step. This evaluation likely will include both gray-scale and color Doppler examination. The initial concern always must be to identify ovarian malignancy.

Despite morphological scoring systems as well as the use of Doppler ultrasonography, there remains a lack of agreement and acceptance. In a 2008 multicenter study, Timmerman and colleagues evaluated 1,066 patients with 1,233 persistent adnexal tumors via transvaginal grayscale and Doppler ultrasound; 73% were benign tumors, and 27% were malignant tumors. Information on 42 gray-scale ultrasound variables and 6 Doppler variables was collected and evaluated to determine which variables had the highest positive predictive value for a malignant tumor and for a benign mass (Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365).

Five simple rules were selected that best predict malignancy (M-rules), as follows:

• Irregular solid tumor.
• Ascites.
• At least four papillary projections.
• Irregular multilocular-solid tumor with a greatest diameter greater than or equal to 10 cm.
• Very high color content on Doppler exam.

The following five simple rules suggested that a mass is benign (B-rules):

• Unilocular cyst.
• Largest solid component less than 7 mm.
• Acoustic shadows.
• Smooth multilocular tumor less than 10 cm.
• No detectable blood flow with Doppler exam.

Unfortunately, despite a sensitivity of 93% and specificity of 90%, and a positive and negative predictive value of 80% and 97%, these 10 simple rules were applicable to only 76% of tumors.

To assist those of us who are not gynecologic oncologists and who are often faced with having to determine whether surgery is recommended, I have elicited the expertise of Jubilee Brown, MD, professor and associate director of gynecologic oncology at the Levine Cancer Institute, Carolinas HealthCare System, in Charlotte, N.C., and the current president of the AAGL, to lead us in a review of evaluating an ovarian mass.
 

Dr. Miller is professor of obstetrics & gynecology in the department of clinical sciences, Rosalind Franklin University, North Chicago, Ill., and director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, both in Illinois. Email him at [email protected].

Ovarian masses are common in women of all ages. It is important not to miss even one ovarian cancer, but we must also identify masses that will resolve on their own over time to avoid overtreatment. These concurrent goals of excluding malignancy while not overtreating patients are the basis for management of the pelvic mass. Additionally, fertility preservation is important when surgery is performed in a reproductive-aged woman.

An ovarian mass may be anything from a simple functional or physiologic cyst to an endometrioma to an epithelial carcinoma, a germ-cell tumor, or a stromal tumor (the latter three of which may metastasize). Across the general population, women have a 5%-10% lifetime risk of needing surgery for a suspected ovarian mass and a 1.4% (1 in 70) risk that this mass is cancerous. The majority of ovarian cysts or masses therefore are benign.

A thorough history – including family history – and physical examination with appropriate laboratory testing and directed imaging are important first steps for the ob.gyn. Fortunately, we have guidelines and criteria governing not only when observation or surgery is warranted but also when patients should be referred to a gynecologic oncologist. By following these guidelines,¹ we are able to achieve the best outcomes.
 

Transvaginal ultrasound

A 2007 groundbreaking study led by Barbara Goff, MD, demonstrated that there are warning signs for ovarian cancer – symptoms that are significantly associated with malignancy. Dr. Goff and her coinvestigators evaluated the charts of hundreds of patients, including about 150 with ovarian cancer, and found that pelvic/abdominal pressure or pain, bloating, increase in abdominal size, and difficulty eating or feeling full were significantly and independently associated with cancer if these symptoms were present for less than a year and occurred at least 12 times per month.²

A pelvic examination is an integral part of evaluating every patient who has such concerns. That said, pelvic exams have limited ability to identify adnexal masses, especially in women who are obese – and that’s where imaging becomes especially important.

Masses generally can be considered simple or complex based on their appearance. A simple cyst is fluid-filled with thin, smooth walls and the absence of solid components or septations; it is significantly more likely to resolve on its own and is less likely to imply malignancy than a complex cyst, especially in a premenopausal woman. A complex cyst is multiseptated and/or solid – possibly with papillary projections – and is more concerning, especially if there is increased, new vascularity. Making this distinction helps us determine the risk of malignancy.

Transvaginal ultrasound (TVUS) is the preferred method for imaging, and our threshold for obtaining a TVUS should be very low. Women who have symptoms or concerns that can’t be attributed to a particular condition, and women in whom a mass can be palpated (even if asymptomatic) should have a TVUS. The imaging modality is cost effective and well tolerated by patients, does not expose the patient to ionizing radiation, and should generally be considered first-line imaging.^3,4

Size is not predictive of malignancy, but it is important for determining whether surgery is warranted. In our experience, a mass of 8-10 cm or larger on TVUS is at risk of torsion and is unlikely to resolve on its own, even in a premenopausal woman. While large masses generally require surgery, patients of any age who have simple cysts smaller than 8-10 cm generally can be followed with serial exams and ultrasound; spontaneous regression is common.

Doppler ultrasonography is useful for evaluating blood flow in and around an ovarian mass and can be helpful for confirming suspected characteristics of a mass.

Recent studies from the radiology community have looked at the utility of the resistive index – a measure of the impedance and velocity of blood flow – as a predictor of ovarian malignancy. However, we caution against using Doppler to determine whether a mass is benign or malignant, or to determine the necessity of surgery. An abnormal ovary may have what is considered to be a normal resistive index, and the resistive index of a normal ovary may fall within the abnormal range. Doppler flow can be helpful, but it must be combined with other predictive features, like solid components with flow or papillary projections within a cyst, to define a decision about surgery.^4,5

Magnetic resonance imaging can be useful in differentiating a fibroid from an ovarian mass, and a CT scan can be helpful in looking for disseminated disease when ovarian cancer is suspected based on ultrasound imaging, physical and history, and serum markers. A CT is useful, for instance, in a patient whose ovary is distended with ascites or who has upper abdominal complaints and a complex cyst. CT, PET, and MRI are not recommended in the initial evaluation of an ovarian mass.

The utility of serum biomarkers

Cancer antigen 125 (CA-125) testing may be helpful – in combination with other findings – for decision-making regarding the likelihood of malignancy and the need to refer patients. CA-125 is like Doppler in that a normal CA-125 cannot eliminate the possibility of cancer, and an abnormal CA-125 does not in and of itself imply malignancy. It’s far from a perfect cancer screening test.

CA-125 is a protein associated with epithelial ovarian malignancies, the type of ovarian cancer most commonly seen in postmenopausal women with genetic predispositions. Its specificity and positive predictive value are much higher in postmenopausal women than in average-risk premenopausal women (those without a family history or a known mutation that predisposes them to ovarian cancer). Levels of the marker are elevated in association with many nonmalignant conditions in premenopausal women – endometriosis, fibroids, and various inflammatory conditions, for instance – so the marker’s utility in this population is limited.

For women who have a family history of ovarian cancer or a known breast cancer gene 1 (BRCA1) or BRCA2 mutation, there are some data that suggest that monitoring with CA-125 measurements and TVUS may be a good approach to following patients prior to the age at which risk-reducing surgery can best be performed.

In an adolescent girl or a woman of reproductive age, we think less about epithelial cancer and more about germ-cell and stromal tumors. When a solid mass is palpated or visualized on imaging, we therefore will utilize a different set of markers; alpha-fetoprotein, L-lactate dehydrogenase, and beta-HCG, for instance, have much higher specificity than CA-125 does for germ-cell tumors in this age group and may be helpful in the evaluation. Similarly, in cases of a very large mass resembling a mucinous tumor, a carcinoembryonic antigen may be helpful.

A number of proprietary profiling technologies have been developed to determine the risk of a diagnosed mass being malignant. For instance, the OVA1 assay looks at five serum markers and scores the results, and the Risk of Ovarian Malignancy Algorithm (ROMA) combines the results of three serum markers with menopausal status into a numerical score. Both have Food and Drug Administration approval for use in women in whom surgery has been deemed necessary. These panels can be fairly predictive of risk and may be helpful – especially in rural areas – in determining which women should be referred to a gynecologic oncologist for surgery.

It is important to appreciate that an ovarian cyst or mass should never be biopsied or aspirated lest a malignant tumor confined to one ovary be potentially spread to the peritoneum.
 

Referral to a gynecologic oncologist

Postmenopausal women with a CA-125 greater than 35 U/mL should be referred, as should postmenopausal women with ascites, those with a nodular or fixed pelvic mass, and those with suspected abdominal or distant metastases (per a CT scan, for instance).

In premenopausal women, ascites, a nodular or fixed mass, and evidence of metastases also are reasons for referral to a gynecologic oncologist. CA-125, again, is much more likely to be elevated for reasons other than malignancy and therefore is not as strong a driver for referral as in postmenopausal women. Patients with markedly elevated levels, however, should probably be referred – particularly when other clinical factors also suggest the need for consultation. While there is no evidence-based threshold for CA-125 in premenopausal women, a CA-125 greater than 200 U/mL is a good cutoff for referral.

