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The AGA Future Leaders Program: A Mentee-Mentor Triad Perspective
Two of us (Parakkal Deepak and Edward L. Barnes) were part of the American Gastroenterological Association’s (AGA) Future Leaders Program (FLP) class of 2022-2023, and our mentor was Aasma Shaukat. We were invited to share our experiences as participants in the FLP and its impact in our careers.
Why Was the Future Leaders Program Conceived?
To understand this, one must first understand that the AGA, like all other GI professional organizations, relies on volunteer leaders to develop its long-term vision and execute this through strategic initiatives and programs. and understand the governance structure of the AGA to help lead it to face these challenges effectively.
The AGA FLP was thus conceived and launched in 2014-2015 by the founding chairs, Byron Cryer, MD, who is a professor of medicine and associate dean for faculty diversity at University of Texas Southwestern Medical School and Suzanne Rose, MD, MSEd, AGAF, who is a professor of medicine and senior vice dean for medical education at Perelman School of Medicine at the University of Pennsylvania. They envisioned a leadership pathway that would position early career GIs on a track to positively affect the AGA and the field of GI.
How Does One Apply for the Program?
Our FLP cohort applications were invited in October of 2021 and mentees accepted into the program in November 2021. The application process is competitive – applicants are encouraged to detail why they feel they would benefit from the FLP, what existing skillsets they have that can be further enhanced through the program, and what their long-term vision is for their growth as leaders, both within their institution and within the AGA. This is further accompanied by letters of support from their divisional chiefs and other key supervisors within the division who are intimately aware of their leadership potential and career trajectory. This process identified 18 future leaders for our class of 2022-2023.
What Is Involved?
Following acceptance into the AGA Future Leaders Program, we embarked on a series of virtual and in-person meetings with our mentorship triads (one mentor and two mentees) and other mentorship teams over the 18-month program (see Figure). These meetings covered highly focused topics ranging from the role of advocacy in leadership to negotiation and developing a business plan, with ample opportunities for individually tailored mentorship within the mentorship triads.
We also completed personality assessments that helped us understand our strengths and areas of improvement, and ways to use the information to hone our leadership styles.
A large portion of programming and the mentorship experience during the AGA Future Leaders Program is focused on a leadership project that is aimed at addressing a societal driver of interest for the AGA. Examples of these societal drivers of interest include maximizing the role of women in gastroenterology, the role of artificial intelligence in gastroenterology, burnout, and the impact of climate change on gastroenterology. Mentorship triads propose novel methods for addressing these critical issues, outlining the roles that the AGA and other stakeholders may embrace to address these anticipated growing challenges head on.
Our mentorship triad was asked to address the issue of ending disparities within gastroenterology. Given our research and clinical interest in inflammatory bowel disease (IBD), we immediately recognized an opportunity to evaluate and potentially offer solutions for the geographic disparities that exist in the field of IBD. These disparities affect access to care for patients with Crohn’s disease and ulcerative colitis, leading to delays in diagnosis and ultimately effective therapy decisions.
In addition to developing a proposal for the AGA to expand access to care to major IBD centers in rural areas where these disparities exist, we also initiated an examination of geographic disparities in our own multidisciplinary IBD centers (abstract accepted for presentation at Digestive Diseases Week 2024). This allowed us to expand our respective research footprints at our institutions, utilizing new methods of geocoding to directly measure factors affecting clinical outcomes in IBD. Given our in-depth evaluation of this topic as part of our Future Leaders Program training, at the suggestion of our mentor, our mentorship triad also published a commentary on geographic disparities in the Diversity, Equity, and Inclusion sections of Gastroenterology and Clinical Gastroenterology and Hepatology.1, 2
Impact on the Field and Our Careers
Our mentorship triad had the unique experience of having a mentor who had previously participated in the Future Leaders Program as a mentee. As the Future Leaders Program has now enrolled 72 participants, these occasions will likely become more frequent, given the opportunities for career development and growth within the AGA (and our field) that are available after participating in the Future Leaders Program.
To have a mentor with this insight of having been a mentee in the program was invaluable, given her direct experience and understanding of the growth opportunities available, and opportunities to maximize participation in the Future Leaders Program. Additionally, as evidenced by Dr. Shaukat’s recommendations to grow our initial assignment into published commentaries, need statements for our field, and ultimately growing research projects, her keen insights as a mentor were a critical component of our individual growth in the program and the success of our mentorship triad. We benefited from networking with peers and learning about their work, which can lead to future collaborations. We had access to the highly accomplished mentors from diverse settings and learned models of leadership, while developing skills to foster our own leadership style.
In terms of programmatic impact, more than 90% of FLP alumni are serving in AGA leadership on committees, task forces, editorial boards, and councils. What is also important is the impact of content developed by mentee-mentor triads during the FLP cohorts over time. More than 700 GIs have benefited from online leadership development content created by the FLP. Based on our experience, we highly recommend all early career GI physicians to apply!
Dr. Parakkal (@P_DeepakIBDMD) is based in the division of gastroenterology, Washington University in St. Louis (Mo.) School of Medicine. He is supported by a Junior Faculty Development Award from the American College of Gastroenterology and IBD Plexus of the Crohn’s & Colitis Foundation. He has received research support under a sponsored research agreement unrelated to the data in the paper from AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim, Bristol Myers Squibb, Janssen, Prometheus Biosciences, Takeda Pharmaceuticals, Roche-Genentech, and CorEvitas LLC. He has served as a consultant for AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Scipher Medicine, Fresenius Kabi, Roche-Genentech, and CorEvitas LLC. Dr. Barnes (@EdBarnesMD) is based in the division of gastroenterology and hepatology, University of North Carolina at Chapel Hill. He is supported by National Institutes of Health K23DK127157-01, and has served as a consultant for Eli Lilly, Bristol-Meyers Squibb, and Target RWE. Dr. Shaukat (@AasmaShaukatMD) is based in the division of gastroenterology, New York University, New York. She has served as a consultant for Iterative health, Motus, Freenome, and Geneoscopy. Research support by the Steve and Alex Cohen Foundation.
References
1. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Gastroenterology. 2023 July. doi: 10.1053/j.gastro.2023.05.017.
2. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Clin Gastroenterol Hepatol. 2023 July. doi: 10.1016/j.cgh.2023.04.006.
Two of us (Parakkal Deepak and Edward L. Barnes) were part of the American Gastroenterological Association’s (AGA) Future Leaders Program (FLP) class of 2022-2023, and our mentor was Aasma Shaukat. We were invited to share our experiences as participants in the FLP and its impact in our careers.
Why Was the Future Leaders Program Conceived?
To understand this, one must first understand that the AGA, like all other GI professional organizations, relies on volunteer leaders to develop its long-term vision and execute this through strategic initiatives and programs. and understand the governance structure of the AGA to help lead it to face these challenges effectively.
The AGA FLP was thus conceived and launched in 2014-2015 by the founding chairs, Byron Cryer, MD, who is a professor of medicine and associate dean for faculty diversity at University of Texas Southwestern Medical School and Suzanne Rose, MD, MSEd, AGAF, who is a professor of medicine and senior vice dean for medical education at Perelman School of Medicine at the University of Pennsylvania. They envisioned a leadership pathway that would position early career GIs on a track to positively affect the AGA and the field of GI.
How Does One Apply for the Program?
Our FLP cohort applications were invited in October of 2021 and mentees accepted into the program in November 2021. The application process is competitive – applicants are encouraged to detail why they feel they would benefit from the FLP, what existing skillsets they have that can be further enhanced through the program, and what their long-term vision is for their growth as leaders, both within their institution and within the AGA. This is further accompanied by letters of support from their divisional chiefs and other key supervisors within the division who are intimately aware of their leadership potential and career trajectory. This process identified 18 future leaders for our class of 2022-2023.
What Is Involved?
Following acceptance into the AGA Future Leaders Program, we embarked on a series of virtual and in-person meetings with our mentorship triads (one mentor and two mentees) and other mentorship teams over the 18-month program (see Figure). These meetings covered highly focused topics ranging from the role of advocacy in leadership to negotiation and developing a business plan, with ample opportunities for individually tailored mentorship within the mentorship triads.
We also completed personality assessments that helped us understand our strengths and areas of improvement, and ways to use the information to hone our leadership styles.
A large portion of programming and the mentorship experience during the AGA Future Leaders Program is focused on a leadership project that is aimed at addressing a societal driver of interest for the AGA. Examples of these societal drivers of interest include maximizing the role of women in gastroenterology, the role of artificial intelligence in gastroenterology, burnout, and the impact of climate change on gastroenterology. Mentorship triads propose novel methods for addressing these critical issues, outlining the roles that the AGA and other stakeholders may embrace to address these anticipated growing challenges head on.
Our mentorship triad was asked to address the issue of ending disparities within gastroenterology. Given our research and clinical interest in inflammatory bowel disease (IBD), we immediately recognized an opportunity to evaluate and potentially offer solutions for the geographic disparities that exist in the field of IBD. These disparities affect access to care for patients with Crohn’s disease and ulcerative colitis, leading to delays in diagnosis and ultimately effective therapy decisions.
In addition to developing a proposal for the AGA to expand access to care to major IBD centers in rural areas where these disparities exist, we also initiated an examination of geographic disparities in our own multidisciplinary IBD centers (abstract accepted for presentation at Digestive Diseases Week 2024). This allowed us to expand our respective research footprints at our institutions, utilizing new methods of geocoding to directly measure factors affecting clinical outcomes in IBD. Given our in-depth evaluation of this topic as part of our Future Leaders Program training, at the suggestion of our mentor, our mentorship triad also published a commentary on geographic disparities in the Diversity, Equity, and Inclusion sections of Gastroenterology and Clinical Gastroenterology and Hepatology.1, 2
Impact on the Field and Our Careers
Our mentorship triad had the unique experience of having a mentor who had previously participated in the Future Leaders Program as a mentee. As the Future Leaders Program has now enrolled 72 participants, these occasions will likely become more frequent, given the opportunities for career development and growth within the AGA (and our field) that are available after participating in the Future Leaders Program.
To have a mentor with this insight of having been a mentee in the program was invaluable, given her direct experience and understanding of the growth opportunities available, and opportunities to maximize participation in the Future Leaders Program. Additionally, as evidenced by Dr. Shaukat’s recommendations to grow our initial assignment into published commentaries, need statements for our field, and ultimately growing research projects, her keen insights as a mentor were a critical component of our individual growth in the program and the success of our mentorship triad. We benefited from networking with peers and learning about their work, which can lead to future collaborations. We had access to the highly accomplished mentors from diverse settings and learned models of leadership, while developing skills to foster our own leadership style.
In terms of programmatic impact, more than 90% of FLP alumni are serving in AGA leadership on committees, task forces, editorial boards, and councils. What is also important is the impact of content developed by mentee-mentor triads during the FLP cohorts over time. More than 700 GIs have benefited from online leadership development content created by the FLP. Based on our experience, we highly recommend all early career GI physicians to apply!
Dr. Parakkal (@P_DeepakIBDMD) is based in the division of gastroenterology, Washington University in St. Louis (Mo.) School of Medicine. He is supported by a Junior Faculty Development Award from the American College of Gastroenterology and IBD Plexus of the Crohn’s & Colitis Foundation. He has received research support under a sponsored research agreement unrelated to the data in the paper from AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim, Bristol Myers Squibb, Janssen, Prometheus Biosciences, Takeda Pharmaceuticals, Roche-Genentech, and CorEvitas LLC. He has served as a consultant for AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Scipher Medicine, Fresenius Kabi, Roche-Genentech, and CorEvitas LLC. Dr. Barnes (@EdBarnesMD) is based in the division of gastroenterology and hepatology, University of North Carolina at Chapel Hill. He is supported by National Institutes of Health K23DK127157-01, and has served as a consultant for Eli Lilly, Bristol-Meyers Squibb, and Target RWE. Dr. Shaukat (@AasmaShaukatMD) is based in the division of gastroenterology, New York University, New York. She has served as a consultant for Iterative health, Motus, Freenome, and Geneoscopy. Research support by the Steve and Alex Cohen Foundation.
References
1. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Gastroenterology. 2023 July. doi: 10.1053/j.gastro.2023.05.017.
2. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Clin Gastroenterol Hepatol. 2023 July. doi: 10.1016/j.cgh.2023.04.006.
Two of us (Parakkal Deepak and Edward L. Barnes) were part of the American Gastroenterological Association’s (AGA) Future Leaders Program (FLP) class of 2022-2023, and our mentor was Aasma Shaukat. We were invited to share our experiences as participants in the FLP and its impact in our careers.
Why Was the Future Leaders Program Conceived?
To understand this, one must first understand that the AGA, like all other GI professional organizations, relies on volunteer leaders to develop its long-term vision and execute this through strategic initiatives and programs. and understand the governance structure of the AGA to help lead it to face these challenges effectively.
The AGA FLP was thus conceived and launched in 2014-2015 by the founding chairs, Byron Cryer, MD, who is a professor of medicine and associate dean for faculty diversity at University of Texas Southwestern Medical School and Suzanne Rose, MD, MSEd, AGAF, who is a professor of medicine and senior vice dean for medical education at Perelman School of Medicine at the University of Pennsylvania. They envisioned a leadership pathway that would position early career GIs on a track to positively affect the AGA and the field of GI.
How Does One Apply for the Program?
Our FLP cohort applications were invited in October of 2021 and mentees accepted into the program in November 2021. The application process is competitive – applicants are encouraged to detail why they feel they would benefit from the FLP, what existing skillsets they have that can be further enhanced through the program, and what their long-term vision is for their growth as leaders, both within their institution and within the AGA. This is further accompanied by letters of support from their divisional chiefs and other key supervisors within the division who are intimately aware of their leadership potential and career trajectory. This process identified 18 future leaders for our class of 2022-2023.
What Is Involved?
Following acceptance into the AGA Future Leaders Program, we embarked on a series of virtual and in-person meetings with our mentorship triads (one mentor and two mentees) and other mentorship teams over the 18-month program (see Figure). These meetings covered highly focused topics ranging from the role of advocacy in leadership to negotiation and developing a business plan, with ample opportunities for individually tailored mentorship within the mentorship triads.
We also completed personality assessments that helped us understand our strengths and areas of improvement, and ways to use the information to hone our leadership styles.
A large portion of programming and the mentorship experience during the AGA Future Leaders Program is focused on a leadership project that is aimed at addressing a societal driver of interest for the AGA. Examples of these societal drivers of interest include maximizing the role of women in gastroenterology, the role of artificial intelligence in gastroenterology, burnout, and the impact of climate change on gastroenterology. Mentorship triads propose novel methods for addressing these critical issues, outlining the roles that the AGA and other stakeholders may embrace to address these anticipated growing challenges head on.
Our mentorship triad was asked to address the issue of ending disparities within gastroenterology. Given our research and clinical interest in inflammatory bowel disease (IBD), we immediately recognized an opportunity to evaluate and potentially offer solutions for the geographic disparities that exist in the field of IBD. These disparities affect access to care for patients with Crohn’s disease and ulcerative colitis, leading to delays in diagnosis and ultimately effective therapy decisions.
In addition to developing a proposal for the AGA to expand access to care to major IBD centers in rural areas where these disparities exist, we also initiated an examination of geographic disparities in our own multidisciplinary IBD centers (abstract accepted for presentation at Digestive Diseases Week 2024). This allowed us to expand our respective research footprints at our institutions, utilizing new methods of geocoding to directly measure factors affecting clinical outcomes in IBD. Given our in-depth evaluation of this topic as part of our Future Leaders Program training, at the suggestion of our mentor, our mentorship triad also published a commentary on geographic disparities in the Diversity, Equity, and Inclusion sections of Gastroenterology and Clinical Gastroenterology and Hepatology.1, 2
Impact on the Field and Our Careers
Our mentorship triad had the unique experience of having a mentor who had previously participated in the Future Leaders Program as a mentee. As the Future Leaders Program has now enrolled 72 participants, these occasions will likely become more frequent, given the opportunities for career development and growth within the AGA (and our field) that are available after participating in the Future Leaders Program.
To have a mentor with this insight of having been a mentee in the program was invaluable, given her direct experience and understanding of the growth opportunities available, and opportunities to maximize participation in the Future Leaders Program. Additionally, as evidenced by Dr. Shaukat’s recommendations to grow our initial assignment into published commentaries, need statements for our field, and ultimately growing research projects, her keen insights as a mentor were a critical component of our individual growth in the program and the success of our mentorship triad. We benefited from networking with peers and learning about their work, which can lead to future collaborations. We had access to the highly accomplished mentors from diverse settings and learned models of leadership, while developing skills to foster our own leadership style.
In terms of programmatic impact, more than 90% of FLP alumni are serving in AGA leadership on committees, task forces, editorial boards, and councils. What is also important is the impact of content developed by mentee-mentor triads during the FLP cohorts over time. More than 700 GIs have benefited from online leadership development content created by the FLP. Based on our experience, we highly recommend all early career GI physicians to apply!
Dr. Parakkal (@P_DeepakIBDMD) is based in the division of gastroenterology, Washington University in St. Louis (Mo.) School of Medicine. He is supported by a Junior Faculty Development Award from the American College of Gastroenterology and IBD Plexus of the Crohn’s & Colitis Foundation. He has received research support under a sponsored research agreement unrelated to the data in the paper from AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim, Bristol Myers Squibb, Janssen, Prometheus Biosciences, Takeda Pharmaceuticals, Roche-Genentech, and CorEvitas LLC. He has served as a consultant for AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Scipher Medicine, Fresenius Kabi, Roche-Genentech, and CorEvitas LLC. Dr. Barnes (@EdBarnesMD) is based in the division of gastroenterology and hepatology, University of North Carolina at Chapel Hill. He is supported by National Institutes of Health K23DK127157-01, and has served as a consultant for Eli Lilly, Bristol-Meyers Squibb, and Target RWE. Dr. Shaukat (@AasmaShaukatMD) is based in the division of gastroenterology, New York University, New York. She has served as a consultant for Iterative health, Motus, Freenome, and Geneoscopy. Research support by the Steve and Alex Cohen Foundation.
References
1. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Gastroenterology. 2023 July. doi: 10.1053/j.gastro.2023.05.017.
2. Deepak P, Barnes EL, Shaukat A. Health Disparities in Inflammatory Bowel Disease Care Driven by Rural Versus Urban Residence: Challenges and Potential Solutions. Clin Gastroenterol Hepatol. 2023 July. doi: 10.1016/j.cgh.2023.04.006.
Navigating the Search for a Financial Adviser
As gastroenterologists, we spend innumerable years in medical training with an abrupt and significant increase in our earning potential upon beginning practice. The majority of us also carry a sizeable amount of student loan debt. This combination results in a unique situation that can make us hesitant about how best to set ourselves up financially while also making us vulnerable to potentially predatory financial practices.
Although your initial steps to achieve financial wellness and build wealth can be obtained on your own with some education, a financial adviser becomes indispensable when you have significant assets, a high income, complex finances, and/or are experiencing a major life change. Additionally, as there are so many avenues to invest and grow your capital, a financial adviser can assist in designing a portfolio to best accomplish specific monetary goals. Studies have demonstrated that those working with a financial adviser reduce their single-stock risk and have more significant increase in portfolio value, reducing the total cost associated with their investments’ management.1 Those working with a financial adviser will also net up to a 3% larger annual return, compared with a standard baseline investment plan.2,3
Based on this information, it may appear that working with a personal financial adviser would be a no-brainer. Unfortunately, there is a caveat: There is no legal regulation regarding who can use the title “financial adviser.” It is therefore crucial to be aware of common practices and terminology to best help you identify a reputable financial adviser and reduce your risk of excessive fees or financial loss. This is also a highly personal decision and your search should first begin with understanding why you are looking for an adviser, as this will determine the appropriate type of service to look for.
Types of Advisers
A certified financial planner (CFP) is an expert in estate planning, taxes, retirement saving, and financial planning who has a formal designation by the Certified Financial Planner Board of Standards Inc.4 They must undergo stringent licensing examinations following a 3-year course with required continuing education to maintain their credentials. CFPs are fiduciaries, meaning they must make financial decisions in your best interest, even if they may make less money with that product or investment strategy. In other words, they are beholden to give honest, impartial recommendations to their clients, and may face sanctions by the CFP Board if found to violate its Code of Ethics and Standards of Conduct, which includes failure to act in a fiduciary duty.5
CFPs evaluate your total financial picture, such as investments, insurance policies, and overall current financial position, to develop a comprehensive strategy that will successfully guide you to your financial goal. There are many individuals who may refer to themselves as financial planners without having the CFP designation; while they may offer similar services as above, they will not be required to act as a fiduciary. Hence, it is important to do your due diligence and verify they hold this certification via the CFP Board website: www.cfp.net/verify-a-cfp-professional.
An investment adviser is a legal term from the U.S. Securities and Exchange Commission (SEC) and the Financial Industry Regulatory Authority (FINRA) referring to an individual who provides recommendations and analyses for financial securities such as stock. Both of these agencies ensure investment advisers adhere to regulatory requirements designed to protect client investers. Similar to CFPs, they are held to a fiduciary standard, and their firm is required to register with the SEC or the state of practice based on the amount of assets under management.6
An individual investment adviser must also register with their state as an Investment Adviser Representative (IAR), the distinctive term referring to an individual as opposed to an investment advising firm. Investment advisers are required to pass the extensive Series 65, Uniform Investment Advisor Law Exam, or equivalent, by states requiring licensure.7 They can guide you on the selection of particular investments and portfolio management based on a discussion with you regarding your current financial standing and what fiscal ambitions you wish to achieve.
A financial adviser provides direction on a multitude of financially related topics such as investing, tax laws, and life insurance with the goal to help you reach specific financial objectives. However, this term is often used quite ubiquitously given the lack of formal regulation of the title. Essentially, those with varying types of educational background can give themselves the title of financial adviser.
If a financial adviser buys or sells financial securities such as stocks or bonds, then they must be registered as a licensed broker with the SEC and IAR and pass the Series 6 or Series 7 exam. Unlike CFPs and investment advisers, a financial adviser (if also a licensed broker) is not required to be a fiduciary, and instead works under the suitability standard.8 Suitability requires that financial recommendations made by the adviser are appropriate but not necessarily the best for the client. In fact, these recommendations do not even have to be the most suitable. This is where conflicts of interest can arise with the adviser recommending products and securities that best compensate them while not serving the best return on investment for you.
Making the search for a financial adviser more complex, an individual can be a combination of any of the above, pending the appropriate licensing. For example, a CFP can also be an asset manager and thus hold the title of a financial adviser and/or IAR. A financial adviser may also not directly manage your assets if they have a partnership with a third party or another licensed individual. Questions to ask of your potential financial adviser should therefore include the following:
- What licensure and related education do you have?
- What is your particular area of expertise?
- How long have you been in practice?
- How will you be managing my assets?
Financial Adviser Fee Schedules
Prior to working with a financial adviser, you must also inquire about their fee structure. There are two kinds of fee schedules used by financial advisers: fee-only and fee-based.
Fee-only advisers receive payment solely for the services they provide. They do not collect commissions from third parties providing the recommended products. There is variability in how this type of payment schedule is structured, encompassing flat fees, hourly rates, or the adviser charging a retainer. The Table below compares the types of fee-only structures and range of charges based on 2023 rates.9 Of note, fee-only advisers serve as fiduciaries.10
Fee-based financial advisers receive payment for services but may also receive commission on specific products they sell to you.9 Most, if not all, financial experts recommend avoiding advisers using commission-based charges given the potential conflict of interest: How can one be absolutely sure this recommended financial product is best for you, knowing your adviser has a financial stake in said item?
In addition to charging the fees above, your financial adviser, if they are actively managing your investment portfolio, will also charge an assets under management (AUM) fee. This is a percentage of the dollar amount within your portfolio. For example, if your adviser charges a 1% AUM rate for your account totaling $100,000, this equates to a $1,000 fee in that calendar year. AUM fees typically decrease as the size of your portfolio increases. As seen in the Table, there is a wide range of the average AUM rate (0.5%–2%); however, an AUM fee approaching 2% is unnecessarily high and consumes a significant portion of your portfolio. Thus, it is recommended to look for a money manager with an approximate 1% AUM fee.
Many of us delay or avoid working with a financial adviser due to the potential perceived risks of having poor portfolio management from an adviser not working in our best interest, along with the concern for excessive fees. In many ways, it is how we counsel our patients. While they can seek medical information on their own, their best care is under the guidance of an expert: a healthcare professional. That being said, personal finance is indeed personal, so I hope this guide helps facilitate your search and increase your financial wellness.
Dr. Luthra is a therapeutic endoscopist at Moffitt Cancer Center, Tampa, Florida, and the founder of The Scope of Finance, a financial wellness education and coaching company focused on physicians. Her interest in financial well-being is thanks to the teachings of her father, an entrepreneur and former Certified Financial Planner (CFP). She can be found on Instagram (thescopeoffinance) and X (@ScopeofFinance). She reports no financial disclosures relevant to this article.
References
1. Pagliaro CA and Utkus SP. Assessing the value of advice. Vanguard. 2019 Sept.
2. Kinniry Jr. FM et al. Putting a value on your value: Quantifying Vanguard Advisor’s Alpha. Vanguard. 2022 July.
3. Horan S. What Are the Benefits of Working with a Financial Advisor? – 2021 Study. Smart Asset. 2023 July 27.
4. Kagan J. Certified Financial PlannerTM(CFP): What It Is and How to Become One. Investopedia. 2023 Aug 3.
5. CFP Board. Our Commitment to Ethical Standards. CFP Board. 2024.
6. Staff of the Investment Adviser Regulation Office Division of Investment Management, U.S. Securities and Exchange Commission. Regulation of Investment Advisers by the U.S. Securities and Exchange Commission. 2013 Mar.
7. Hicks C. Investment Advisor vs. Financial Advisor: There is a Difference. US News & World Report. 2019 June 13.
8. Roberts K. Financial advisor vs. financial planner: What is the difference? Bankrate. 2023 Nov 21.
9. Clancy D. Average Fees for Financial Advisors in 2023. Harness Wealth. 2023 May 25.
10. Palmer B. Fee- vs. Commission-Based Advisor: What’s the Difference? Investopedia. 2023 June 20.
As gastroenterologists, we spend innumerable years in medical training with an abrupt and significant increase in our earning potential upon beginning practice. The majority of us also carry a sizeable amount of student loan debt. This combination results in a unique situation that can make us hesitant about how best to set ourselves up financially while also making us vulnerable to potentially predatory financial practices.
Although your initial steps to achieve financial wellness and build wealth can be obtained on your own with some education, a financial adviser becomes indispensable when you have significant assets, a high income, complex finances, and/or are experiencing a major life change. Additionally, as there are so many avenues to invest and grow your capital, a financial adviser can assist in designing a portfolio to best accomplish specific monetary goals. Studies have demonstrated that those working with a financial adviser reduce their single-stock risk and have more significant increase in portfolio value, reducing the total cost associated with their investments’ management.1 Those working with a financial adviser will also net up to a 3% larger annual return, compared with a standard baseline investment plan.2,3
Based on this information, it may appear that working with a personal financial adviser would be a no-brainer. Unfortunately, there is a caveat: There is no legal regulation regarding who can use the title “financial adviser.” It is therefore crucial to be aware of common practices and terminology to best help you identify a reputable financial adviser and reduce your risk of excessive fees or financial loss. This is also a highly personal decision and your search should first begin with understanding why you are looking for an adviser, as this will determine the appropriate type of service to look for.