For any patient, family history of breast and/or ovarian cancer – especially in a first-degree relative – raises the risk of malignancy and should figure prominently into decision-making regarding referral. Criteria for referral are among the points discussed in the ACOG 2016 Practice Bulletin on Evaluation and Management of Adnexal Masses.¹

A note on BRCA mutations

As the American College of Obstetricians and Gynecologists says in its practice bulletin, the most important personal risk factor for ovarian cancer is a strong family history of breast or ovarian cancer. Women with such a family history can undergo genetic testing for BRCA mutations and have the opportunity to prevent ovarian cancers when mutations are detected. This simple blood test can save lives.

A modeling study we recently completed – not yet published – shows that it actually would be cost effective to do population screening with BRCA testing performed on every woman at age 30 years.

According to the National Cancer Institute website (last review: 2018), it is estimated that about 44% of women who inherit a BRCA1 mutation, and about 17% of those who inherit a BRAC2 mutation, will develop ovarian cancer by the age of 80 years. By identifying those mutations, women may undergo risk-reducing surgery at designated ages after childbearing is complete and bring their risk down to under 5%.

An international take on managing adnexal masses

• Pelvic ultrasound should include the transvaginal approach. Use Doppler imaging as indicated.
• Although simple ovarian cysts are not precursor lesions to a malignant ovarian cancer, perform a high-quality examination to make sure there are no solid/papillary structures before classifying a cyst as a simple cyst. The risk of progression to malignancy is extremely low, but some follow-up is prudent.
• The most accurate method of characterizing an ovarian mass currently is real-time pattern recognition sonography in the hands of an experienced imager.
• Pattern recognition sonography or a risk model such as the International Ovarian Tumor Analysis (IOTA) Simple Rules can be used to initially characterize an ovarian mass.
• When an ovarian lesion is classified as benign, the patient may be followed conservatively, or if indicated, surgery can be performed by a general gynecologist.
• Serial sonography can be beneficial, but there are limited prospective data to support an exact interval and duration.
• Fewer surgical interventions may result in an increase in sonographic surveillance.
• When an ovarian lesion is considered indeterminate on initial sonography, and after appropriate clinical evaluation, a “second-step” evaluation may include referral to an expert sonologist, serial sonography, application of established risk-prediction models, correlation with serum biomarkers, correlation with MRI, or referral to a gynecologic oncologist for further evaluation.

From the First International Consensus Report on Adnexal Masses: Management Recommendations

Source: Glanc P et al. J Ultrasound Med. 2017 May;36(5):849-63.

Dr. Brown reported that she had received an earlier grant from Aspira Labs, the company that developed the OVA1 assay. Dr. Miller reported that he has no relevant financial disclosures.

References

1. Obstet Gynecol. 2016 Nov. doi: 10.1097/AOG.0000000000001768.

2. Cancer. 2007 Jan 15. doi: 10.1002/cncr.22371.

3. Clin Obstet Gynecol. 2015 Mar. doi: 10.1097/GRF.0000000000000083.

4. Ultrasound Q. 2013 Mar. doi: 10.1097/RUQ.0b013e3182814d9b.

5. Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365.

Ovarian masses are common in women of all ages. It is important not to miss even one ovarian cancer, but we must also identify masses that will resolve on their own over time to avoid overtreatment. These concurrent goals of excluding malignancy while not overtreating patients are the basis for management of the pelvic mass. Additionally, fertility preservation is important when surgery is performed in a reproductive-aged woman.

An ovarian mass may be anything from a simple functional or physiologic cyst to an endometrioma to an epithelial carcinoma, a germ-cell tumor, or a stromal tumor (the latter three of which may metastasize). Across the general population, women have a 5%-10% lifetime risk of needing surgery for a suspected ovarian mass and a 1.4% (1 in 70) risk that this mass is cancerous. The majority of ovarian cysts or masses therefore are benign.

A thorough history – including family history – and physical examination with appropriate laboratory testing and directed imaging are important first steps for the ob.gyn. Fortunately, we have guidelines and criteria governing not only when observation or surgery is warranted but also when patients should be referred to a gynecologic oncologist. By following these guidelines,¹ we are able to achieve the best outcomes.
 

Transvaginal ultrasound

A 2007 groundbreaking study led by Barbara Goff, MD, demonstrated that there are warning signs for ovarian cancer – symptoms that are significantly associated with malignancy. Dr. Goff and her coinvestigators evaluated the charts of hundreds of patients, including about 150 with ovarian cancer, and found that pelvic/abdominal pressure or pain, bloating, increase in abdominal size, and difficulty eating or feeling full were significantly and independently associated with cancer if these symptoms were present for less than a year and occurred at least 12 times per month.²

A pelvic examination is an integral part of evaluating every patient who has such concerns. That said, pelvic exams have limited ability to identify adnexal masses, especially in women who are obese – and that’s where imaging becomes especially important.

Masses generally can be considered simple or complex based on their appearance. A simple cyst is fluid-filled with thin, smooth walls and the absence of solid components or septations; it is significantly more likely to resolve on its own and is less likely to imply malignancy than a complex cyst, especially in a premenopausal woman. A complex cyst is multiseptated and/or solid – possibly with papillary projections – and is more concerning, especially if there is increased, new vascularity. Making this distinction helps us determine the risk of malignancy.

Transvaginal ultrasound (TVUS) is the preferred method for imaging, and our threshold for obtaining a TVUS should be very low. Women who have symptoms or concerns that can’t be attributed to a particular condition, and women in whom a mass can be palpated (even if asymptomatic) should have a TVUS. The imaging modality is cost effective and well tolerated by patients, does not expose the patient to ionizing radiation, and should generally be considered first-line imaging.^3,4

Size is not predictive of malignancy, but it is important for determining whether surgery is warranted. In our experience, a mass of 8-10 cm or larger on TVUS is at risk of torsion and is unlikely to resolve on its own, even in a premenopausal woman. While large masses generally require surgery, patients of any age who have simple cysts smaller than 8-10 cm generally can be followed with serial exams and ultrasound; spontaneous regression is common.

Doppler ultrasonography is useful for evaluating blood flow in and around an ovarian mass and can be helpful for confirming suspected characteristics of a mass.

Recent studies from the radiology community have looked at the utility of the resistive index – a measure of the impedance and velocity of blood flow – as a predictor of ovarian malignancy. However, we caution against using Doppler to determine whether a mass is benign or malignant, or to determine the necessity of surgery. An abnormal ovary may have what is considered to be a normal resistive index, and the resistive index of a normal ovary may fall within the abnormal range. Doppler flow can be helpful, but it must be combined with other predictive features, like solid components with flow or papillary projections within a cyst, to define a decision about surgery.^4,5

Magnetic resonance imaging can be useful in differentiating a fibroid from an ovarian mass, and a CT scan can be helpful in looking for disseminated disease when ovarian cancer is suspected based on ultrasound imaging, physical and history, and serum markers. A CT is useful, for instance, in a patient whose ovary is distended with ascites or who has upper abdominal complaints and a complex cyst. CT, PET, and MRI are not recommended in the initial evaluation of an ovarian mass.

The utility of serum biomarkers

Cancer antigen 125 (CA-125) testing may be helpful – in combination with other findings – for decision-making regarding the likelihood of malignancy and the need to refer patients. CA-125 is like Doppler in that a normal CA-125 cannot eliminate the possibility of cancer, and an abnormal CA-125 does not in and of itself imply malignancy. It’s far from a perfect cancer screening test.

CA-125 is a protein associated with epithelial ovarian malignancies, the type of ovarian cancer most commonly seen in postmenopausal women with genetic predispositions. Its specificity and positive predictive value are much higher in postmenopausal women than in average-risk premenopausal women (those without a family history or a known mutation that predisposes them to ovarian cancer). Levels of the marker are elevated in association with many nonmalignant conditions in premenopausal women – endometriosis, fibroids, and various inflammatory conditions, for instance – so the marker’s utility in this population is limited.

For women who have a family history of ovarian cancer or a known breast cancer gene 1 (BRCA1) or BRCA2 mutation, there are some data that suggest that monitoring with CA-125 measurements and TVUS may be a good approach to following patients prior to the age at which risk-reducing surgery can best be performed.

In an adolescent girl or a woman of reproductive age, we think less about epithelial cancer and more about germ-cell and stromal tumors. When a solid mass is palpated or visualized on imaging, we therefore will utilize a different set of markers; alpha-fetoprotein, L-lactate dehydrogenase, and beta-HCG, for instance, have much higher specificity than CA-125 does for germ-cell tumors in this age group and may be helpful in the evaluation. Similarly, in cases of a very large mass resembling a mucinous tumor, a carcinoembryonic antigen may be helpful.

A number of proprietary profiling technologies have been developed to determine the risk of a diagnosed mass being malignant. For instance, the OVA1 assay looks at five serum markers and scores the results, and the Risk of Ovarian Malignancy Algorithm (ROMA) combines the results of three serum markers with menopausal status into a numerical score. Both have Food and Drug Administration approval for use in women in whom surgery has been deemed necessary. These panels can be fairly predictive of risk and may be helpful – especially in rural areas – in determining which women should be referred to a gynecologic oncologist for surgery.