Types of Advisers
A certified financial planner (CFP) is an expert in estate planning, taxes, retirement saving, and financial planning who has a formal designation by the Certified Financial Planner Board of Standards Inc.4 They must undergo stringent licensing examinations following a 3-year course with required continuing education to maintain their credentials. CFPs are fiduciaries, meaning they must make financial decisions in your best interest, even if they may make less money with that product or investment strategy. In other words, they are beholden to give honest, impartial recommendations to their clients, and may face sanctions by the CFP Board if found to violate its Code of Ethics and Standards of Conduct, which includes failure to act in a fiduciary duty.5
CFPs evaluate your total financial picture, such as investments, insurance policies, and overall current financial position, to develop a comprehensive strategy that will successfully guide you to your financial goal. There are many individuals who may refer to themselves as financial planners without having the CFP designation; while they may offer similar services as above, they will not be required to act as a fiduciary. Hence, it is important to do your due diligence and verify they hold this certification via the CFP Board website: www.cfp.net/verify-a-cfp-professional.
An investment adviser is a legal term from the U.S. Securities and Exchange Commission (SEC) and the Financial Industry Regulatory Authority (FINRA) referring to an individual who provides recommendations and analyses for financial securities such as stock. Both of these agencies ensure investment advisers adhere to regulatory requirements designed to protect client investers. Similar to CFPs, they are held to a fiduciary standard, and their firm is required to register with the SEC or the state of practice based on the amount of assets under management.6
An individual investment adviser must also register with their state as an Investment Adviser Representative (IAR), the distinctive term referring to an individual as opposed to an investment advising firm. Investment advisers are required to pass the extensive Series 65, Uniform Investment Advisor Law Exam, or equivalent, by states requiring licensure.7 They can guide you on the selection of particular investments and portfolio management based on a discussion with you regarding your current financial standing and what fiscal ambitions you wish to achieve.
A financial adviser provides direction on a multitude of financially related topics such as investing, tax laws, and life insurance with the goal to help you reach specific financial objectives. However, this term is often used quite ubiquitously given the lack of formal regulation of the title. Essentially, those with varying types of educational background can give themselves the title of financial adviser.
If a financial adviser buys or sells financial securities such as stocks or bonds, then they must be registered as a licensed broker with the SEC and IAR and pass the Series 6 or Series 7 exam. Unlike CFPs and investment advisers, a financial adviser (if also a licensed broker) is not required to be a fiduciary, and instead works under the suitability standard.8 Suitability requires that financial recommendations made by the adviser are appropriate but not necessarily the best for the client. In fact, these recommendations do not even have to be the most suitable. This is where conflicts of interest can arise with the adviser recommending products and securities that best compensate them while not serving the best return on investment for you.
Making the search for a financial adviser more complex, an individual can be a combination of any of the above, pending the appropriate licensing. For example, a CFP can also be an asset manager and thus hold the title of a financial adviser and/or IAR. A financial adviser may also not directly manage your assets if they have a partnership with a third party or another licensed individual. Questions to ask of your potential financial adviser should therefore include the following:
- What licensure and related education do you have?
- What is your particular area of expertise?
- How long have you been in practice?
- How will you be managing my assets?
Financial Adviser Fee Schedules
Prior to working with a financial adviser, you must also inquire about their fee structure. There are two kinds of fee schedules used by financial advisers: fee-only and fee-based.
Fee-only advisers receive payment solely for the services they provide. They do not collect commissions from third parties providing the recommended products. There is variability in how this type of payment schedule is structured, encompassing flat fees, hourly rates, or the adviser charging a retainer. The Table below compares the types of fee-only structures and range of charges based on 2023 rates.9 Of note, fee-only advisers serve as fiduciaries.10
Fee-based financial advisers receive payment for services but may also receive commission on specific products they sell to you.9 Most, if not all, financial experts recommend avoiding advisers using commission-based charges given the potential conflict of interest: How can one be absolutely sure this recommended financial product is best for you, knowing your adviser has a financial stake in said item?
In addition to charging the fees above, your financial adviser, if they are actively managing your investment portfolio, will also charge an assets under management (AUM) fee. This is a percentage of the dollar amount within your portfolio. For example, if your adviser charges a 1% AUM rate for your account totaling $100,000, this equates to a $1,000 fee in that calendar year. AUM fees typically decrease as the size of your portfolio increases. As seen in the Table, there is a wide range of the average AUM rate (0.5%–2%); however, an AUM fee approaching 2% is unnecessarily high and consumes a significant portion of your portfolio. Thus, it is recommended to look for a money manager with an approximate 1% AUM fee.
Many of us delay or avoid working with a financial adviser due to the potential perceived risks of having poor portfolio management from an adviser not working in our best interest, along with the concern for excessive fees. In many ways, it is how we counsel our patients. While they can seek medical information on their own, their best care is under the guidance of an expert: a healthcare professional. That being said, personal finance is indeed personal, so I hope this guide helps facilitate your search and increase your financial wellness.
Dr. Luthra is a therapeutic endoscopist at Moffitt Cancer Center, Tampa, Florida, and the founder of The Scope of Finance, a financial wellness education and coaching company focused on physicians. Her interest in financial well-being is thanks to the teachings of her father, an entrepreneur and former Certified Financial Planner (CFP). She can be found on Instagram (thescopeoffinance) and X (@ScopeofFinance). She reports no financial disclosures relevant to this article.
References
1. Pagliaro CA and Utkus SP. Assessing the value of advice. Vanguard. 2019 Sept.
2. Kinniry Jr. FM et al. Putting a value on your value: Quantifying Vanguard Advisor’s Alpha. Vanguard. 2022 July.
3. Horan S. What Are the Benefits of Working with a Financial Advisor? – 2021 Study. Smart Asset. 2023 July 27.
4. Kagan J. Certified Financial PlannerTM(CFP): What It Is and How to Become One. Investopedia. 2023 Aug 3.
5. CFP Board. Our Commitment to Ethical Standards. CFP Board. 2024.
6. Staff of the Investment Adviser Regulation Office Division of Investment Management, U.S. Securities and Exchange Commission. Regulation of Investment Advisers by the U.S. Securities and Exchange Commission. 2013 Mar.
7. Hicks C. Investment Advisor vs. Financial Advisor: There is a Difference. US News & World Report. 2019 June 13.
8. Roberts K. Financial advisor vs. financial planner: What is the difference? Bankrate. 2023 Nov 21.
9. Clancy D. Average Fees for Financial Advisors in 2023. Harness Wealth. 2023 May 25.
10. Palmer B. Fee- vs. Commission-Based Advisor: What’s the Difference? Investopedia. 2023 June 20.
As gastroenterologists, we spend innumerable years in medical training with an abrupt and significant increase in our earning potential upon beginning practice. The majority of us also carry a sizeable amount of student loan debt. This combination results in a unique situation that can make us hesitant about how best to set ourselves up financially while also making us vulnerable to potentially predatory financial practices.
Although your initial steps to achieve financial wellness and build wealth can be obtained on your own with some education, a financial adviser becomes indispensable when you have significant assets, a high income, complex finances, and/or are experiencing a major life change. Additionally, as there are so many avenues to invest and grow your capital, a financial adviser can assist in designing a portfolio to best accomplish specific monetary goals. Studies have demonstrated that those working with a financial adviser reduce their single-stock risk and have more significant increase in portfolio value, reducing the total cost associated with their investments’ management.1 Those working with a financial adviser will also net up to a 3% larger annual return, compared with a standard baseline investment plan.2,3
Based on this information, it may appear that working with a personal financial adviser would be a no-brainer. Unfortunately, there is a caveat: There is no legal regulation regarding who can use the title “financial adviser.” It is therefore crucial to be aware of common practices and terminology to best help you identify a reputable financial adviser and reduce your risk of excessive fees or financial loss. This is also a highly personal decision and your search should first begin with understanding why you are looking for an adviser, as this will determine the appropriate type of service to look for.
Types of Advisers
A certified financial planner (CFP) is an expert in estate planning, taxes, retirement saving, and financial planning who has a formal designation by the Certified Financial Planner Board of Standards Inc.4 They must undergo stringent licensing examinations following a 3-year course with required continuing education to maintain their credentials. CFPs are fiduciaries, meaning they must make financial decisions in your best interest, even if they may make less money with that product or investment strategy. In other words, they are beholden to give honest, impartial recommendations to their clients, and may face sanctions by the CFP Board if found to violate its Code of Ethics and Standards of Conduct, which includes failure to act in a fiduciary duty.5
CFPs evaluate your total financial picture, such as investments, insurance policies, and overall current financial position, to develop a comprehensive strategy that will successfully guide you to your financial goal. There are many individuals who may refer to themselves as financial planners without having the CFP designation; while they may offer similar services as above, they will not be required to act as a fiduciary. Hence, it is important to do your due diligence and verify they hold this certification via the CFP Board website: www.cfp.net/verify-a-cfp-professional.
An investment adviser is a legal term from the U.S. Securities and Exchange Commission (SEC) and the Financial Industry Regulatory Authority (FINRA) referring to an individual who provides recommendations and analyses for financial securities such as stock. Both of these agencies ensure investment advisers adhere to regulatory requirements designed to protect client investers. Similar to CFPs, they are held to a fiduciary standard, and their firm is required to register with the SEC or the state of practice based on the amount of assets under management.6
An individual investment adviser must also register with their state as an Investment Adviser Representative (IAR), the distinctive term referring to an individual as opposed to an investment advising firm. Investment advisers are required to pass the extensive Series 65, Uniform Investment Advisor Law Exam, or equivalent, by states requiring licensure.7 They can guide you on the selection of particular investments and portfolio management based on a discussion with you regarding your current financial standing and what fiscal ambitions you wish to achieve.
A financial adviser provides direction on a multitude of financially related topics such as investing, tax laws, and life insurance with the goal to help you reach specific financial objectives. However, this term is often used quite ubiquitously given the lack of formal regulation of the title. Essentially, those with varying types of educational background can give themselves the title of financial adviser.
If a financial adviser buys or sells financial securities such as stocks or bonds, then they must be registered as a licensed broker with the SEC and IAR and pass the Series 6 or Series 7 exam. Unlike CFPs and investment advisers, a financial adviser (if also a licensed broker) is not required to be a fiduciary, and instead works under the suitability standard.8 Suitability requires that financial recommendations made by the adviser are appropriate but not necessarily the best for the client. In fact, these recommendations do not even have to be the most suitable. This is where conflicts of interest can arise with the adviser recommending products and securities that best compensate them while not serving the best return on investment for you.
Making the search for a financial adviser more complex, an individual can be a combination of any of the above, pending the appropriate licensing. For example, a CFP can also be an asset manager and thus hold the title of a financial adviser and/or IAR. A financial adviser may also not directly manage your assets if they have a partnership with a third party or another licensed individual. Questions to ask of your potential financial adviser should therefore include the following:
- What licensure and related education do you have?
- What is your particular area of expertise?
- How long have you been in practice?
- How will you be managing my assets?
Financial Adviser Fee Schedules
Prior to working with a financial adviser, you must also inquire about their fee structure. There are two kinds of fee schedules used by financial advisers: fee-only and fee-based.
Fee-only advisers receive payment solely for the services they provide. They do not collect commissions from third parties providing the recommended products. There is variability in how this type of payment schedule is structured, encompassing flat fees, hourly rates, or the adviser charging a retainer. The Table below compares the types of fee-only structures and range of charges based on 2023 rates.9 Of note, fee-only advisers serve as fiduciaries.10
Fee-based financial advisers receive payment for services but may also receive commission on specific products they sell to you.9 Most, if not all, financial experts recommend avoiding advisers using commission-based charges given the potential conflict of interest: How can one be absolutely sure this recommended financial product is best for you, knowing your adviser has a financial stake in said item?
In addition to charging the fees above, your financial adviser, if they are actively managing your investment portfolio, will also charge an assets under management (AUM) fee. This is a percentage of the dollar amount within your portfolio. For example, if your adviser charges a 1% AUM rate for your account totaling $100,000, this equates to a $1,000 fee in that calendar year. AUM fees typically decrease as the size of your portfolio increases. As seen in the Table, there is a wide range of the average AUM rate (0.5%–2%); however, an AUM fee approaching 2% is unnecessarily high and consumes a significant portion of your portfolio. Thus, it is recommended to look for a money manager with an approximate 1% AUM fee.
Many of us delay or avoid working with a financial adviser due to the potential perceived risks of having poor portfolio management from an adviser not working in our best interest, along with the concern for excessive fees. In many ways, it is how we counsel our patients. While they can seek medical information on their own, their best care is under the guidance of an expert: a healthcare professional. That being said, personal finance is indeed personal, so I hope this guide helps facilitate your search and increase your financial wellness.
Dr. Luthra is a therapeutic endoscopist at Moffitt Cancer Center, Tampa, Florida, and the founder of The Scope of Finance, a financial wellness education and coaching company focused on physicians. Her interest in financial well-being is thanks to the teachings of her father, an entrepreneur and former Certified Financial Planner (CFP). She can be found on Instagram (thescopeoffinance) and X (@ScopeofFinance). She reports no financial disclosures relevant to this article.
References
1. Pagliaro CA and Utkus SP. Assessing the value of advice. Vanguard. 2019 Sept.
2. Kinniry Jr. FM et al. Putting a value on your value: Quantifying Vanguard Advisor’s Alpha. Vanguard. 2022 July.
3. Horan S. What Are the Benefits of Working with a Financial Advisor? – 2021 Study. Smart Asset. 2023 July 27.
4. Kagan J. Certified Financial PlannerTM(CFP): What It Is and How to Become One. Investopedia. 2023 Aug 3.
5. CFP Board. Our Commitment to Ethical Standards. CFP Board. 2024.
6. Staff of the Investment Adviser Regulation Office Division of Investment Management, U.S. Securities and Exchange Commission. Regulation of Investment Advisers by the U.S. Securities and Exchange Commission. 2013 Mar.
7. Hicks C. Investment Advisor vs. Financial Advisor: There is a Difference. US News & World Report. 2019 June 13.
8. Roberts K. Financial advisor vs. financial planner: What is the difference? Bankrate. 2023 Nov 21.
9. Clancy D. Average Fees for Financial Advisors in 2023. Harness Wealth. 2023 May 25.
10. Palmer B. Fee- vs. Commission-Based Advisor: What’s the Difference? Investopedia. 2023 June 20.
Achieving Promotion for Junior Faculty in Academic Medicine: An Interview With Experts
Academic medicine plays a crucial role at the crossroads of medical practice, education, and research, influencing the future landscape of healthcare. Many physicians aspire to pursue and sustain a career in academic medicine to contribute to the advancement of medical knowledge, enhance patient care, and influence the trajectory of the medical field. Opting for a career in academic medicine can offer benefits such as increased autonomy and scheduling flexibility, which can significantly improve the quality of life. In addition, engagement in scholarly activities and working in a dynamic environment with continuous learning opportunities can help mitigate burnout.
However, embarking on an academic career can be daunting for junior faculty members who face the challenge of providing clinical care while excelling in research and dedicating time to mentorship and teaching trainees. According to a report by the Association of American Medical Colleges, 38% of physicians leave academic medicine within a decade of obtaining a faculty position. Barriers to promotion and retention within academic medicine include ineffective mentorship, unclear or inconsistent promotion criteria, and disparities in gender/ethnic representation.
In this article, we interview two accomplished physicians in academic medicine who have attained the rank of professors.
Interview with Sophie Balzora, MD
Dr. Balzora is a professor of medicine at NYU Grossman School of Medicine and a practicing gastroenterologist specializing in the care of patients with inflammatory bowel disease at NYU Langone Health. She serves as the American College of Gastroenterology’s Diversity, Equity, and Inclusion Committee Chair, on the Advisory Board of ACG’s Leadership, Ethics, and Equity (LE&E) Center, and is president and cofounder of the Association of Black Gastroenterologists and Hepatologists (ABGH). Dr. Balzora was promoted to full professor 11 years after graduating from fellowship.
What would you identify as some of the most important factors that led to your success in achieving a promotion to professor of medicine?
Surround yourself with individuals whose professional and personal priorities align with yours. To achieve this, it is essential to gain an understanding of what is important to you, what you envision your success to look like, and establish a timeline to achieve it. The concept of personal success and how to best achieve it will absolutely change as you grow, and that is okay and expected. Connecting with those outside of your clinical interests, at other institutions, and even outside of the medical field, can help you achieve these goals and better shape how you see your career unfolding and how you want it to look.
Historically, the proportion of physicians who achieve professorship is lower among women compared with men. What do you believe are some of the barriers involved in this, and how would you counsel women who are interested in pursuing the rank of professor?
Systemic gender bias and discrimination, over-mentorship and under-sponsorship, inconsistent parental leave, and delayed parenthood are a few of the factors that contribute to the observed disparities in academic rank. Predictably, for women from underrepresented backgrounds in medicine, the chasm grows.
What has helped me most is to keep my eyes on the prize, and to recognize that the prize is different for everyone. It’s important not to make direct comparisons to any other individual, because they are not you. Harness what makes you different and drown out the naysayers — the “we’ve never seen this done before” camp, the “it’s too soon [for someone like you] to go up for promotion” folks. While these voices are sometimes well intentioned, they can distract you from your goals and ambitions because they are rooted in bias and adherence to traditional expectations. To do something new, and to change the game, requires going against the grain and utilizing your skills and talents to achieve what you want to achieve in a way that works for you.
What are some practical tips you have for junior gastroenterologists to track their promotion in academia?
- Keep your curriculum vitae (CV) up to date and formatted to your institutional guidelines. Ensure that you document your academic activities, even if it doesn’t seem important in the moment. When it’s time to submit that promotion portfolio, you want to be ready and organized.
- Remember: “No” is a full sentence, and saying it takes practice and time and confidence. It is a skill I still struggle to adopt at times, but it’s important to recognize the power of no, for it opens opportunities to say yes to other things.
- Lift as you climb — a critical part of changing the status quo is fostering the future of those underrepresented in medicine. A professional goal of mine that keeps me steady and passionate is to create supporting and enriching systemic and institutional changes that work to dismantle the obstacles perpetuating disparities in academic rank for women and those underrepresented in medicine. Discovering your “why” is a complex, difficult, and rewarding journey.
Interview with Mark Schattner, MD, AGAF
Dr. Schattner is a professor of clinical medicine at Weill Cornell College of Medicine and chief of the gastroenterology, hepatology, and nutrition service at Memorial Sloan Kettering Cancer Center, both in New York. He is a former president of the New York Society for Gastrointestinal Endoscopy and a fellow of the AGA and ASGE.
In your role as chief, you serve as a mentor for early career gastroenterologists for pursuing career promotion. What advice do you have for achieving this?
Promoting junior faculty is one of the prime responsibilities of a service chief. Generally, the early steps of promotion are straightforward, with criteria becoming more stringent as you progress. I think it is critical to understand the criteria used by promotion committees and to be aware of the various available tracks. I believe every meeting a junior faculty member has with their service chief should include, at the least, a brief check-in on where they are in the promotion process and plans (both short term and long term) to move forward. Successful promotion is facilitated when done upon a solid foundation of production and accomplishment. It is very challenging or even impossible when trying to piece together a package from discordant activities.
Most institutions require or encourage academic involvement at both national and international levels for career promotion. Do you have advice for junior faculty about how to achieve this type of recognition or experience?
The easiest place to start is with regional professional societies. Active involvement in these local societies fosters valuable networking and lays the groundwork for involvement at the national or international level. I would strongly encourage junior faculty to seek opportunities for a leadership position at any level in these societies and move up the ladder as their career matures. This is also a very good avenue to network and get invited to join collaborative research projects, which can be a fruitful means to enhance your academic productivity.
In your opinion, what factors are likely to hinder or delay an individual’s promotion?
I think it is crucial to consider the career track you are on. If you are very clinically productive and love to teach, that is completely appropriate, and most institutions will recognize the value of that and promote you along a clinical-educator tract. On the other hand, if you have a passion for research and can successfully lead research and compete for grants, then you would move along a traditional tenure track. It is also critical to think ahead, know the criteria on which you will be judged, and incorporate that into your practice early. Trying to scramble to enhance your CV in a short time just for promotion will likely prove ineffective.
Do you have advice for junior faculty who have families about how to manage career goals but also prioritize time with family?
There is no one-size-fits-all approach to this. I think this requires a lot of shared decision-making with your family. Compromise will undoubtedly be required. For example, I always chose to live in close proximity to my workplace, eliminating any commuting time. This choice really allowed me spend time with my family.
In conclusion, a career in academic medicine presents both opportunities and challenges. A successful academic career, and achieving promotion to the rank of professor of medicine, requires a combination of factors including understanding institution-specific criteria for promotion, proactive engagement at the regional and national level, and envisioning your career goals and creating a timeline to achieve them. There are challenges to promotion, including navigating systemic biases and balancing career goals with family commitments, which also requires consideration and open communication. Ultimately, we hope these insights provide valuable guidance and advice for junior faculty who are navigating this complex environment of academic medicine and are motivated toward achieving professional fulfillment and satisfaction in their careers.
Dr. Rolston is based in the Department of Gastroenterology, Hepatology, and Nutrition, Memorial Sloan Kettering Cancer Center, New York. She reports no conflicts in relation this article. Dr. Balzora and Dr. Schattner are based in the Division of Gastroenterology and Hepatology, New York University Langone Health, New York. Dr. Schattner is a consultant for Boston Scientific and Novo Nordisk. Dr. Balzora reports no conflicts in relation to this article.
References
Campbell KM. Mitigating the isolation of minoritized faculty in academic medicine. J Gen Intern Med. 2023 May. doi: 10.1007/s11606-022-07982-8.
Howard-Anderson JR et al. Strategies for developing a successful career in academic medicine. Am J Med Sci. 2024 Apr. doi: 10.1016/j.amjms.2023.12.010.
Murphy M et al. Women’s experiences of promotion and tenure in academic medicine and potential implications for gender disparities in career advancement: A qualitative analysis. JAMA Netw Open. 2021 Sep 1. doi: 10.1001/jamanetworkopen.2021.25843.
Sambunjak D et al. Mentoring in academic medicine: A systematic review. JAMA. 2006 Sep 6. doi: 10.1001/jama.296.9.1103.
Shen MR et al. Impact of mentoring on academic career success for women in medicine: A systematic review. Acad Med. 2022 Mar 1. doi: 10.1097/ACM.0000000000004563.
Academic medicine plays a crucial role at the crossroads of medical practice, education, and research, influencing the future landscape of healthcare. Many physicians aspire to pursue and sustain a career in academic medicine to contribute to the advancement of medical knowledge, enhance patient care, and influence the trajectory of the medical field. Opting for a career in academic medicine can offer benefits such as increased autonomy and scheduling flexibility, which can significantly improve the quality of life. In addition, engagement in scholarly activities and working in a dynamic environment with continuous learning opportunities can help mitigate burnout.
However, embarking on an academic career can be daunting for junior faculty members who face the challenge of providing clinical care while excelling in research and dedicating time to mentorship and teaching trainees. According to a report by the Association of American Medical Colleges, 38% of physicians leave academic medicine within a decade of obtaining a faculty position. Barriers to promotion and retention within academic medicine include ineffective mentorship, unclear or inconsistent promotion criteria, and disparities in gender/ethnic representation.
In this article, we interview two accomplished physicians in academic medicine who have attained the rank of professors.
Interview with Sophie Balzora, MD
Dr. Balzora is a professor of medicine at NYU Grossman School of Medicine and a practicing gastroenterologist specializing in the care of patients with inflammatory bowel disease at NYU Langone Health. She serves as the American College of Gastroenterology’s Diversity, Equity, and Inclusion Committee Chair, on the Advisory Board of ACG’s Leadership, Ethics, and Equity (LE&E) Center, and is president and cofounder of the Association of Black Gastroenterologists and Hepatologists (ABGH). Dr. Balzora was promoted to full professor 11 years after graduating from fellowship.
What would you identify as some of the most important factors that led to your success in achieving a promotion to professor of medicine?
Surround yourself with individuals whose professional and personal priorities align with yours. To achieve this, it is essential to gain an understanding of what is important to you, what you envision your success to look like, and establish a timeline to achieve it. The concept of personal success and how to best achieve it will absolutely change as you grow, and that is okay and expected. Connecting with those outside of your clinical interests, at other institutions, and even outside of the medical field, can help you achieve these goals and better shape how you see your career unfolding and how you want it to look.
Historically, the proportion of physicians who achieve professorship is lower among women compared with men. What do you believe are some of the barriers involved in this, and how would you counsel women who are interested in pursuing the rank of professor?
Systemic gender bias and discrimination, over-mentorship and under-sponsorship, inconsistent parental leave, and delayed parenthood are a few of the factors that contribute to the observed disparities in academic rank. Predictably, for women from underrepresented backgrounds in medicine, the chasm grows.
What has helped me most is to keep my eyes on the prize, and to recognize that the prize is different for everyone. It’s important not to make direct comparisons to any other individual, because they are not you. Harness what makes you different and drown out the naysayers — the “we’ve never seen this done before” camp, the “it’s too soon [for someone like you] to go up for promotion” folks. While these voices are sometimes well intentioned, they can distract you from your goals and ambitions because they are rooted in bias and adherence to traditional expectations. To do something new, and to change the game, requires going against the grain and utilizing your skills and talents to achieve what you want to achieve in a way that works for you.
What are some practical tips you have for junior gastroenterologists to track their promotion in academia?
- Keep your curriculum vitae (CV) up to date and formatted to your institutional guidelines. Ensure that you document your academic activities, even if it doesn’t seem important in the moment. When it’s time to submit that promotion portfolio, you want to be ready and organized.
- Remember: “No” is a full sentence, and saying it takes practice and time and confidence. It is a skill I still struggle to adopt at times, but it’s important to recognize the power of no, for it opens opportunities to say yes to other things.
- Lift as you climb — a critical part of changing the status quo is fostering the future of those underrepresented in medicine. A professional goal of mine that keeps me steady and passionate is to create supporting and enriching systemic and institutional changes that work to dismantle the obstacles perpetuating disparities in academic rank for women and those underrepresented in medicine. Discovering your “why” is a complex, difficult, and rewarding journey.
Interview with Mark Schattner, MD, AGAF
Dr. Schattner is a professor of clinical medicine at Weill Cornell College of Medicine and chief of the gastroenterology, hepatology, and nutrition service at Memorial Sloan Kettering Cancer Center, both in New York. He is a former president of the New York Society for Gastrointestinal Endoscopy and a fellow of the AGA and ASGE.
In your role as chief, you serve as a mentor for early career gastroenterologists for pursuing career promotion. What advice do you have for achieving this?
Promoting junior faculty is one of the prime responsibilities of a service chief. Generally, the early steps of promotion are straightforward, with criteria becoming more stringent as you progress. I think it is critical to understand the criteria used by promotion committees and to be aware of the various available tracks. I believe every meeting a junior faculty member has with their service chief should include, at the least, a brief check-in on where they are in the promotion process and plans (both short term and long term) to move forward. Successful promotion is facilitated when done upon a solid foundation of production and accomplishment. It is very challenging or even impossible when trying to piece together a package from discordant activities.
Most institutions require or encourage academic involvement at both national and international levels for career promotion. Do you have advice for junior faculty about how to achieve this type of recognition or experience?
The easiest place to start is with regional professional societies. Active involvement in these local societies fosters valuable networking and lays the groundwork for involvement at the national or international level. I would strongly encourage junior faculty to seek opportunities for a leadership position at any level in these societies and move up the ladder as their career matures. This is also a very good avenue to network and get invited to join collaborative research projects, which can be a fruitful means to enhance your academic productivity.
In your opinion, what factors are likely to hinder or delay an individual’s promotion?
I think it is crucial to consider the career track you are on. If you are very clinically productive and love to teach, that is completely appropriate, and most institutions will recognize the value of that and promote you along a clinical-educator tract. On the other hand, if you have a passion for research and can successfully lead research and compete for grants, then you would move along a traditional tenure track. It is also critical to think ahead, know the criteria on which you will be judged, and incorporate that into your practice early. Trying to scramble to enhance your CV in a short time just for promotion will likely prove ineffective.