It is important to appreciate that an ovarian cyst or mass should never be biopsied or aspirated lest a malignant tumor confined to one ovary be potentially spread to the peritoneum.
 

Referral to a gynecologic oncologist

Postmenopausal women with a CA-125 greater than 35 U/mL should be referred, as should postmenopausal women with ascites, those with a nodular or fixed pelvic mass, and those with suspected abdominal or distant metastases (per a CT scan, for instance).

In premenopausal women, ascites, a nodular or fixed mass, and evidence of metastases also are reasons for referral to a gynecologic oncologist. CA-125, again, is much more likely to be elevated for reasons other than malignancy and therefore is not as strong a driver for referral as in postmenopausal women. Patients with markedly elevated levels, however, should probably be referred – particularly when other clinical factors also suggest the need for consultation. While there is no evidence-based threshold for CA-125 in premenopausal women, a CA-125 greater than 200 U/mL is a good cutoff for referral.

For any patient, family history of breast and/or ovarian cancer – especially in a first-degree relative – raises the risk of malignancy and should figure prominently into decision-making regarding referral. Criteria for referral are among the points discussed in the ACOG 2016 Practice Bulletin on Evaluation and Management of Adnexal Masses.¹

A note on BRCA mutations

As the American College of Obstetricians and Gynecologists says in its practice bulletin, the most important personal risk factor for ovarian cancer is a strong family history of breast or ovarian cancer. Women with such a family history can undergo genetic testing for BRCA mutations and have the opportunity to prevent ovarian cancers when mutations are detected. This simple blood test can save lives.

A modeling study we recently completed – not yet published – shows that it actually would be cost effective to do population screening with BRCA testing performed on every woman at age 30 years.

According to the National Cancer Institute website (last review: 2018), it is estimated that about 44% of women who inherit a BRCA1 mutation, and about 17% of those who inherit a BRAC2 mutation, will develop ovarian cancer by the age of 80 years. By identifying those mutations, women may undergo risk-reducing surgery at designated ages after childbearing is complete and bring their risk down to under 5%.

An international take on managing adnexal masses

• Pelvic ultrasound should include the transvaginal approach. Use Doppler imaging as indicated.
• Although simple ovarian cysts are not precursor lesions to a malignant ovarian cancer, perform a high-quality examination to make sure there are no solid/papillary structures before classifying a cyst as a simple cyst. The risk of progression to malignancy is extremely low, but some follow-up is prudent.
• The most accurate method of characterizing an ovarian mass currently is real-time pattern recognition sonography in the hands of an experienced imager.
• Pattern recognition sonography or a risk model such as the International Ovarian Tumor Analysis (IOTA) Simple Rules can be used to initially characterize an ovarian mass.
• When an ovarian lesion is classified as benign, the patient may be followed conservatively, or if indicated, surgery can be performed by a general gynecologist.
• Serial sonography can be beneficial, but there are limited prospective data to support an exact interval and duration.
• Fewer surgical interventions may result in an increase in sonographic surveillance.
• When an ovarian lesion is considered indeterminate on initial sonography, and after appropriate clinical evaluation, a “second-step” evaluation may include referral to an expert sonologist, serial sonography, application of established risk-prediction models, correlation with serum biomarkers, correlation with MRI, or referral to a gynecologic oncologist for further evaluation.

From the First International Consensus Report on Adnexal Masses: Management Recommendations

Source: Glanc P et al. J Ultrasound Med. 2017 May;36(5):849-63.

Dr. Brown reported that she had received an earlier grant from Aspira Labs, the company that developed the OVA1 assay. Dr. Miller reported that he has no relevant financial disclosures.

References

1. Obstet Gynecol. 2016 Nov. doi: 10.1097/AOG.0000000000001768.

2. Cancer. 2007 Jan 15. doi: 10.1002/cncr.22371.

3. Clin Obstet Gynecol. 2015 Mar. doi: 10.1097/GRF.0000000000000083.

4. Ultrasound Q. 2013 Mar. doi: 10.1097/RUQ.0b013e3182814d9b.

5. Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365.

Ovarian masses are common in women of all ages. It is important not to miss even one ovarian cancer, but we must also identify masses that will resolve on their own over time to avoid overtreatment. These concurrent goals of excluding malignancy while not overtreating patients are the basis for management of the pelvic mass. Additionally, fertility preservation is important when surgery is performed in a reproductive-aged woman.

An ovarian mass may be anything from a simple functional or physiologic cyst to an endometrioma to an epithelial carcinoma, a germ-cell tumor, or a stromal tumor (the latter three of which may metastasize). Across the general population, women have a 5%-10% lifetime risk of needing surgery for a suspected ovarian mass and a 1.4% (1 in 70) risk that this mass is cancerous. The majority of ovarian cysts or masses therefore are benign.

A thorough history – including family history – and physical examination with appropriate laboratory testing and directed imaging are important first steps for the ob.gyn. Fortunately, we have guidelines and criteria governing not only when observation or surgery is warranted but also when patients should be referred to a gynecologic oncologist. By following these guidelines,¹ we are able to achieve the best outcomes.
 

Transvaginal ultrasound

A 2007 groundbreaking study led by Barbara Goff, MD, demonstrated that there are warning signs for ovarian cancer – symptoms that are significantly associated with malignancy. Dr. Goff and her coinvestigators evaluated the charts of hundreds of patients, including about 150 with ovarian cancer, and found that pelvic/abdominal pressure or pain, bloating, increase in abdominal size, and difficulty eating or feeling full were significantly and independently associated with cancer if these symptoms were present for less than a year and occurred at least 12 times per month.²

A pelvic examination is an integral part of evaluating every patient who has such concerns. That said, pelvic exams have limited ability to identify adnexal masses, especially in women who are obese – and that’s where imaging becomes especially important.

Masses generally can be considered simple or complex based on their appearance. A simple cyst is fluid-filled with thin, smooth walls and the absence of solid components or septations; it is significantly more likely to resolve on its own and is less likely to imply malignancy than a complex cyst, especially in a premenopausal woman. A complex cyst is multiseptated and/or solid – possibly with papillary projections – and is more concerning, especially if there is increased, new vascularity. Making this distinction helps us determine the risk of malignancy.

Transvaginal ultrasound (TVUS) is the preferred method for imaging, and our threshold for obtaining a TVUS should be very low. Women who have symptoms or concerns that can’t be attributed to a particular condition, and women in whom a mass can be palpated (even if asymptomatic) should have a TVUS. The imaging modality is cost effective and well tolerated by patients, does not expose the patient to ionizing radiation, and should generally be considered first-line imaging.^3,4

Size is not predictive of malignancy, but it is important for determining whether surgery is warranted. In our experience, a mass of 8-10 cm or larger on TVUS is at risk of torsion and is unlikely to resolve on its own, even in a premenopausal woman. While large masses generally require surgery, patients of any age who have simple cysts smaller than 8-10 cm generally can be followed with serial exams and ultrasound; spontaneous regression is common.

Doppler ultrasonography is useful for evaluating blood flow in and around an ovarian mass and can be helpful for confirming suspected characteristics of a mass.

Recent studies from the radiology community have looked at the utility of the resistive index – a measure of the impedance and velocity of blood flow – as a predictor of ovarian malignancy. However, we caution against using Doppler to determine whether a mass is benign or malignant, or to determine the necessity of surgery. An abnormal ovary may have what is considered to be a normal resistive index, and the resistive index of a normal ovary may fall within the abnormal range. Doppler flow can be helpful, but it must be combined with other predictive features, like solid components with flow or papillary projections within a cyst, to define a decision about surgery.^4,5

Magnetic resonance imaging can be useful in differentiating a fibroid from an ovarian mass, and a CT scan can be helpful in looking for disseminated disease when ovarian cancer is suspected based on ultrasound imaging, physical and history, and serum markers. A CT is useful, for instance, in a patient whose ovary is distended with ascites or who has upper abdominal complaints and a complex cyst. CT, PET, and MRI are not recommended in the initial evaluation of an ovarian mass.

The utility of serum biomarkers

Cancer antigen 125 (CA-125) testing may be helpful – in combination with other findings – for decision-making regarding the likelihood of malignancy and the need to refer patients. CA-125 is like Doppler in that a normal CA-125 cannot eliminate the possibility of cancer, and an abnormal CA-125 does not in and of itself imply malignancy. It’s far from a perfect cancer screening test.

CA-125 is a protein associated with epithelial ovarian malignancies, the type of ovarian cancer most commonly seen in postmenopausal women with genetic predispositions. Its specificity and positive predictive value are much higher in postmenopausal women than in average-risk premenopausal women (those without a family history or a known mutation that predisposes them to ovarian cancer). Levels of the marker are elevated in association with many nonmalignant conditions in premenopausal women – endometriosis, fibroids, and various inflammatory conditions, for instance – so the marker’s utility in this population is limited.

For women who have a family history of ovarian cancer or a known breast cancer gene 1 (BRCA1) or BRCA2 mutation, there are some data that suggest that monitoring with CA-125 measurements and TVUS may be a good approach to following patients prior to the age at which risk-reducing surgery can best be performed.

In an adolescent girl or a woman of reproductive age, we think less about epithelial cancer and more about germ-cell and stromal tumors. When a solid mass is palpated or visualized on imaging, we therefore will utilize a different set of markers; alpha-fetoprotein, L-lactate dehydrogenase, and beta-HCG, for instance, have much higher specificity than CA-125 does for germ-cell tumors in this age group and may be helpful in the evaluation. Similarly, in cases of a very large mass resembling a mucinous tumor, a carcinoembryonic antigen may be helpful.

A number of proprietary profiling technologies have been developed to determine the risk of a diagnosed mass being malignant. For instance, the OVA1 assay looks at five serum markers and scores the results, and the Risk of Ovarian Malignancy Algorithm (ROMA) combines the results of three serum markers with menopausal status into a numerical score. Both have Food and Drug Administration approval for use in women in whom surgery has been deemed necessary. These panels can be fairly predictive of risk and may be helpful – especially in rural areas – in determining which women should be referred to a gynecologic oncologist for surgery.

It is important to appreciate that an ovarian cyst or mass should never be biopsied or aspirated lest a malignant tumor confined to one ovary be potentially spread to the peritoneum.
 

Referral to a gynecologic oncologist

Postmenopausal women with a CA-125 greater than 35 U/mL should be referred, as should postmenopausal women with ascites, those with a nodular or fixed pelvic mass, and those with suspected abdominal or distant metastases (per a CT scan, for instance).

In premenopausal women, ascites, a nodular or fixed mass, and evidence of metastases also are reasons for referral to a gynecologic oncologist. CA-125, again, is much more likely to be elevated for reasons other than malignancy and therefore is not as strong a driver for referral as in postmenopausal women. Patients with markedly elevated levels, however, should probably be referred – particularly when other clinical factors also suggest the need for consultation. While there is no evidence-based threshold for CA-125 in premenopausal women, a CA-125 greater than 200 U/mL is a good cutoff for referral.

For any patient, family history of breast and/or ovarian cancer – especially in a first-degree relative – raises the risk of malignancy and should figure prominently into decision-making regarding referral. Criteria for referral are among the points discussed in the ACOG 2016 Practice Bulletin on Evaluation and Management of Adnexal Masses.¹

A note on BRCA mutations

As the American College of Obstetricians and Gynecologists says in its practice bulletin, the most important personal risk factor for ovarian cancer is a strong family history of breast or ovarian cancer. Women with such a family history can undergo genetic testing for BRCA mutations and have the opportunity to prevent ovarian cancers when mutations are detected. This simple blood test can save lives.

A modeling study we recently completed – not yet published – shows that it actually would be cost effective to do population screening with BRCA testing performed on every woman at age 30 years.

According to the National Cancer Institute website (last review: 2018), it is estimated that about 44% of women who inherit a BRCA1 mutation, and about 17% of those who inherit a BRAC2 mutation, will develop ovarian cancer by the age of 80 years. By identifying those mutations, women may undergo risk-reducing surgery at designated ages after childbearing is complete and bring their risk down to under 5%.

An international take on managing adnexal masses

• Pelvic ultrasound should include the transvaginal approach. Use Doppler imaging as indicated.
• Although simple ovarian cysts are not precursor lesions to a malignant ovarian cancer, perform a high-quality examination to make sure there are no solid/papillary structures before classifying a cyst as a simple cyst. The risk of progression to malignancy is extremely low, but some follow-up is prudent.
• The most accurate method of characterizing an ovarian mass currently is real-time pattern recognition sonography in the hands of an experienced imager.
• Pattern recognition sonography or a risk model such as the International Ovarian Tumor Analysis (IOTA) Simple Rules can be used to initially characterize an ovarian mass.
• When an ovarian lesion is classified as benign, the patient may be followed conservatively, or if indicated, surgery can be performed by a general gynecologist.
• Serial sonography can be beneficial, but there are limited prospective data to support an exact interval and duration.
• Fewer surgical interventions may result in an increase in sonographic surveillance.
• When an ovarian lesion is considered indeterminate on initial sonography, and after appropriate clinical evaluation, a “second-step” evaluation may include referral to an expert sonologist, serial sonography, application of established risk-prediction models, correlation with serum biomarkers, correlation with MRI, or referral to a gynecologic oncologist for further evaluation.

From the First International Consensus Report on Adnexal Masses: Management Recommendations

Source: Glanc P et al. J Ultrasound Med. 2017 May;36(5):849-63.

Dr. Brown reported that she had received an earlier grant from Aspira Labs, the company that developed the OVA1 assay. Dr. Miller reported that he has no relevant financial disclosures.

References

1. Obstet Gynecol. 2016 Nov. doi: 10.1097/AOG.0000000000001768.

2. Cancer. 2007 Jan 15. doi: 10.1002/cncr.22371.

3. Clin Obstet Gynecol. 2015 Mar. doi: 10.1097/GRF.0000000000000083.

4. Ultrasound Q. 2013 Mar. doi: 10.1097/RUQ.0b013e3182814d9b.

5. Ultrasound Obstet Gynecol. 2008 Jun. doi: 10.1002/uog.5365.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

Uterine papillary serous carcinoma (UPSC) is an infrequent but deadly form of endometrial cancer comprising 10% of cases but contributing 40% of deaths from the disease. Recurrence rates are high for this disease. Five-year survival is 55% for all patients and only 70% for stage I disease.¹ Patterns of recurrence tend to be distant (extrapelvic and extraabdominal) as frequently as they are localized to the pelvis, and metastases and recurrences are unrelated to the extent of uterine disease (such as myometrial invasion). It is for these reasons that the recommended course of adjuvant therapy for this disease is systemic therapy (typically six doses of carboplatin and paclitaxel chemotherapy) with consideration for radiation to the vagina or pelvis to consolidate pelvic and vaginal control.² This differs from early-stage high/intermediate–risk endometrioid adenocarcinomas, for which adjuvant chemotherapy has not been found to be helpful.

Dr Joshua Kish

Because of the lower incidence of UPSC, it frequently has been studied alongside endometrioid cell types in clinical trials which explore novel adjuvant therapies. However, UPSC is biologically distinct from endometrioid endometrial cancers, which likely results in inferior clinical responses to conventional interventions. Fortunately we are beginning to better understand UPSC at a molecular level, and advancements are being made in the targeted therapies for these patients that are unique, compared with those applied to other cancer subtypes.

As discussed above, UPSC is a particularly aggressive form of uterine cancer. Histologically it is characterized by a precursor lesion of endometrial glandular dysplasia progressing to endometrial intraepithelial neoplasia (EIC). Histologically it presents with a highly atypical slit-like glandular configuration, which appears similar to serous carcinomas of the fallopian tube and ovary. Molecularly these tumors commonly manifest mutations in tumor protein p53 (TP53) and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), which are both genes associated with oncogenic potential.¹ While most UPSC tumors have loss of expression in hormone receptors such as estrogen and progesterone, 25%-30% of cases overexpress the tyrosine kinase receptor human epidermal growth factor receptor 2 (HER2).^3-5 This has proven to provide an exciting target for therapeutic interventions.
 

A target for therapeutic intervention

HER2 is a transmembrane receptor which, when activated, signals complex downstream pathways responsible for cellular proliferation, dedifferentiation, and metastasis. In a recent multi-institutional analysis of early-stage UPSC, HER2 overexpression was identified among 25% of cases.⁴ Approximately 30% of cases of advanced disease manifest overexpression of this biomarker.⁵ HER2 overexpression (HER2-positive status) is significantly associated with higher rates of recurrence and mortality, even among patients treated with conventional therapies.³ Thus HER2-positive status is obviously an indicator of particularly aggressive disease.

Fortunately this particular biomarker is one for which we have established and developing therapeutics. The humanized monoclonal antibody, trastuzumab, has been highly effective in improving survival for HER2-positive breast cancer.⁶ More recently, it was studied in a phase 2 trial with carboplatin and paclitaxel chemotherapy for advanced or recurrent HER2-positive UPSC.⁵ This trial showed that the addition of this targeted therapy to conventional chemotherapy improved recurrence-free survival from 8 months to 12 months, and improved overall survival from 24.4 months to 29.6 months.⁵
 

^{One discovery leads to another treatment}

This discovery led to the approval of trastuzumab to be used in addition to chemotherapy for advanced or recurrent disease.² The most significant effects appear to be among those who have not received prior therapies, with a doubling of progression-free survival among these patients, and a more modest response among patients treated for recurrent, mostly pretreated disease.

Work currently is underway to explore an array of antibody or small-molecule blockades of HER2 in addition to vaccines against the protein or treatment with conjugate compounds in which an antibody to HER2 is paired with a cytotoxic drug able to be internalized into HER2-expressing cells.⁷ This represents a form of personalized medicine referred to as biomarker-driven targeted therapy, in which therapies are prescribed based on the expression of specific molecular markers (such as HER2 expression) typically in combination with other clinical markers such as surgical staging results, race, age, etc. These approaches can be very effective strategies in rare tumor subtypes with distinct molecular and clinical behaviors.