Do you have advice for junior faculty who have families about how to manage career goals but also prioritize time with family?
There is no one-size-fits-all approach to this. I think this requires a lot of shared decision-making with your family. Compromise will undoubtedly be required. For example, I always chose to live in close proximity to my workplace, eliminating any commuting time. This choice really allowed me spend time with my family.
In conclusion, a career in academic medicine presents both opportunities and challenges. A successful academic career, and achieving promotion to the rank of professor of medicine, requires a combination of factors including understanding institution-specific criteria for promotion, proactive engagement at the regional and national level, and envisioning your career goals and creating a timeline to achieve them. There are challenges to promotion, including navigating systemic biases and balancing career goals with family commitments, which also requires consideration and open communication. Ultimately, we hope these insights provide valuable guidance and advice for junior faculty who are navigating this complex environment of academic medicine and are motivated toward achieving professional fulfillment and satisfaction in their careers.
Dr. Rolston is based in the Department of Gastroenterology, Hepatology, and Nutrition, Memorial Sloan Kettering Cancer Center, New York. She reports no conflicts in relation this article. Dr. Balzora and Dr. Schattner are based in the Division of Gastroenterology and Hepatology, New York University Langone Health, New York. Dr. Schattner is a consultant for Boston Scientific and Novo Nordisk. Dr. Balzora reports no conflicts in relation to this article.
References
Campbell KM. Mitigating the isolation of minoritized faculty in academic medicine. J Gen Intern Med. 2023 May. doi: 10.1007/s11606-022-07982-8.
Howard-Anderson JR et al. Strategies for developing a successful career in academic medicine. Am J Med Sci. 2024 Apr. doi: 10.1016/j.amjms.2023.12.010.
Murphy M et al. Women’s experiences of promotion and tenure in academic medicine and potential implications for gender disparities in career advancement: A qualitative analysis. JAMA Netw Open. 2021 Sep 1. doi: 10.1001/jamanetworkopen.2021.25843.
Sambunjak D et al. Mentoring in academic medicine: A systematic review. JAMA. 2006 Sep 6. doi: 10.1001/jama.296.9.1103.
Shen MR et al. Impact of mentoring on academic career success for women in medicine: A systematic review. Acad Med. 2022 Mar 1. doi: 10.1097/ACM.0000000000004563.
Academic medicine plays a crucial role at the crossroads of medical practice, education, and research, influencing the future landscape of healthcare. Many physicians aspire to pursue and sustain a career in academic medicine to contribute to the advancement of medical knowledge, enhance patient care, and influence the trajectory of the medical field. Opting for a career in academic medicine can offer benefits such as increased autonomy and scheduling flexibility, which can significantly improve the quality of life. In addition, engagement in scholarly activities and working in a dynamic environment with continuous learning opportunities can help mitigate burnout.
However, embarking on an academic career can be daunting for junior faculty members who face the challenge of providing clinical care while excelling in research and dedicating time to mentorship and teaching trainees. According to a report by the Association of American Medical Colleges, 38% of physicians leave academic medicine within a decade of obtaining a faculty position. Barriers to promotion and retention within academic medicine include ineffective mentorship, unclear or inconsistent promotion criteria, and disparities in gender/ethnic representation.
In this article, we interview two accomplished physicians in academic medicine who have attained the rank of professors.
Interview with Sophie Balzora, MD
Dr. Balzora is a professor of medicine at NYU Grossman School of Medicine and a practicing gastroenterologist specializing in the care of patients with inflammatory bowel disease at NYU Langone Health. She serves as the American College of Gastroenterology’s Diversity, Equity, and Inclusion Committee Chair, on the Advisory Board of ACG’s Leadership, Ethics, and Equity (LE&E) Center, and is president and cofounder of the Association of Black Gastroenterologists and Hepatologists (ABGH). Dr. Balzora was promoted to full professor 11 years after graduating from fellowship.
What would you identify as some of the most important factors that led to your success in achieving a promotion to professor of medicine?
Surround yourself with individuals whose professional and personal priorities align with yours. To achieve this, it is essential to gain an understanding of what is important to you, what you envision your success to look like, and establish a timeline to achieve it. The concept of personal success and how to best achieve it will absolutely change as you grow, and that is okay and expected. Connecting with those outside of your clinical interests, at other institutions, and even outside of the medical field, can help you achieve these goals and better shape how you see your career unfolding and how you want it to look.
Historically, the proportion of physicians who achieve professorship is lower among women compared with men. What do you believe are some of the barriers involved in this, and how would you counsel women who are interested in pursuing the rank of professor?
Systemic gender bias and discrimination, over-mentorship and under-sponsorship, inconsistent parental leave, and delayed parenthood are a few of the factors that contribute to the observed disparities in academic rank. Predictably, for women from underrepresented backgrounds in medicine, the chasm grows.
What has helped me most is to keep my eyes on the prize, and to recognize that the prize is different for everyone. It’s important not to make direct comparisons to any other individual, because they are not you. Harness what makes you different and drown out the naysayers — the “we’ve never seen this done before” camp, the “it’s too soon [for someone like you] to go up for promotion” folks. While these voices are sometimes well intentioned, they can distract you from your goals and ambitions because they are rooted in bias and adherence to traditional expectations. To do something new, and to change the game, requires going against the grain and utilizing your skills and talents to achieve what you want to achieve in a way that works for you.
What are some practical tips you have for junior gastroenterologists to track their promotion in academia?
- Keep your curriculum vitae (CV) up to date and formatted to your institutional guidelines. Ensure that you document your academic activities, even if it doesn’t seem important in the moment. When it’s time to submit that promotion portfolio, you want to be ready and organized.
- Remember: “No” is a full sentence, and saying it takes practice and time and confidence. It is a skill I still struggle to adopt at times, but it’s important to recognize the power of no, for it opens opportunities to say yes to other things.
- Lift as you climb — a critical part of changing the status quo is fostering the future of those underrepresented in medicine. A professional goal of mine that keeps me steady and passionate is to create supporting and enriching systemic and institutional changes that work to dismantle the obstacles perpetuating disparities in academic rank for women and those underrepresented in medicine. Discovering your “why” is a complex, difficult, and rewarding journey.
Interview with Mark Schattner, MD, AGAF
Dr. Schattner is a professor of clinical medicine at Weill Cornell College of Medicine and chief of the gastroenterology, hepatology, and nutrition service at Memorial Sloan Kettering Cancer Center, both in New York. He is a former president of the New York Society for Gastrointestinal Endoscopy and a fellow of the AGA and ASGE.
In your role as chief, you serve as a mentor for early career gastroenterologists for pursuing career promotion. What advice do you have for achieving this?
Promoting junior faculty is one of the prime responsibilities of a service chief. Generally, the early steps of promotion are straightforward, with criteria becoming more stringent as you progress. I think it is critical to understand the criteria used by promotion committees and to be aware of the various available tracks. I believe every meeting a junior faculty member has with their service chief should include, at the least, a brief check-in on where they are in the promotion process and plans (both short term and long term) to move forward. Successful promotion is facilitated when done upon a solid foundation of production and accomplishment. It is very challenging or even impossible when trying to piece together a package from discordant activities.
Most institutions require or encourage academic involvement at both national and international levels for career promotion. Do you have advice for junior faculty about how to achieve this type of recognition or experience?
The easiest place to start is with regional professional societies. Active involvement in these local societies fosters valuable networking and lays the groundwork for involvement at the national or international level. I would strongly encourage junior faculty to seek opportunities for a leadership position at any level in these societies and move up the ladder as their career matures. This is also a very good avenue to network and get invited to join collaborative research projects, which can be a fruitful means to enhance your academic productivity.
In your opinion, what factors are likely to hinder or delay an individual’s promotion?
I think it is crucial to consider the career track you are on. If you are very clinically productive and love to teach, that is completely appropriate, and most institutions will recognize the value of that and promote you along a clinical-educator tract. On the other hand, if you have a passion for research and can successfully lead research and compete for grants, then you would move along a traditional tenure track. It is also critical to think ahead, know the criteria on which you will be judged, and incorporate that into your practice early. Trying to scramble to enhance your CV in a short time just for promotion will likely prove ineffective.
Do you have advice for junior faculty who have families about how to manage career goals but also prioritize time with family?
There is no one-size-fits-all approach to this. I think this requires a lot of shared decision-making with your family. Compromise will undoubtedly be required. For example, I always chose to live in close proximity to my workplace, eliminating any commuting time. This choice really allowed me spend time with my family.
In conclusion, a career in academic medicine presents both opportunities and challenges. A successful academic career, and achieving promotion to the rank of professor of medicine, requires a combination of factors including understanding institution-specific criteria for promotion, proactive engagement at the regional and national level, and envisioning your career goals and creating a timeline to achieve them. There are challenges to promotion, including navigating systemic biases and balancing career goals with family commitments, which also requires consideration and open communication. Ultimately, we hope these insights provide valuable guidance and advice for junior faculty who are navigating this complex environment of academic medicine and are motivated toward achieving professional fulfillment and satisfaction in their careers.
Dr. Rolston is based in the Department of Gastroenterology, Hepatology, and Nutrition, Memorial Sloan Kettering Cancer Center, New York. She reports no conflicts in relation this article. Dr. Balzora and Dr. Schattner are based in the Division of Gastroenterology and Hepatology, New York University Langone Health, New York. Dr. Schattner is a consultant for Boston Scientific and Novo Nordisk. Dr. Balzora reports no conflicts in relation to this article.
References
Campbell KM. Mitigating the isolation of minoritized faculty in academic medicine. J Gen Intern Med. 2023 May. doi: 10.1007/s11606-022-07982-8.
Howard-Anderson JR et al. Strategies for developing a successful career in academic medicine. Am J Med Sci. 2024 Apr. doi: 10.1016/j.amjms.2023.12.010.
Murphy M et al. Women’s experiences of promotion and tenure in academic medicine and potential implications for gender disparities in career advancement: A qualitative analysis. JAMA Netw Open. 2021 Sep 1. doi: 10.1001/jamanetworkopen.2021.25843.
Sambunjak D et al. Mentoring in academic medicine: A systematic review. JAMA. 2006 Sep 6. doi: 10.1001/jama.296.9.1103.
Shen MR et al. Impact of mentoring on academic career success for women in medicine: A systematic review. Acad Med. 2022 Mar 1. doi: 10.1097/ACM.0000000000004563.
A Simplified Approach to Pelvic Floor Dysfunction
Pelvic floor dysfunction (PFD) represents a spectrum of symptoms involving sensory and emptying abnormalities of the bowel and bladder and pelvic organ prolapse. The pelvic floor refers to a group of muscles that spans the pelvic outlet, providing support to the pelvic organs and coordinating constrictor mechanisms to control urination and defecation. Symptoms reported by patients experiencing PFD include involuntary loss of stool or urine, incomplete emptying of the bowel and bladder, a sensation of fullness, bulging in the vagina, and sexual dysfunction.1
As such, symptoms related to PFD are very common concerns raised by patients to their gastroenterologists. Data from the National Health and Nutrition Examination Survey show that 23.7% of women over the age of 20 had at least one symptom of PFD.2 Unfortunately, patients experiencing pelvic floor dysfunction often are hesitant to seek care because of embarrassment or perception that limited treatment options exist for their symptoms.
Pelvic Floor Anatomy
Regions of the pelvis are often referred to by anatomic compartment: anterior (bladder and urethra), middle (vagina and uterus or prostate), and posterior (colon, rectum, and anal canal). Supporting these compartments is the levator ani, a muscle group that is used synonymously with the term “pelvic diaphragm.”
Continence of stool is provided by the anal sphincter muscles and the puborectalis muscle, which wraps around the posterior aspect of the anorectal canal. Damage to the musculature or sensory perception to this area may result in fecal incontinence. Defecation is a coordinated process during which the abdominal and rectal muscles contract, while the anal sphincter muscles and puborectalis simultaneously relax. A disturbance in neuromuscular coordination (dyssynergic defecation) or structural pathology such as pelvic organ prolapse may lead to obstructed defecation.
PFD is thought to be a result of one or more insults to the pelvic floor such as chronic straining, childbirth, iatrogenic injury, or systemic disease such as diabetes.3
Evaluation of PFD Symptoms
Patients presenting with suspected PFD necessitate a comprehensive interdisciplinary assessment. In addition to obtaining a medical, surgical, and obstetric history, details about symptoms and lifestyle should include toileting habits, diet, and physical activity. The Pelvic Floor Distress Inventory (PFDI-20) is a commonly used tool that can be employed in the clinical setting.4
A pelvic exam can reveal pelvic organ prolapse and other mucosal pathology. The Pelvic Organ Prolapse Quantification System (POP-Q) is a widely used classification system for describing pelvic organ prolapse.5 Protrusion of the rectal wall into the vagina is referred to as a rectocele, while prolapse of small bowel into the upper posterior wall of the vagina is called an enterocele. While the finding of a rectocele on exam is common in parous women and may not cause any symptoms, a larger rectocele may cause a sensation of incomplete evacuation of stool.
A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.
Initial Management
A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention. For patients reporting liquid stool consistency, the evaluation should pivot toward the workup and management of diarrhea, which can easily overwhelm continence mechanisms and cause fecal incontinence. Fiber supplementation to normalize stool consistency is considered first-line therapy for patients presenting with both fecal incontinence and obstructed defecation. Other tools for fecal incontinence include avoiding foods that trigger diarrhea and use of loperamide.6 For patients with obstructed defecation, a trial of laxatives can be followed by a prescription agent if needed, such as a secretagogue or prokinetic.7
Vaginal splinting is a technique that can be used in patients with rectocele, whereby a finger is inserted into the vagina and pressure is applied on the posterior vaginal wall toward the rectum. Reducing the rectocele can facilitate emptying stool from the rectum and prevent leakage of retained stool.8 Similarly, use of rectal irrigation enemas can also help clear retained stool.