As previously mentioned, the targeting of HER2 overexpression with trastuzumab has been shown to be highly effective in the treatment of HER2-positive breast cancers where even patients with early-stage disease receive a multimodal therapy approach including antibody, chemotherapy, surgical, and often radiation treatments.⁶ We are moving towards a similar multimodal comprehensive treatment strategy for UPSC. If it is as successful as it is in breast cancer, it will be long overdue, and desperately necessary given the poor prognosis of this disease for all stages because of the inadequacies of current treatments strategies.

Routine testing of UPSC for HER2 expression is now a part of routine molecular substaging of uterine cancers in the same way we have embraced testing for microsatellite instability and hormone-receptor status. While a diagnosis of HER2 overexpression in UPSC portends a poor prognosis, patients can be reassured that treatment strategies exist that can target this malignant mechanism in advanced disease and more are under further development for early-stage disease.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at [email protected].

References

1. Curr Opin Obstet Gynecol. 2010 Feb. doi: 10.1097/GCO.0b013e328334d8a3.

2. National Comprehensive Cancer Network. Uterine Neoplasms (version 2.2020).

3. Cancer 2005 Oct 1. doi: 10.1002/cncr.21308.

4. Gynecol Oncol 2020 doi: 10.1016/j.ygyno.2020.07.016.

5. J Clin Oncol 2018. doi: 10.1200/JCO.2017.76.5966.

6. N Engl J Med 2011. doi: 10.1056/NEJMoa0910383.

7. Discov Med. 2016 Apr;21(116):293-303.

Uterine papillary serous carcinoma (UPSC) is an infrequent but deadly form of endometrial cancer comprising 10% of cases but contributing 40% of deaths from the disease. Recurrence rates are high for this disease. Five-year survival is 55% for all patients and only 70% for stage I disease.¹ Patterns of recurrence tend to be distant (extrapelvic and extraabdominal) as frequently as they are localized to the pelvis, and metastases and recurrences are unrelated to the extent of uterine disease (such as myometrial invasion). It is for these reasons that the recommended course of adjuvant therapy for this disease is systemic therapy (typically six doses of carboplatin and paclitaxel chemotherapy) with consideration for radiation to the vagina or pelvis to consolidate pelvic and vaginal control.² This differs from early-stage high/intermediate–risk endometrioid adenocarcinomas, for which adjuvant chemotherapy has not been found to be helpful.

Dr Joshua Kish

Because of the lower incidence of UPSC, it frequently has been studied alongside endometrioid cell types in clinical trials which explore novel adjuvant therapies. However, UPSC is biologically distinct from endometrioid endometrial cancers, which likely results in inferior clinical responses to conventional interventions. Fortunately we are beginning to better understand UPSC at a molecular level, and advancements are being made in the targeted therapies for these patients that are unique, compared with those applied to other cancer subtypes.

As discussed above, UPSC is a particularly aggressive form of uterine cancer. Histologically it is characterized by a precursor lesion of endometrial glandular dysplasia progressing to endometrial intraepithelial neoplasia (EIC). Histologically it presents with a highly atypical slit-like glandular configuration, which appears similar to serous carcinomas of the fallopian tube and ovary. Molecularly these tumors commonly manifest mutations in tumor protein p53 (TP53) and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), which are both genes associated with oncogenic potential.¹ While most UPSC tumors have loss of expression in hormone receptors such as estrogen and progesterone, 25%-30% of cases overexpress the tyrosine kinase receptor human epidermal growth factor receptor 2 (HER2).^3-5 This has proven to provide an exciting target for therapeutic interventions.
 

A target for therapeutic intervention

HER2 is a transmembrane receptor which, when activated, signals complex downstream pathways responsible for cellular proliferation, dedifferentiation, and metastasis. In a recent multi-institutional analysis of early-stage UPSC, HER2 overexpression was identified among 25% of cases.⁴ Approximately 30% of cases of advanced disease manifest overexpression of this biomarker.⁵ HER2 overexpression (HER2-positive status) is significantly associated with higher rates of recurrence and mortality, even among patients treated with conventional therapies.³ Thus HER2-positive status is obviously an indicator of particularly aggressive disease.

Fortunately this particular biomarker is one for which we have established and developing therapeutics. The humanized monoclonal antibody, trastuzumab, has been highly effective in improving survival for HER2-positive breast cancer.⁶ More recently, it was studied in a phase 2 trial with carboplatin and paclitaxel chemotherapy for advanced or recurrent HER2-positive UPSC.⁵ This trial showed that the addition of this targeted therapy to conventional chemotherapy improved recurrence-free survival from 8 months to 12 months, and improved overall survival from 24.4 months to 29.6 months.⁵
 

^{One discovery leads to another treatment}

This discovery led to the approval of trastuzumab to be used in addition to chemotherapy for advanced or recurrent disease.² The most significant effects appear to be among those who have not received prior therapies, with a doubling of progression-free survival among these patients, and a more modest response among patients treated for recurrent, mostly pretreated disease.

Work currently is underway to explore an array of antibody or small-molecule blockades of HER2 in addition to vaccines against the protein or treatment with conjugate compounds in which an antibody to HER2 is paired with a cytotoxic drug able to be internalized into HER2-expressing cells.⁷ This represents a form of personalized medicine referred to as biomarker-driven targeted therapy, in which therapies are prescribed based on the expression of specific molecular markers (such as HER2 expression) typically in combination with other clinical markers such as surgical staging results, race, age, etc. These approaches can be very effective strategies in rare tumor subtypes with distinct molecular and clinical behaviors.

As previously mentioned, the targeting of HER2 overexpression with trastuzumab has been shown to be highly effective in the treatment of HER2-positive breast cancers where even patients with early-stage disease receive a multimodal therapy approach including antibody, chemotherapy, surgical, and often radiation treatments.⁶ We are moving towards a similar multimodal comprehensive treatment strategy for UPSC. If it is as successful as it is in breast cancer, it will be long overdue, and desperately necessary given the poor prognosis of this disease for all stages because of the inadequacies of current treatments strategies.

Routine testing of UPSC for HER2 expression is now a part of routine molecular substaging of uterine cancers in the same way we have embraced testing for microsatellite instability and hormone-receptor status. While a diagnosis of HER2 overexpression in UPSC portends a poor prognosis, patients can be reassured that treatment strategies exist that can target this malignant mechanism in advanced disease and more are under further development for early-stage disease.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at [email protected].

References

1. Curr Opin Obstet Gynecol. 2010 Feb. doi: 10.1097/GCO.0b013e328334d8a3.

2. National Comprehensive Cancer Network. Uterine Neoplasms (version 2.2020).

3. Cancer 2005 Oct 1. doi: 10.1002/cncr.21308.

4. Gynecol Oncol 2020 doi: 10.1016/j.ygyno.2020.07.016.

5. J Clin Oncol 2018. doi: 10.1200/JCO.2017.76.5966.

6. N Engl J Med 2011. doi: 10.1056/NEJMoa0910383.

7. Discov Med. 2016 Apr;21(116):293-303.

Uterine papillary serous carcinoma (UPSC) is an infrequent but deadly form of endometrial cancer comprising 10% of cases but contributing 40% of deaths from the disease. Recurrence rates are high for this disease. Five-year survival is 55% for all patients and only 70% for stage I disease.¹ Patterns of recurrence tend to be distant (extrapelvic and extraabdominal) as frequently as they are localized to the pelvis, and metastases and recurrences are unrelated to the extent of uterine disease (such as myometrial invasion). It is for these reasons that the recommended course of adjuvant therapy for this disease is systemic therapy (typically six doses of carboplatin and paclitaxel chemotherapy) with consideration for radiation to the vagina or pelvis to consolidate pelvic and vaginal control.² This differs from early-stage high/intermediate–risk endometrioid adenocarcinomas, for which adjuvant chemotherapy has not been found to be helpful.

Dr Joshua Kish

Because of the lower incidence of UPSC, it frequently has been studied alongside endometrioid cell types in clinical trials which explore novel adjuvant therapies. However, UPSC is biologically distinct from endometrioid endometrial cancers, which likely results in inferior clinical responses to conventional interventions. Fortunately we are beginning to better understand UPSC at a molecular level, and advancements are being made in the targeted therapies for these patients that are unique, compared with those applied to other cancer subtypes.

As discussed above, UPSC is a particularly aggressive form of uterine cancer. Histologically it is characterized by a precursor lesion of endometrial glandular dysplasia progressing to endometrial intraepithelial neoplasia (EIC). Histologically it presents with a highly atypical slit-like glandular configuration, which appears similar to serous carcinomas of the fallopian tube and ovary. Molecularly these tumors commonly manifest mutations in tumor protein p53 (TP53) and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), which are both genes associated with oncogenic potential.¹ While most UPSC tumors have loss of expression in hormone receptors such as estrogen and progesterone, 25%-30% of cases overexpress the tyrosine kinase receptor human epidermal growth factor receptor 2 (HER2).^3-5 This has proven to provide an exciting target for therapeutic interventions.
 

A target for therapeutic intervention

HER2 is a transmembrane receptor which, when activated, signals complex downstream pathways responsible for cellular proliferation, dedifferentiation, and metastasis. In a recent multi-institutional analysis of early-stage UPSC, HER2 overexpression was identified among 25% of cases.⁴ Approximately 30% of cases of advanced disease manifest overexpression of this biomarker.⁵ HER2 overexpression (HER2-positive status) is significantly associated with higher rates of recurrence and mortality, even among patients treated with conventional therapies.³ Thus HER2-positive status is obviously an indicator of particularly aggressive disease.

Fortunately this particular biomarker is one for which we have established and developing therapeutics. The humanized monoclonal antibody, trastuzumab, has been highly effective in improving survival for HER2-positive breast cancer.⁶ More recently, it was studied in a phase 2 trial with carboplatin and paclitaxel chemotherapy for advanced or recurrent HER2-positive UPSC.⁵ This trial showed that the addition of this targeted therapy to conventional chemotherapy improved recurrence-free survival from 8 months to 12 months, and improved overall survival from 24.4 months to 29.6 months.⁵
 

^{One discovery leads to another treatment}

This discovery led to the approval of trastuzumab to be used in addition to chemotherapy for advanced or recurrent disease.² The most significant effects appear to be among those who have not received prior therapies, with a doubling of progression-free survival among these patients, and a more modest response among patients treated for recurrent, mostly pretreated disease.

Work currently is underway to explore an array of antibody or small-molecule blockades of HER2 in addition to vaccines against the protein or treatment with conjugate compounds in which an antibody to HER2 is paired with a cytotoxic drug able to be internalized into HER2-expressing cells.⁷ This represents a form of personalized medicine referred to as biomarker-driven targeted therapy, in which therapies are prescribed based on the expression of specific molecular markers (such as HER2 expression) typically in combination with other clinical markers such as surgical staging results, race, age, etc. These approaches can be very effective strategies in rare tumor subtypes with distinct molecular and clinical behaviors.

As previously mentioned, the targeting of HER2 overexpression with trastuzumab has been shown to be highly effective in the treatment of HER2-positive breast cancers where even patients with early-stage disease receive a multimodal therapy approach including antibody, chemotherapy, surgical, and often radiation treatments.⁶ We are moving towards a similar multimodal comprehensive treatment strategy for UPSC. If it is as successful as it is in breast cancer, it will be long overdue, and desperately necessary given the poor prognosis of this disease for all stages because of the inadequacies of current treatments strategies.

Routine testing of UPSC for HER2 expression is now a part of routine molecular substaging of uterine cancers in the same way we have embraced testing for microsatellite instability and hormone-receptor status. While a diagnosis of HER2 overexpression in UPSC portends a poor prognosis, patients can be reassured that treatment strategies exist that can target this malignant mechanism in advanced disease and more are under further development for early-stage disease.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at [email protected].

References

1. Curr Opin Obstet Gynecol. 2010 Feb. doi: 10.1097/GCO.0b013e328334d8a3.

2. National Comprehensive Cancer Network. Uterine Neoplasms (version 2.2020).

3. Cancer 2005 Oct 1. doi: 10.1002/cncr.21308.

4. Gynecol Oncol 2020 doi: 10.1016/j.ygyno.2020.07.016.

5. J Clin Oncol 2018. doi: 10.1200/JCO.2017.76.5966.

6. N Engl J Med 2011. doi: 10.1056/NEJMoa0910383.

7. Discov Med. 2016 Apr;21(116):293-303.

Another great morning, seeing patients in the comfort of quarantine!

Here goes. I’ll invite Gretchen by text: 617-555-5555. “TOO LONG.” How can 10 digits be too long? Trying again: 617-555-5555. “TOO LONG!” What the heck, let me leave off the last digit: 617-555-555. “TOO SHORT.”

Never mind, I’ll invite her by email.

Five minutes have gone by. Better call to see if she got the invite.

“Hello, is this Gretchen? Don’t hang up, I’m not a telemarketer! This is Dr. Rockoff. I sent you an invitation for our computer visit.

“You got it, great. Yes, you have to click on it to sign in. I know, your appointment’s at 8:30. It’s now 8:28. Let’s start early, why not?

“Hi, there! I can see you. Can you hear me? You’re nodding and your lips are moving. I can’t hear you. Did you enable your microphone?

“Nope, still can’t hear. I’ll call your cell, and we’ll talk that way.

“Yes, it’s me, Dr. Rockoff. What’s that? You enabled the microphone along with your video when you logged on? Well, there we go. How can I help today?

“You want a refill on your tretinoin gel for age management? Not a problem. Let’s see, you’ve been using it since 1996. No, you look great! Not a day over 76, really! I’ll have the staff escribe it right over.

“Okay, take care. Three years should be about right. Happy 80th!”

Wonder what happened there. Maybe things will go better for the next patient. Okay, I’m emailing an invite to Rob.

There he is! “Hi. Can you see me? Hear me? Nope, can’t hear you. Let me just call your cell.”

Okay, 972-555-5555. Ringing ... oh no, right to voicemail. “You have reached 972-555-5555. The mailbox is full and cannot accept messages. Please try some other time.”

“Okay, I’m back with you on the screen, Rob. Nope, still can’t hear you. I tried your cell but it went to voicemail. Yes, I see you’re holding the phone in your hand. Let me try you again.

“972-555-5555. Right to voicemail. Doesn’t your phone ring? You never make voice calls, only send texts? Look, please call me: 781-555-5555, write it down.

“Excellent, we’re in business. You’re worried about a mole that’s changing. You sent a photo to the office. Great, I’ll look right now on your record ... nope, not uploaded. Can you email me the photo? Please write down my email address: alanrockoffmdskincarespecialistist@myfabuloustelemedicineportal.now. Got that? Okay, please send the picture ...

“Returned as undeliverable? Show me what you typed ... Oh, wait. It’s ‘telemedicine,’ not ‘TellaMedicine.’ ” Yeah, that should do it.

“Okay, got the picture. You do fabulous super-closeups! Is that your navel next to it? Your left nostril? Okay. You tried to razor off the hair growing out it? Yes, that could account for the bleeding. Tell you what, go easy on it for the next 2 weeks, and send me another picture. Same email address.

“You have another question? Sure. You want a refill of your clindamycin gel because the tube from 2013 ran out? Guess you haven’t grown out of your acne yet. Sure, happy to send it in for you. Same pharmacy we have on file? You’re bunking with your parents in Wichita? No problem. Just need the pharmacy name and street. Boston, Wichita, whatever.

“Sure, happy to help. Enjoy your stay with your parents. You’ve been there 4 months? Are you cleaning your room? Mostly? Good. Take care. I’ll respond to your email in 2 weeks. Meantime, you might empty out your full voicemail box ... Oh, right, your generation only texts ...”

Okay, one more. Here’s Henrietta. I emailed her an invitation ... Holy Cow, she’s checked in! Let’s see, click “Join.” I can see her!

“Henrietta, is that you? Can you hear me? You can? You can hear me! Henrietta can hear me! And I can hear her!

“Yes, Henrietta, I’m all right. Just doing cartwheels around my study. Between COVID and the 95-degree heat and 100% humidity, it’s all the exercise I get.

“How can I help you today?

“Henrietta? HENRIETTA! Where have you gone, Henrietta?”

THERE IS A PROBLEM WITH YOUR CALL. DISCONNECT YOUR ROUTER, WAIT 65 SECONDS, RECONNECT, THEN RESTART YOUR WIFI, AND LOG IN AGAIN.

Maybe it’s time to go back to the office. A face shield and HAZMAT suit are sounding better all the time.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

Another great morning, seeing patients in the comfort of quarantine!

Here goes. I’ll invite Gretchen by text: 617-555-5555. “TOO LONG.” How can 10 digits be too long? Trying again: 617-555-5555. “TOO LONG!” What the heck, let me leave off the last digit: 617-555-555. “TOO SHORT.”

Never mind, I’ll invite her by email.

Five minutes have gone by. Better call to see if she got the invite.

“Hello, is this Gretchen? Don’t hang up, I’m not a telemarketer! This is Dr. Rockoff. I sent you an invitation for our computer visit.

“You got it, great. Yes, you have to click on it to sign in. I know, your appointment’s at 8:30. It’s now 8:28. Let’s start early, why not?

“Hi, there! I can see you. Can you hear me? You’re nodding and your lips are moving. I can’t hear you. Did you enable your microphone?

“Nope, still can’t hear. I’ll call your cell, and we’ll talk that way.

“Yes, it’s me, Dr. Rockoff. What’s that? You enabled the microphone along with your video when you logged on? Well, there we go. How can I help today?

“You want a refill on your tretinoin gel for age management? Not a problem. Let’s see, you’ve been using it since 1996. No, you look great! Not a day over 76, really! I’ll have the staff escribe it right over.

“Okay, take care. Three years should be about right. Happy 80th!”

Wonder what happened there. Maybe things will go better for the next patient. Okay, I’m emailing an invite to Rob.