Pelvic floor physical therapists examine the strength, coordination, and tone of the pelvic floor muscles. When hypertonic musculature is present, manual interventions may be performed including trigger point release, myofascial release, and dry needling.9 When hypotonic musculature or dyssynergia is present, strengthening and neuromuscular re-education are recommended. Biofeedback can be administered via surface electromyography and/or balloon training to improve rectal sensitivity. Proper defecation techniques, including positioning, breathing, and behavioral modifications, improve clinical outcomes.
Diagnostic Testing
For patients who do not improve with conservative management, further testing is recommended to characterize the underlying pathology. Typically, anorectal manometry (ARM) is performed in conjunction with the balloon expulsion test and imaging. Each modality has its strengths and limitations (see Table 1).
ARM allows for the assessment of rectal sensation and recto-anal pressures and coordination.10
Dynamic imaging, by barium defecography under fluoroscopy or MRI, captures anatomy at rest and with simulated defecation to identify pelvic organ prolapse, compartmental defects, and organ mobility.11 Endoanal ultrasonography is considered in patients experiencing fecal incontinence to evaluate the integrity of the anal sphincter muscles.
Minimally Invasive Procedures and Surgical Options for PFD
Functional abnormalities such as dyssynergia often coexist with structural abnormalities. Because structural abnormalities are commonly found in asymptomatic patients, noninvasive functional therapy, such as pelvic floor physical therapy and anorectal biofeedback, are preferred prior to surgical repair of a structural finding. For patients with fecal incontinence, sacral nerve stimulation (SNS) has emerged as a preferred therapy due to demonstrated efficacy in symptom improvement.12 Sphincteroplasty is reserved for those with acute sphincter injury or failure of SNS.
In patients with findings of intussusception, prolapse, or rectocele that have not responded to conservative therapy, referral for surgical repair may be considered. While the specific surgical approach will depend on many factors, the goal is typically excision and/or suspension of rectal tissue and reinforcement of the rectovaginal septum.
It is critical that we are equipped with the available knowledge and tools to provide these patients with optimal care.
Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.
References
1. Grimes WR and Stratton M. Pelvic floor dysfunction. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2024 Jan. PMID: 32644672.
2. Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. doi: 10.1001/jama.300.11.1311.
3. Lawrence JM et al. Pelvic floor disorders, diabetes, and obesity in women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct. doi: 10.2337/dc07-0262.
4. Barber MD et al. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul. doi: 10.1016/j.ajog.2004.12.025.
5. Persu C et al. Pelvic Organ Prolapse Quantification System (POP-Q) — A new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar. PMID: 21505577.
6. Wald A et al. ACG Clinical Guidelines: Management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. doi: 10.14309/ajg.0000000000001507.
7. Bharucha AE and Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020 Apr. doi: 10.1053/j.gastro.2019.12.034.
8. Menees S and Chey WD. Fecal incontinence: Pathogenesis, diagnosis, and updated treatment strategies. Gastroenterol Clin North Am. 2022 Mar. doi: 10.1016/j.gtc.2021.10.005.
9. Wallace SL et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec. doi: 10.1097/GCO.0000000000000584.
10. Carrington EV et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan. doi: 10.1111/nmo.13679.
11. El Sayed RF et al. Magnetic resonance imaging of pelvic floor dysfunction — Joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017 May. doi: 10.1007/s00330-016-4471-7.
12. Thaha MA et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24. doi: 10.1002/14651858.CD004464.pub3.
13. Chiarioni G et al. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005 Jul. doi: 10.1053/j.gastro.2005.05.015.
14. Grossi U et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016 Mar. doi: 10.1136/gutjnl-2014-308835.
15. Albuquerque A. Endoanal ultrasonography in fecal incontinence: Current and future perspectives. World J Gastrointest Endosc. 2015 Jun 10. doi: 10.4253/wjge.v7.i6.575.
Pelvic floor dysfunction (PFD) represents a spectrum of symptoms involving sensory and emptying abnormalities of the bowel and bladder and pelvic organ prolapse. The pelvic floor refers to a group of muscles that spans the pelvic outlet, providing support to the pelvic organs and coordinating constrictor mechanisms to control urination and defecation. Symptoms reported by patients experiencing PFD include involuntary loss of stool or urine, incomplete emptying of the bowel and bladder, a sensation of fullness, bulging in the vagina, and sexual dysfunction.1
As such, symptoms related to PFD are very common concerns raised by patients to their gastroenterologists. Data from the National Health and Nutrition Examination Survey show that 23.7% of women over the age of 20 had at least one symptom of PFD.2 Unfortunately, patients experiencing pelvic floor dysfunction often are hesitant to seek care because of embarrassment or perception that limited treatment options exist for their symptoms.
Pelvic Floor Anatomy
Regions of the pelvis are often referred to by anatomic compartment: anterior (bladder and urethra), middle (vagina and uterus or prostate), and posterior (colon, rectum, and anal canal). Supporting these compartments is the levator ani, a muscle group that is used synonymously with the term “pelvic diaphragm.”
Continence of stool is provided by the anal sphincter muscles and the puborectalis muscle, which wraps around the posterior aspect of the anorectal canal. Damage to the musculature or sensory perception to this area may result in fecal incontinence. Defecation is a coordinated process during which the abdominal and rectal muscles contract, while the anal sphincter muscles and puborectalis simultaneously relax. A disturbance in neuromuscular coordination (dyssynergic defecation) or structural pathology such as pelvic organ prolapse may lead to obstructed defecation.
PFD is thought to be a result of one or more insults to the pelvic floor such as chronic straining, childbirth, iatrogenic injury, or systemic disease such as diabetes.3
Evaluation of PFD Symptoms
Patients presenting with suspected PFD necessitate a comprehensive interdisciplinary assessment. In addition to obtaining a medical, surgical, and obstetric history, details about symptoms and lifestyle should include toileting habits, diet, and physical activity. The Pelvic Floor Distress Inventory (PFDI-20) is a commonly used tool that can be employed in the clinical setting.4
A pelvic exam can reveal pelvic organ prolapse and other mucosal pathology. The Pelvic Organ Prolapse Quantification System (POP-Q) is a widely used classification system for describing pelvic organ prolapse.5 Protrusion of the rectal wall into the vagina is referred to as a rectocele, while prolapse of small bowel into the upper posterior wall of the vagina is called an enterocele. While the finding of a rectocele on exam is common in parous women and may not cause any symptoms, a larger rectocele may cause a sensation of incomplete evacuation of stool.
A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.
Initial Management
A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention. For patients reporting liquid stool consistency, the evaluation should pivot toward the workup and management of diarrhea, which can easily overwhelm continence mechanisms and cause fecal incontinence. Fiber supplementation to normalize stool consistency is considered first-line therapy for patients presenting with both fecal incontinence and obstructed defecation. Other tools for fecal incontinence include avoiding foods that trigger diarrhea and use of loperamide.6 For patients with obstructed defecation, a trial of laxatives can be followed by a prescription agent if needed, such as a secretagogue or prokinetic.7
Vaginal splinting is a technique that can be used in patients with rectocele, whereby a finger is inserted into the vagina and pressure is applied on the posterior vaginal wall toward the rectum. Reducing the rectocele can facilitate emptying stool from the rectum and prevent leakage of retained stool.8 Similarly, use of rectal irrigation enemas can also help clear retained stool.
Pelvic floor physical therapists examine the strength, coordination, and tone of the pelvic floor muscles. When hypertonic musculature is present, manual interventions may be performed including trigger point release, myofascial release, and dry needling.9 When hypotonic musculature or dyssynergia is present, strengthening and neuromuscular re-education are recommended. Biofeedback can be administered via surface electromyography and/or balloon training to improve rectal sensitivity. Proper defecation techniques, including positioning, breathing, and behavioral modifications, improve clinical outcomes.
Diagnostic Testing
For patients who do not improve with conservative management, further testing is recommended to characterize the underlying pathology. Typically, anorectal manometry (ARM) is performed in conjunction with the balloon expulsion test and imaging. Each modality has its strengths and limitations (see Table 1).
ARM allows for the assessment of rectal sensation and recto-anal pressures and coordination.10
Dynamic imaging, by barium defecography under fluoroscopy or MRI, captures anatomy at rest and with simulated defecation to identify pelvic organ prolapse, compartmental defects, and organ mobility.11 Endoanal ultrasonography is considered in patients experiencing fecal incontinence to evaluate the integrity of the anal sphincter muscles.
Minimally Invasive Procedures and Surgical Options for PFD
Functional abnormalities such as dyssynergia often coexist with structural abnormalities. Because structural abnormalities are commonly found in asymptomatic patients, noninvasive functional therapy, such as pelvic floor physical therapy and anorectal biofeedback, are preferred prior to surgical repair of a structural finding. For patients with fecal incontinence, sacral nerve stimulation (SNS) has emerged as a preferred therapy due to demonstrated efficacy in symptom improvement.12 Sphincteroplasty is reserved for those with acute sphincter injury or failure of SNS.
In patients with findings of intussusception, prolapse, or rectocele that have not responded to conservative therapy, referral for surgical repair may be considered. While the specific surgical approach will depend on many factors, the goal is typically excision and/or suspension of rectal tissue and reinforcement of the rectovaginal septum.
It is critical that we are equipped with the available knowledge and tools to provide these patients with optimal care.
Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.
References
1. Grimes WR and Stratton M. Pelvic floor dysfunction. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2024 Jan. PMID: 32644672.
2. Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. doi: 10.1001/jama.300.11.1311.
3. Lawrence JM et al. Pelvic floor disorders, diabetes, and obesity in women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct. doi: 10.2337/dc07-0262.
4. Barber MD et al. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul. doi: 10.1016/j.ajog.2004.12.025.
5. Persu C et al. Pelvic Organ Prolapse Quantification System (POP-Q) — A new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar. PMID: 21505577.
6. Wald A et al. ACG Clinical Guidelines: Management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. doi: 10.14309/ajg.0000000000001507.
7. Bharucha AE and Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020 Apr. doi: 10.1053/j.gastro.2019.12.034.
8. Menees S and Chey WD. Fecal incontinence: Pathogenesis, diagnosis, and updated treatment strategies. Gastroenterol Clin North Am. 2022 Mar. doi: 10.1016/j.gtc.2021.10.005.
9. Wallace SL et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec. doi: 10.1097/GCO.0000000000000584.
10. Carrington EV et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan. doi: 10.1111/nmo.13679.
11. El Sayed RF et al. Magnetic resonance imaging of pelvic floor dysfunction — Joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017 May. doi: 10.1007/s00330-016-4471-7.
12. Thaha MA et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24. doi: 10.1002/14651858.CD004464.pub3.
13. Chiarioni G et al. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005 Jul. doi: 10.1053/j.gastro.2005.05.015.
14. Grossi U et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016 Mar. doi: 10.1136/gutjnl-2014-308835.
15. Albuquerque A. Endoanal ultrasonography in fecal incontinence: Current and future perspectives. World J Gastrointest Endosc. 2015 Jun 10. doi: 10.4253/wjge.v7.i6.575.
Pelvic floor dysfunction (PFD) represents a spectrum of symptoms involving sensory and emptying abnormalities of the bowel and bladder and pelvic organ prolapse. The pelvic floor refers to a group of muscles that spans the pelvic outlet, providing support to the pelvic organs and coordinating constrictor mechanisms to control urination and defecation. Symptoms reported by patients experiencing PFD include involuntary loss of stool or urine, incomplete emptying of the bowel and bladder, a sensation of fullness, bulging in the vagina, and sexual dysfunction.1
As such, symptoms related to PFD are very common concerns raised by patients to their gastroenterologists. Data from the National Health and Nutrition Examination Survey show that 23.7% of women over the age of 20 had at least one symptom of PFD.2 Unfortunately, patients experiencing pelvic floor dysfunction often are hesitant to seek care because of embarrassment or perception that limited treatment options exist for their symptoms.
Pelvic Floor Anatomy
Regions of the pelvis are often referred to by anatomic compartment: anterior (bladder and urethra), middle (vagina and uterus or prostate), and posterior (colon, rectum, and anal canal). Supporting these compartments is the levator ani, a muscle group that is used synonymously with the term “pelvic diaphragm.”
Continence of stool is provided by the anal sphincter muscles and the puborectalis muscle, which wraps around the posterior aspect of the anorectal canal. Damage to the musculature or sensory perception to this area may result in fecal incontinence. Defecation is a coordinated process during which the abdominal and rectal muscles contract, while the anal sphincter muscles and puborectalis simultaneously relax. A disturbance in neuromuscular coordination (dyssynergic defecation) or structural pathology such as pelvic organ prolapse may lead to obstructed defecation.
PFD is thought to be a result of one or more insults to the pelvic floor such as chronic straining, childbirth, iatrogenic injury, or systemic disease such as diabetes.3
Evaluation of PFD Symptoms
Patients presenting with suspected PFD necessitate a comprehensive interdisciplinary assessment. In addition to obtaining a medical, surgical, and obstetric history, details about symptoms and lifestyle should include toileting habits, diet, and physical activity. The Pelvic Floor Distress Inventory (PFDI-20) is a commonly used tool that can be employed in the clinical setting.4
A pelvic exam can reveal pelvic organ prolapse and other mucosal pathology. The Pelvic Organ Prolapse Quantification System (POP-Q) is a widely used classification system for describing pelvic organ prolapse.5 Protrusion of the rectal wall into the vagina is referred to as a rectocele, while prolapse of small bowel into the upper posterior wall of the vagina is called an enterocele. While the finding of a rectocele on exam is common in parous women and may not cause any symptoms, a larger rectocele may cause a sensation of incomplete evacuation of stool.
A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.
Initial Management
A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention. For patients reporting liquid stool consistency, the evaluation should pivot toward the workup and management of diarrhea, which can easily overwhelm continence mechanisms and cause fecal incontinence. Fiber supplementation to normalize stool consistency is considered first-line therapy for patients presenting with both fecal incontinence and obstructed defecation. Other tools for fecal incontinence include avoiding foods that trigger diarrhea and use of loperamide.6 For patients with obstructed defecation, a trial of laxatives can be followed by a prescription agent if needed, such as a secretagogue or prokinetic.7
Vaginal splinting is a technique that can be used in patients with rectocele, whereby a finger is inserted into the vagina and pressure is applied on the posterior vaginal wall toward the rectum. Reducing the rectocele can facilitate emptying stool from the rectum and prevent leakage of retained stool.8 Similarly, use of rectal irrigation enemas can also help clear retained stool.
Pelvic floor physical therapists examine the strength, coordination, and tone of the pelvic floor muscles. When hypertonic musculature is present, manual interventions may be performed including trigger point release, myofascial release, and dry needling.9 When hypotonic musculature or dyssynergia is present, strengthening and neuromuscular re-education are recommended. Biofeedback can be administered via surface electromyography and/or balloon training to improve rectal sensitivity. Proper defecation techniques, including positioning, breathing, and behavioral modifications, improve clinical outcomes.
Diagnostic Testing
For patients who do not improve with conservative management, further testing is recommended to characterize the underlying pathology. Typically, anorectal manometry (ARM) is performed in conjunction with the balloon expulsion test and imaging. Each modality has its strengths and limitations (see Table 1).
ARM allows for the assessment of rectal sensation and recto-anal pressures and coordination.10
Dynamic imaging, by barium defecography under fluoroscopy or MRI, captures anatomy at rest and with simulated defecation to identify pelvic organ prolapse, compartmental defects, and organ mobility.11 Endoanal ultrasonography is considered in patients experiencing fecal incontinence to evaluate the integrity of the anal sphincter muscles.
Minimally Invasive Procedures and Surgical Options for PFD
Functional abnormalities such as dyssynergia often coexist with structural abnormalities. Because structural abnormalities are commonly found in asymptomatic patients, noninvasive functional therapy, such as pelvic floor physical therapy and anorectal biofeedback, are preferred prior to surgical repair of a structural finding. For patients with fecal incontinence, sacral nerve stimulation (SNS) has emerged as a preferred therapy due to demonstrated efficacy in symptom improvement.12 Sphincteroplasty is reserved for those with acute sphincter injury or failure of SNS.
In patients with findings of intussusception, prolapse, or rectocele that have not responded to conservative therapy, referral for surgical repair may be considered. While the specific surgical approach will depend on many factors, the goal is typically excision and/or suspension of rectal tissue and reinforcement of the rectovaginal septum.
It is critical that we are equipped with the available knowledge and tools to provide these patients with optimal care.
Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.
References
1. Grimes WR and Stratton M. Pelvic floor dysfunction. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2024 Jan. PMID: 32644672.
2. Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. doi: 10.1001/jama.300.11.1311.
3. Lawrence JM et al. Pelvic floor disorders, diabetes, and obesity in women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct. doi: 10.2337/dc07-0262.
4. Barber MD et al. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul. doi: 10.1016/j.ajog.2004.12.025.
5. Persu C et al. Pelvic Organ Prolapse Quantification System (POP-Q) — A new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar. PMID: 21505577.
6. Wald A et al. ACG Clinical Guidelines: Management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. doi: 10.14309/ajg.0000000000001507.
7. Bharucha AE and Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020 Apr. doi: 10.1053/j.gastro.2019.12.034.
8. Menees S and Chey WD. Fecal incontinence: Pathogenesis, diagnosis, and updated treatment strategies. Gastroenterol Clin North Am. 2022 Mar. doi: 10.1016/j.gtc.2021.10.005.
9. Wallace SL et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec. doi: 10.1097/GCO.0000000000000584.
10. Carrington EV et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan. doi: 10.1111/nmo.13679.
11. El Sayed RF et al. Magnetic resonance imaging of pelvic floor dysfunction — Joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017 May. doi: 10.1007/s00330-016-4471-7.
12. Thaha MA et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24. doi: 10.1002/14651858.CD004464.pub3.
13. Chiarioni G et al. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005 Jul. doi: 10.1053/j.gastro.2005.05.015.
14. Grossi U et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016 Mar. doi: 10.1136/gutjnl-2014-308835.
15. Albuquerque A. Endoanal ultrasonography in fecal incontinence: Current and future perspectives. World J Gastrointest Endosc. 2015 Jun 10. doi: 10.4253/wjge.v7.i6.575.
Defining Your ‘Success’
Dear Friends,
The prevailing theme of this issue is “Success.” I have learned that “success” is personal and personalized. What “success” looked like 10, or even 5, years ago to me is very different from how I perceive it now; and I know it may be different 5 years from now. My definition of success should not look like another’s — that was the best advice I have gotten over the years and it has kept me constantly redefining what is important to me and placing value on where I want to allocate my time and efforts, at work and at home.
This issue of The New Gastroenterologist highlights topics from successful GIs within their own realms of expertise, offering insights on advancing in academic medicine, navigating financial wellness with a financial adviser, and becoming a future leader in GI.
In this issue’s clinically-focused articles, we spotlight two very nuanced and challenging topics. Dr. Sachin Srinivasan and Dr. Prateek Sharma review Barrett’s esophagus management for our “In Focus” section, with a particular emphasis on Barrett’s endoscopic therapy modalities for dysplasia and early neoplasia. Dr. Brooke Corning and team simplify their approach to pelvic floor dysfunction (PFD) in our “Short Clinical Reviews.” They suggest validated ways to assess patient history, pros and cons of various diagnostic tests, and stepwise management of PFD.
Navigating academic promotion can be overwhelming and may not be at the forefront with our early career GIs’ priorities. In our “Early Career” section, Dr. Vineet Rolston interviews two highly accomplished professors in academic medicine, Dr. Sophie Balzora and Dr. Mark Schattner, for their insights into the promotion process and recommendations for junior faculty.
Dr. Anjuli K. Luthra, a therapeutic endoscopist and founder of The Scope of Finance, emphasizes financial wellness for physicians. She breaks down the search for a financial adviser, including the different types, what to ask when searching for the right fit, and what to expect.
Lastly, this issue highlights an AGA program that invests in the development of leaders for the field — the Future Leaders Program (FLP). Dr. Parakkal Deepak and Dr. Edward L. Barnes, along with their mentor, Dr. Aasma Shaukat, describe their experience as a mentee-mentor triad of FLP and how this program has impacted their careers.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Danielle Kiefer ([email protected]), managing editor of TNG.
Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: Dr. C.G. Stockton was the first AGA president in 1897, a Professor of the Principles and Practice of Medicine and Clinical Medicine at the University of Buffalo in New York, and published on the relationship between GI/Hepatology and gout in the Journal of the American Medical Association the same year of his presidency.
Yours truly,
Judy A. Trieu, MD, MPH
Editor-in-Chief
Interventional Endoscopy, Division of Gastroenterology
Washington University in St. Louis
Dear Friends,
The prevailing theme of this issue is “Success.” I have learned that “success” is personal and personalized. What “success” looked like 10, or even 5, years ago to me is very different from how I perceive it now; and I know it may be different 5 years from now. My definition of success should not look like another’s — that was the best advice I have gotten over the years and it has kept me constantly redefining what is important to me and placing value on where I want to allocate my time and efforts, at work and at home.
This issue of The New Gastroenterologist highlights topics from successful GIs within their own realms of expertise, offering insights on advancing in academic medicine, navigating financial wellness with a financial adviser, and becoming a future leader in GI.
In this issue’s clinically-focused articles, we spotlight two very nuanced and challenging topics. Dr. Sachin Srinivasan and Dr. Prateek Sharma review Barrett’s esophagus management for our “In Focus” section, with a particular emphasis on Barrett’s endoscopic therapy modalities for dysplasia and early neoplasia. Dr. Brooke Corning and team simplify their approach to pelvic floor dysfunction (PFD) in our “Short Clinical Reviews.” They suggest validated ways to assess patient history, pros and cons of various diagnostic tests, and stepwise management of PFD.
Navigating academic promotion can be overwhelming and may not be at the forefront with our early career GIs’ priorities. In our “Early Career” section, Dr. Vineet Rolston interviews two highly accomplished professors in academic medicine, Dr. Sophie Balzora and Dr. Mark Schattner, for their insights into the promotion process and recommendations for junior faculty.
Dr. Anjuli K. Luthra, a therapeutic endoscopist and founder of The Scope of Finance, emphasizes financial wellness for physicians. She breaks down the search for a financial adviser, including the different types, what to ask when searching for the right fit, and what to expect.
Lastly, this issue highlights an AGA program that invests in the development of leaders for the field — the Future Leaders Program (FLP). Dr. Parakkal Deepak and Dr. Edward L. Barnes, along with their mentor, Dr. Aasma Shaukat, describe their experience as a mentee-mentor triad of FLP and how this program has impacted their careers.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Danielle Kiefer ([email protected]), managing editor of TNG.
Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: Dr. C.G. Stockton was the first AGA president in 1897, a Professor of the Principles and Practice of Medicine and Clinical Medicine at the University of Buffalo in New York, and published on the relationship between GI/Hepatology and gout in the Journal of the American Medical Association the same year of his presidency.
Yours truly,
Judy A. Trieu, MD, MPH
Editor-in-Chief
Interventional Endoscopy, Division of Gastroenterology
Washington University in St. Louis
Dear Friends,
The prevailing theme of this issue is “Success.” I have learned that “success” is personal and personalized. What “success” looked like 10, or even 5, years ago to me is very different from how I perceive it now; and I know it may be different 5 years from now. My definition of success should not look like another’s — that was the best advice I have gotten over the years and it has kept me constantly redefining what is important to me and placing value on where I want to allocate my time and efforts, at work and at home.
This issue of The New Gastroenterologist highlights topics from successful GIs within their own realms of expertise, offering insights on advancing in academic medicine, navigating financial wellness with a financial adviser, and becoming a future leader in GI.
In this issue’s clinically-focused articles, we spotlight two very nuanced and challenging topics. Dr. Sachin Srinivasan and Dr. Prateek Sharma review Barrett’s esophagus management for our “In Focus” section, with a particular emphasis on Barrett’s endoscopic therapy modalities for dysplasia and early neoplasia. Dr. Brooke Corning and team simplify their approach to pelvic floor dysfunction (PFD) in our “Short Clinical Reviews.” They suggest validated ways to assess patient history, pros and cons of various diagnostic tests, and stepwise management of PFD.
Navigating academic promotion can be overwhelming and may not be at the forefront with our early career GIs’ priorities. In our “Early Career” section, Dr. Vineet Rolston interviews two highly accomplished professors in academic medicine, Dr. Sophie Balzora and Dr. Mark Schattner, for their insights into the promotion process and recommendations for junior faculty.
Dr. Anjuli K. Luthra, a therapeutic endoscopist and founder of The Scope of Finance, emphasizes financial wellness for physicians. She breaks down the search for a financial adviser, including the different types, what to ask when searching for the right fit, and what to expect.
Lastly, this issue highlights an AGA program that invests in the development of leaders for the field — the Future Leaders Program (FLP). Dr. Parakkal Deepak and Dr. Edward L. Barnes, along with their mentor, Dr. Aasma Shaukat, describe their experience as a mentee-mentor triad of FLP and how this program has impacted their careers.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Danielle Kiefer ([email protected]), managing editor of TNG.
Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: Dr. C.G. Stockton was the first AGA president in 1897, a Professor of the Principles and Practice of Medicine and Clinical Medicine at the University of Buffalo in New York, and published on the relationship between GI/Hepatology and gout in the Journal of the American Medical Association the same year of his presidency.
Yours truly,
Judy A. Trieu, MD, MPH
Editor-in-Chief
Interventional Endoscopy, Division of Gastroenterology
Washington University in St. Louis
GI Doc Aims to Lift Barriers to CRC Screening for Black Patients
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
Converging on Our Nation’s Capital
Release of our May issue coincides with our annual pilgrimage to Digestive Disease Week® (DDW), this year held in our nation’s capital of Washington, D.C.
As we peruse the preliminary program in planning our meeting coverage, I am always amazed at the breadth and depth of programming offered as part of a relatively brief, 4-day meeting — this is a testament to the hard work of the AGA Council and DDW organizing committees, who have the gargantuan task of ensuring an engaging, seamless meeting each year.
This year’s conference features over 400 original scientific sessions and 4,300 oral abstract and poster presentations, in addition to the always well-attended AGA Postgraduate Course. This year’s AGA Presidential Plenary, which will feature a series of thought-provoking panel discussions on the future of GI healthcare and innovations in how we treat, disseminate, and teach, also is not to be missed. Beyond DDW, I hope you will join me in taking advantage of some of D.C.’s amazing cultural offerings, including the Smithsonian museums, National Gallery, Kennedy Center for the Performing Arts, and many others.
In this month’s issue of GIHN, we highlight an important AGA expert consensus commentary published in Clinical Gastroenterology and Hepatology examining the role of blood-based tests (“liquid biopsy”) in colorectal cancer screening. This guidance, which recognizes the promise of such tests but also urges caution in their adoption, is particularly important considering recently published data from the ECLIPSE study (also covered in this issue) evaluating the performance of Guardant’s ctDNA liquid biopsy compared to a screening colonoscopy. Also relevant to CRC screening, we highlight data on the performance of the “next gen” Cologuard test compared with FIT, which was recently published in NEJM. In our May Member Spotlight, we feature gastroenterologist Adjoa Anyane-Yeboa, MD, MPH, who shares her passion for addressing barriers to CRC screening for Black patients. Finally, GIHN Associate Editor Dr. Avi Ketwaroo introduces our quarterly Perspectives column highlighting emerging applications of AI in GI endoscopy and hepatology. We hope you enjoy all the exciting content featured in this issue and look forward to seeing you in Washington, D.C. (or virtually) for DDW.
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
Release of our May issue coincides with our annual pilgrimage to Digestive Disease Week® (DDW), this year held in our nation’s capital of Washington, D.C.
As we peruse the preliminary program in planning our meeting coverage, I am always amazed at the breadth and depth of programming offered as part of a relatively brief, 4-day meeting — this is a testament to the hard work of the AGA Council and DDW organizing committees, who have the gargantuan task of ensuring an engaging, seamless meeting each year.