There he is! “Hi. Can you see me? Hear me? Nope, can’t hear you. Let me just call your cell.”

Okay, 972-555-5555. Ringing ... oh no, right to voicemail. “You have reached 972-555-5555. The mailbox is full and cannot accept messages. Please try some other time.”

“Okay, I’m back with you on the screen, Rob. Nope, still can’t hear you. I tried your cell but it went to voicemail. Yes, I see you’re holding the phone in your hand. Let me try you again.

“972-555-5555. Right to voicemail. Doesn’t your phone ring? You never make voice calls, only send texts? Look, please call me: 781-555-5555, write it down.

“Excellent, we’re in business. You’re worried about a mole that’s changing. You sent a photo to the office. Great, I’ll look right now on your record ... nope, not uploaded. Can you email me the photo? Please write down my email address: alanrockoffmdskincarespecialistist@myfabuloustelemedicineportal.now. Got that? Okay, please send the picture ...

“Returned as undeliverable? Show me what you typed ... Oh, wait. It’s ‘telemedicine,’ not ‘TellaMedicine.’ ” Yeah, that should do it.

“Okay, got the picture. You do fabulous super-closeups! Is that your navel next to it? Your left nostril? Okay. You tried to razor off the hair growing out it? Yes, that could account for the bleeding. Tell you what, go easy on it for the next 2 weeks, and send me another picture. Same email address.

“You have another question? Sure. You want a refill of your clindamycin gel because the tube from 2013 ran out? Guess you haven’t grown out of your acne yet. Sure, happy to send it in for you. Same pharmacy we have on file? You’re bunking with your parents in Wichita? No problem. Just need the pharmacy name and street. Boston, Wichita, whatever.

“Sure, happy to help. Enjoy your stay with your parents. You’ve been there 4 months? Are you cleaning your room? Mostly? Good. Take care. I’ll respond to your email in 2 weeks. Meantime, you might empty out your full voicemail box ... Oh, right, your generation only texts ...”

Okay, one more. Here’s Henrietta. I emailed her an invitation ... Holy Cow, she’s checked in! Let’s see, click “Join.” I can see her!

“Henrietta, is that you? Can you hear me? You can? You can hear me! Henrietta can hear me! And I can hear her!

“Yes, Henrietta, I’m all right. Just doing cartwheels around my study. Between COVID and the 95-degree heat and 100% humidity, it’s all the exercise I get.

“How can I help you today?

“Henrietta? HENRIETTA! Where have you gone, Henrietta?”

THERE IS A PROBLEM WITH YOUR CALL. DISCONNECT YOUR ROUTER, WAIT 65 SECONDS, RECONNECT, THEN RESTART YOUR WIFI, AND LOG IN AGAIN.

Maybe it’s time to go back to the office. A face shield and HAZMAT suit are sounding better all the time.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

Another great morning, seeing patients in the comfort of quarantine!

Here goes. I’ll invite Gretchen by text: 617-555-5555. “TOO LONG.” How can 10 digits be too long? Trying again: 617-555-5555. “TOO LONG!” What the heck, let me leave off the last digit: 617-555-555. “TOO SHORT.”

Never mind, I’ll invite her by email.

Five minutes have gone by. Better call to see if she got the invite.

“Hello, is this Gretchen? Don’t hang up, I’m not a telemarketer! This is Dr. Rockoff. I sent you an invitation for our computer visit.

“You got it, great. Yes, you have to click on it to sign in. I know, your appointment’s at 8:30. It’s now 8:28. Let’s start early, why not?

“Hi, there! I can see you. Can you hear me? You’re nodding and your lips are moving. I can’t hear you. Did you enable your microphone?

“Nope, still can’t hear. I’ll call your cell, and we’ll talk that way.

“Yes, it’s me, Dr. Rockoff. What’s that? You enabled the microphone along with your video when you logged on? Well, there we go. How can I help today?

“You want a refill on your tretinoin gel for age management? Not a problem. Let’s see, you’ve been using it since 1996. No, you look great! Not a day over 76, really! I’ll have the staff escribe it right over.

“Okay, take care. Three years should be about right. Happy 80th!”

Wonder what happened there. Maybe things will go better for the next patient. Okay, I’m emailing an invite to Rob.

There he is! “Hi. Can you see me? Hear me? Nope, can’t hear you. Let me just call your cell.”

Okay, 972-555-5555. Ringing ... oh no, right to voicemail. “You have reached 972-555-5555. The mailbox is full and cannot accept messages. Please try some other time.”

“Okay, I’m back with you on the screen, Rob. Nope, still can’t hear you. I tried your cell but it went to voicemail. Yes, I see you’re holding the phone in your hand. Let me try you again.

“972-555-5555. Right to voicemail. Doesn’t your phone ring? You never make voice calls, only send texts? Look, please call me: 781-555-5555, write it down.

“Excellent, we’re in business. You’re worried about a mole that’s changing. You sent a photo to the office. Great, I’ll look right now on your record ... nope, not uploaded. Can you email me the photo? Please write down my email address: alanrockoffmdskincarespecialistist@myfabuloustelemedicineportal.now. Got that? Okay, please send the picture ...

“Returned as undeliverable? Show me what you typed ... Oh, wait. It’s ‘telemedicine,’ not ‘TellaMedicine.’ ” Yeah, that should do it.

“Okay, got the picture. You do fabulous super-closeups! Is that your navel next to it? Your left nostril? Okay. You tried to razor off the hair growing out it? Yes, that could account for the bleeding. Tell you what, go easy on it for the next 2 weeks, and send me another picture. Same email address.

“You have another question? Sure. You want a refill of your clindamycin gel because the tube from 2013 ran out? Guess you haven’t grown out of your acne yet. Sure, happy to send it in for you. Same pharmacy we have on file? You’re bunking with your parents in Wichita? No problem. Just need the pharmacy name and street. Boston, Wichita, whatever.

“Sure, happy to help. Enjoy your stay with your parents. You’ve been there 4 months? Are you cleaning your room? Mostly? Good. Take care. I’ll respond to your email in 2 weeks. Meantime, you might empty out your full voicemail box ... Oh, right, your generation only texts ...”

Okay, one more. Here’s Henrietta. I emailed her an invitation ... Holy Cow, she’s checked in! Let’s see, click “Join.” I can see her!

“Henrietta, is that you? Can you hear me? You can? You can hear me! Henrietta can hear me! And I can hear her!

“Yes, Henrietta, I’m all right. Just doing cartwheels around my study. Between COVID and the 95-degree heat and 100% humidity, it’s all the exercise I get.

“How can I help you today?

“Henrietta? HENRIETTA! Where have you gone, Henrietta?”

THERE IS A PROBLEM WITH YOUR CALL. DISCONNECT YOUR ROUTER, WAIT 65 SECONDS, RECONNECT, THEN RESTART YOUR WIFI, AND LOG IN AGAIN.

Maybe it’s time to go back to the office. A face shield and HAZMAT suit are sounding better all the time.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available online. Write to him at [email protected].

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

The use of electronic cigarettes (e-cigarettes) in teenagers has been increasing rapidly in the United States, leading Surgeon General Jerome Adams, MD, MPH, to label it a public health concern.¹ Easy accessibility and extensive marketing for e-cigarettes counteract public education campaigns and policies aimed at decreasing e-cigarette use in teenagers.

E-cigarettes are marketed to teenagers as small, easy-to-use pens or USB flash drive–like devices that can be hidden easily. Some devices can be used to smoke nicotine, delta-9-tetrahydrocannabinol (THC), cannabidiol, and butane hash oil. Some are sold with different nicotine flavors to increase their appeal. E-cigarette ads appear in retail stores, movies, magazines, newspapers, and on the internet. 

According to the CDC, the number of middle and high school students using e-cigarettes increased from 3.6 million in 2018 to 5.4 million in 2019.² Nicotine dependence from e-cigarette use can increase the risk of starting to smoke cigarettes. A 2015-2016 National Institute on Drug Abuse survey found a higher prevalence of e-cigarette use among 9th-, 10th-, and 12th-grade students compared with cigarette smoking (9.5%, 14%, 16.2% vs 3.6%, 6.2%, 11.4%, respectively).³ Due to the growing popularity of vaping among adolescents in the United States, Congress recently raised the legal age to purchase tobacco and vaping products to 21 years.

Evidence of adverse health effects associated with e-cigarette use continues to grow. In 2020, the Department of Health and Services in Wisconsin and the Department of Public Health in Illinois looked at e-cigarette use and pulmonary disease.⁴ Of 98 participants who reported e-cigarette use, 97% presented with respiratory symptoms, 77% had gastrointestinal symptoms, and 100% had constitutional symptoms. Chest imaging showed bilateral infiltrates in all patients. In addition, 95% were hospitalized, 26% underwent intubation and mechanical ventilation, and 1 patient died. Most participants (89%) reported using THC in their e-cigarette devices.⁴ Blount et al⁵ recently found a link between e-cigarette- or vaping-associated lung injury and vitamin E acetate, a toxicant found in bronchoalveolar lavage fluid of some patients who reported using e-cigarettes. Also, nicotine dependency from e-cigarettes may adversely affect brain development in children and adolescents.²

The first step in fighting this crisis is to educate children, parents, teachers, and health care professionals about e-cigarette use, including its prevalence, use compared with cigarette smoking, trends among teenagers, marketing techniques, and adverse effects. Fortunately, the US government and medical professionals and organizations have made ongoing efforts to discourage e-cigarette use. For example, the American Academy of Child and Adolescent Psychiatry supports the FDA’s regulation of e-cigarette use; encourages using evidence-based treatments for tobacco cessation; advocates for vigorous education regarding adolescent e-cigarette use; and endorses restrictions on e-cigarette advertisement.⁶ We strongly urge clinicians to be vigilant about e-cigarette use in their adolescent patients and to intervene in this public health crisis.

Immad A. Kiani, MD
PGY-3 Psychiatry Resident
Christiana Care Health Services
Department of Psychiatry
Wilmington, Delaware

Narpinder K. Malhi, MD
Child and Adolescent Psychiatrist
Christiana Care Health Services
Wilmington, Delaware

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.

There are few things that psychiatrists have come to despise more than the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) program. It has become a professional boondoggle for psychiatric practitioners.

The program needs an overhaul and simplification. There are better, more efficient, cost-effective ways to ensure psychiatric physicians’ ongoing clinical competence after they complete their residency training. Technological advances can also facilitate a more valid assessment of competence without having to jump through more and more hoops between recertifications every 10 years.

I passed the boards long before the MOC was created. For 20 years, I also served as a senior examiner for the oral boards, where clinical competency was rigorously assessed by direct observations of psychiatrists examining and establishing rapport with patients and formulating the data into a differential diagnosis, treatment plan, and prognosis. It is noteworthy that psychiatrists who sat for the oral boards had already passed a written exam that tested their cognitive knowledge. Yet approximately one-third of the candidates failed the live oral exam, which clearly implies that passing a written exam is necessary but not sufficient to establish clinical competence, which is the primary purpose of board certification. It was an unfortunate decision to discontinue the face-to-face oral board exam, which is so vital for psychiatry, and to replace it with a written exam and a barrage of time-consuming activities to document lifelong learning and self-assessment, but not genuine clinical competence. The MOC has been MOCkingly referred to as a major pain in the neck for practically all psychiatrists who were not grandfathered with lifetime certification, as was the case in the first 60 years of the ABPN.

Benefits of the patient-based oral exam

Let’s face it: Passing a patient-based oral exam was the ideal mechanism to establish that a psychiatric physician deserved to be a diplomate of the ABPN. During the oral exam, the candidate’s skills were observed from the minute he/she met the patient. The candidate was then observed as he/she systematically explored a wide range of past and current psychiatric symptoms; reviewed the patient’s developmental, medical, family, and social histories; and conducted a competent mental status exam while demonstrating an empathic stance, responding to the patient’s often subtle verbal and nonverbal cues, establishing rapport, and providing psychoeducation before concluding the interview. All these essential components of a psychiatric exam were observed in a compact 30-minute tour de force of clinical skills, communication, and cognitive acumen. This was followed by another 30 minutes of organizing and presenting the clinical data to 2 or 3 colleagues/examiners, in a coherent fashion, connecting all the dots, formulating the case, presenting a meaningful differential diagnosis, and suggesting a rational array of potential treatment options across the biopsychosocial continuum. To top it off, the candidate had to respond effectively, in an evidence-based manner, to a series of questions related to the disease state, its treatment, adverse effects, and prognosis.

It was a joy to watch many colleagues navigate this clinical examination with skill and competence, without crumbling under the pressure of the examiners’ scrutiny. There were some who passed with flying colors, and others who passed despite having a forgivable minor gap here and there because of their overall strong performance. Finally, there were those who stumbled in several components across data collection, doctor–patient interactions, synthesis of the clinical findings, or treatment recommendations. These candidates inevitably received a failing grade by a consensus of 3 examiners. That they failed to demonstrate clinical competence despite having passed the required written exams a year earlier proved that the true competency of a psychiatrist cannot be judged solely by passing a written test but requires a clinical examination of a live patient.

The oral exams represented an unimpeachable evaluation of clinical competence. The examiners often spoke of how they would feel confident and comfortable with referring a family member to those who successfully passed this rigorous, authentic exam on real patients. It was justifiable to give lifetime certification to those who passed the oral exam. Those permanently certified psychiatrists maintained their lifelong learning by having an unrestricted state medical license, which is contingent on acquiring 50 category 1 continuing medical education (CME) credits annually. Why not restore lifelong certification for those who pass both a written and oral exam, as long as they maintain a valid medical license?

According to the ABPN 2019 Annual Report,¹ 31,514 psychiatrists have received lifetime certification, of whom an estimated 9,547 were still clinically active in 2019. This is the “grandfathered” cohort of psychiatrists to which I belong. I was tested on neurologic patients, not just psychiatric patients, a tribute to the strong bridge that existed between these sister brain specialties. As of 2019, of the 33,277 psychiatrists who received a time-limited certification, 29,343 were still clinically active, an attrition rate of 12% over the past 25 years. This includes psychiatrists who found the MOC too onerous to complete, or are in private practice where MOC is not a vital requirement. However, these days most psychiatrists are obligated to be recertified because so many entities require it. This includes hiring institutions, government agencies (Medicare/Medicaid), health insurance companies, hospital medical staff for privileging and credentialing, and various regulatory boards, such as The Joint Commission, the Accreditation Council for Graduate Medical Education, and academic medical centers. Because most psychiatrists are involved with at least one of these entities, 29,343 have no choice but to perform all the requirements of the MOC, with its countless hours, numerous documentations, and many fees, to remain certified by the ABPN. Notably absent is an alternative mechanism for a certification process that is widely accepted by all agencies and institutions. Psychiatrists are actively seeking alternatives.

Continue to: The ABPN...

The ABPN, long regarded as an esteemed nonprofit organization, has been accused of being a monopoly. Some angry psychiatrists have filed a class action lawsuit to demand other board certification methods. Some have gone to the media to complain about the American Board of Medical Specialties (of which the ABPN is a member board), accusing both of unfair regulations or of raking in substantial profits to support excessively compensated executives. Perception often trumps reality, so no matter how vigorously the ABPN defends itself, its procedures, or its MOC requirements, its customers—psychiatric physicians—feel oppressed or exploited.

How the MOC can be improved

So what can be done to improve the MOC? The need for recertification is arguably necessary to document clinical competency over an approximately 40-year psychiatric career following residency. I conducted a brief survey of Current Psychiatry readers. Of the 319 respondents, 86.5% recommended abolishing the MOC, while 13.5% said it should remain or were unsure. In a follow-up question, 60% agreed that the American Psychiatric Association (APA) should establish a Council on Board Certification, and 33% agreed that the MOC should only be a clinical vignette-based written exam every 10 years, along with an unrestricted or active state medical license.

Significant advances in remote communication technology should be harnessed by the ABPN (or the APA, if it decides to conduct its own board certification) to restore the old model at a fraction of the cost. The oral exams have been replaced by a written exam that is not an accurate reflection or documentation of clinical competence. The traditional oral exam (after passing a written exam) was a magnificent but costly feat of massive logistical complexity, with >1,000 candidates and examiners traveling to a city where the ABPN arranged for several hospitals to shut down their clinics for 2 full days to use their clinical offices for the oral exams. Multiple teams examined the candidates twice on the same day: once with a live patient, and again with a video of a real patient. The examiners filled out scoring cards after observing the candidates conduct the live interview or discussing the video. A consensus grade of pass or fail was documented. At the end of the 2 days, examiners and candidates boarded buses to the airport. It was a highly expensive process (exam fees + airfare + hotel + food). Twice a year, the examiners generously donated their time to the ABPN without compensation, as a token of love for and service to the profession.

That initial certification of a written exam, followed by an oral exam, validated the competence of a psychiatrist both cognitively and clinically. The lifetime certification was truly earned. The same model can now be replicated virtually via videoconferencing at a far lower cost to the ABPN, the candidates, and the examiners. The MOC 10-year recertification can be reduced to a written exam with clinical vignettes and an unrestricted license to practice medicine in any state, which implies that the psychiatrist has received the 50 CME annual credits to renew the license. The rest of the bells and whistles can be strongly recommended but not required. The cost in time and money to both the ABPN and the candidates can be significantly reduced, but more importantly, the clinical competence will be validated at baseline with virtual oral boards after passing the written exam (formerly labeled as part I, preceding the part II oral boards).

The traditional board certification model of the past should be resurrected via videoconferencing and offered as an option to the candidates who prefer it to the current MOC. The MOC can then be simplified to lifetime certification or to only a written exam with clinical vignettes every 10 years to ensure that psychiatrists continue to incorporate relevant clinical and treatment advances in their practice. The KISS principle (keep it simple, stupid) worked very well for many generations of psychiatrists in the past, and will work again going forward if offered as an option. Psychiatrists can then focus on treating patients instead of being burdened by the many time-consuming requirements and hoops of the current MOC.