This year’s conference features over 400 original scientific sessions and 4,300 oral abstract and poster presentations, in addition to the always well-attended AGA Postgraduate Course. This year’s AGA Presidential Plenary, which will feature a series of thought-provoking panel discussions on the future of GI healthcare and innovations in how we treat, disseminate, and teach, also is not to be missed. Beyond DDW, I hope you will join me in taking advantage of some of D.C.’s amazing cultural offerings, including the Smithsonian museums, National Gallery, Kennedy Center for the Performing Arts, and many others.
In this month’s issue of GIHN, we highlight an important AGA expert consensus commentary published in Clinical Gastroenterology and Hepatology examining the role of blood-based tests (“liquid biopsy”) in colorectal cancer screening. This guidance, which recognizes the promise of such tests but also urges caution in their adoption, is particularly important considering recently published data from the ECLIPSE study (also covered in this issue) evaluating the performance of Guardant’s ctDNA liquid biopsy compared to a screening colonoscopy. Also relevant to CRC screening, we highlight data on the performance of the “next gen” Cologuard test compared with FIT, which was recently published in NEJM. In our May Member Spotlight, we feature gastroenterologist Adjoa Anyane-Yeboa, MD, MPH, who shares her passion for addressing barriers to CRC screening for Black patients. Finally, GIHN Associate Editor Dr. Avi Ketwaroo introduces our quarterly Perspectives column highlighting emerging applications of AI in GI endoscopy and hepatology. We hope you enjoy all the exciting content featured in this issue and look forward to seeing you in Washington, D.C. (or virtually) for DDW.
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
Release of our May issue coincides with our annual pilgrimage to Digestive Disease Week® (DDW), this year held in our nation’s capital of Washington, D.C.
As we peruse the preliminary program in planning our meeting coverage, I am always amazed at the breadth and depth of programming offered as part of a relatively brief, 4-day meeting — this is a testament to the hard work of the AGA Council and DDW organizing committees, who have the gargantuan task of ensuring an engaging, seamless meeting each year.
This year’s conference features over 400 original scientific sessions and 4,300 oral abstract and poster presentations, in addition to the always well-attended AGA Postgraduate Course. This year’s AGA Presidential Plenary, which will feature a series of thought-provoking panel discussions on the future of GI healthcare and innovations in how we treat, disseminate, and teach, also is not to be missed. Beyond DDW, I hope you will join me in taking advantage of some of D.C.’s amazing cultural offerings, including the Smithsonian museums, National Gallery, Kennedy Center for the Performing Arts, and many others.
In this month’s issue of GIHN, we highlight an important AGA expert consensus commentary published in Clinical Gastroenterology and Hepatology examining the role of blood-based tests (“liquid biopsy”) in colorectal cancer screening. This guidance, which recognizes the promise of such tests but also urges caution in their adoption, is particularly important considering recently published data from the ECLIPSE study (also covered in this issue) evaluating the performance of Guardant’s ctDNA liquid biopsy compared to a screening colonoscopy. Also relevant to CRC screening, we highlight data on the performance of the “next gen” Cologuard test compared with FIT, which was recently published in NEJM. In our May Member Spotlight, we feature gastroenterologist Adjoa Anyane-Yeboa, MD, MPH, who shares her passion for addressing barriers to CRC screening for Black patients. Finally, GIHN Associate Editor Dr. Avi Ketwaroo introduces our quarterly Perspectives column highlighting emerging applications of AI in GI endoscopy and hepatology. We hope you enjoy all the exciting content featured in this issue and look forward to seeing you in Washington, D.C. (or virtually) for DDW.
Megan A. Adams, MD, JD, MSc
Editor-in-Chief
Recurrent Soft Tissue Rosai Dorfman Disease of Right Medial Thigh Lipoma With Lymph Node Involvement
Rosai Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis first described in 1965 by Destombes and again in 1969 by Rosai and Dorfman to depict patients who presented with massive cervical lymphadenopathy.1 The classification for histiocytosis was revised in 2016 based on new insights into the pathologic, genetic, and molecular features of RDD.2,3 Now, RDD is listed under the R group, which includes familial, sporadic, classical (nodal), extranodal RDD, and other noncutaneous, non-Langerhans cell histiocytosis.3 Cutaneous RDD is classified under the C group and typically presents as painless papules, plaques, or nodules without significant lymphadenopathy, or systemic symptoms usually seen in the presentation of RDD.4
The etiology of RDD is poorly understood, although an underlying infectious or genetic component is suspected.5 Several pathogens—including human herpesvirus 6, parvovirus B19, Epstein-Barr virus, cytomegalovirus, Brucella, and Klebsiella—have all been investigated. A link to kinase mutations has been described in nodal and extranodal RDD; however, the molecular profile of cutaneous RDD remains unknown.2 Histologic findings for RDD typically include cells that are S100 positive, CD68 positive, and CD163 positive, and CD1a and langerin (CD207) negative, thus excluding Langerhans cell histiocytosis.2 The hallmark finding of RDD is emperipolesis, which results from “histiocyte-mediated phagocytosis of intact lymphocytes and other immune cells.”6 Immunoglobulin G (Ig) G4-positive plasma cells are also common, but the significance of this finding is controversial. We present a case of a patient with recurrent RDD within a right medial thigh lipoma and include a literature review to explore the significance of histologic findings and various treatment options in the setting of emerging treatment and diagnostic criteria.
Case Presentation
A 56-year-old African American male was evaluated in the rheumatology clinic at the Central Texas Veterans Affairs Medical Center in Temple, Texas, in 2022 for a cutaneous mass of his right medial thigh. The patient previously reported the onset of a right medial thigh mass in 2005 after he had been deployed in Iraq for about 1 year. A biopsy of the mass from 2005 showed infiltration of plasma cells, lymphocytes, and histiocytes and occasional neutrophils with noted reactivity of S100 protein and CD163, but not CD1a. The patient’s original biopsy report from March 2005 was obtained secondhand from an addendum to a Dermatology Consult note. Surgical excision of the mass was not performed until 2012 and systemic therapy was not initiated.
In 2021, the mass recurred and gradually increased in size, prompting a second surgical removal. Pathology results from the 2021 mass showed a lipoma with areas of fibrosis with a mixed inflammatory cell infiltrate, including abundant lymphocytes, plasma cells, occasional hemosiderin-laden histiocytes, and clusters of enlarged histiocytes with foamy to pale eosinophilic, finely granular cytoplasm, and large, round, vesicular nuclei with prominent nucleoli. Emperipolesis was also present (Figure 1).
Special immunohistochemical staining showed most of the lymphocytes were CD20 positive B-cells with a minority of CD3 positive T-cells. Histiocytes were CD163 positive and CD68 positive with patchy reactivity for S100 protein. The plasma cells were CD138 positive. There were > 125 IgG4-positive plasma cells present in a single high-powered field and the overall IgG4:IgG plasma cell ratio was > 40%. Pertinent imaging included a whole-body positron emission tomography/computed tomography (PET/CT) hypermetabolic activity scan of a small right femoral lymph node (9 mm) and nearby medial right femoral lymph node (13 mm) (Figure 2A). A well-defined mass in the medial aspect of the right thigh (2.5 cm x 3.2 cm x 3.9 cm) and a cutaneous/subcutaneous lesion of the anterior medial aspect of the proximal right thigh superior to the mass (2.9 cm) were also evident on imaging (Figure 2B). Each area of hypermetabolic activity had decreased in size and activity when compared to a previous PET/CT obtained 1 month earlier. There was no evidence of skeletal malignancy. A physical examination did not reveal any other soft tissue masses, palpable lymphadenopathy, or areas of skin involvement. Given the patient’s reassuring imaging findings and a lack of any new physical examination findings, no systemic therapy was initiated, and following shared decision making, the patient agreed to a period of watchful waiting.
Discussion
RDD is rare with a prevalence of 1:200,000. It has been reported that multisystem involvement occurs in 19% of cases and the prognosis of RDD correlates with the number of extranodal systems involved in the disease process.7 Although sporadic RDD is usually self-limited with favorable outcomes, it is estimated that 10% of patients may die of RDD due to direct complications, infections, and amyloidosis.2,7 RDD commonly affects young male children and young adults with a mean age of 20 years and has a higher incidence among African American children.2,7,8 Although patients with RDD present bilateral, painless cervical lymphadenopathy in 90% of cases, about 43% of patients with RDD and associated adenopathy present with ≥ 1 site of extranodal involvement, and only 23% of patients with RDD present with isolated extranodal sites without adenopathy.9 As was the case with our patient, the most common extranodal sites are found in the skin and soft tissue (16%).6,9 However, histopathologic diagnosis of RDD in a lipoma is exceedingly rare. We found only 1 other case report of a patient with a history of multiple lipomas who developed a new solitary nodule that was excised and demonstrated RDD upon immunohistochemical staining.4 There has been no documented association between multiple lipomas and RDD.4
Histologically, RDD is often characterized by emperipolesis (the presence of an intact cell within the cytoplasm of anther cell) and a mixed cell infiltrate that includes S100 positive histiocytes, mononuclear cells, plasma cells, and lymphocytes.10 Despite these shared histologic features among the various phenotypes of RDD, other type-specific characteristics may also be present. When compared to nodal RDD, extranodal disease tends to demonstrate a lack of nodal architecture, more fibrosis and collagen deposition, fewer RDD cells, a lower degree of emperipolesis, and alternating pale (histiocyte rich) and dark (lymphocyte rich) regions with notable polygonal histiocytes arranged in a storiform pattern.5,10
Our patient’s histology showed an overall IgG4:IgG plasma cell ratio > 40%. RDD frequently presents with IgG4-positive plasma cells, which has confounded the diagnosis of IgG4-related diseases and hyper-IgG4 disease.11 Given this association, the Histiocyte Society revised classification recommends that all cases of RDD be evaluated for IgG4-positive cell infiltration.2,3 Further discussion on this matter was recently provided after an expert panel published a consensus statement in 2015 detailing the evaluation of IgG4. The panel advocates for stricter terminology and criteria on this issue, advises that isolated IgG4-positive plasma cells are nonspecific, and states that the diagnosis of IgG4 disease should be based on careful judgment and correlation with the clinical scenario and supportive findings.12 Therefore, while IgG4 positivity continues to be misleading in RDD cases, further evaluation for IgG4 disease is recommended.
Sporadic RDD is usually self-limited with a reported remission rate of up to 50%, according to a case series of 80 patients with RDD.13 This leads to the recommendation of a period of watchful monitoring in patients with limited disease.13 In patients with unifocal extranodal disease, surgical excision has shown positive remission results; however, local recurrence of soft tissue lesions can occur at a rate of 21.4% to 51%.14 Although initiation of systemic therapy should be considered in patients with recurrent disease, there is currently no standardized regimen or medication of choice for treatment. Treatment with steroids, including prednisone 40 to 70 mg daily or dexamethasone 8 to 20 mg daily, have been shown to be effective in reducing the nodal size and symptoms, especially in cases of nonresectable multifocal extranodal disease of the central nervous system, bone, and orbital.7,15,16 However, cases of orbital, tracheal, renal, or soft tissue RDD have reported failure in treatment with steroids.17,18
According to the consensus recommendations for the treatment of RDD released in 2018, treatment with chemotherapy has shown mixed results. Anthracycline and alkylating agents have shown minimal efficacy, but combination regimens with vinca alkaloids, methotrexate, and 6-mercaptopurine have helped patients experience remission.19,20 Due to the rarity of RDD and lack of clinical trials, the exact efficacy of these treatment regimens remains unknown and is largely limited to case reports described within the medical literature. Treatment with nucleoside analogs, such as cladribine 2.1 to 5 mg/m2 or clofarabine 25 mg/m2 per day for 5 days every 28 days for 6 months, have shown promising results and helped achieve complete remission in patients with refractory or recurrent RDD.7,21-23 Immunomodulator therapies including TNF-α inhibitor, such as thalidomide and lenalidomide, have also shown to be effective, particularly in patients with refractory disease.24,25 Low-dose thalidomide (100 mg daily) was effective for cases of refractory cutaneous RDD, though no standard dosing regimen exists. Lenalidomide has shown to be effective in patients with multiple refractory nodal or bone RDD, but is associated with more complications given that it is more myelosuppressive than thalidomide.7 Radiotherapy has also been initiated in patients with refractory soft tissue disease or persistent symptoms after resection and in patients who are not candidates for surgery or systemic therapy, though no standard doses of radiotherapy have been established.7,26,27
Conclusions
RDD is a rare histiocytic disorder that presents in a wide range of age groups, different locations in the body, and with variable disease behavior. Multidisciplinary management of the disease and research for mutations and microenvironment of RDD is needed to better understand its clinicopathological nature and improve targeted novel therapies.
Acknowledgments
The authors thank Veterans Affairs Central Texas Health Care Section Chief of Rheumatology, Swastika Jha, MD, for her guidance in this case and Bo Wang, MD, for his preparation of the pathological specimens.
1. Goyal G, Ravindran A, Young JR, et al. Clinicopathological features, treatment approaches, and outcomes in Rosai-Dorfman disease. Haematologica. 2020;105(2):348-357. Published 2020 Jan 31. doi:10.3324/haematol.2019.219626
2. Bruce-Brand C, Schneider JW, Schubert P. Rosai-Dorfman disease: an overview. J Clin Pathol. 2020;73(11):697-705. doi:10.1136/jclinpath-2020-206733
3. Emile JF, Abla O, Fraitag S, et al. Revised classification of histiocytoses and neoplasms of the macrophage-dendritic cell lineages. Blood. 2016;127(22):2672-2681. doi:10.1182/blood-2016-01-690636
4. Farooq U, Chacon AH, Vincek V, Elgart G. Purely cutaneous rosai-dorfman disease with immunohistochemistry. Indian J Dermatol. 2013;58(6):447-450. doi:10.4103/0019-5154.119953
5. Ma H, Zheng Y, Zhu G, Wu J, Lu C, Lai W. Rosai-dorfman disease with massive cutaneous nodule on the shoulder and back. Ann Dermatol. 2015;27(1):71-75. doi:10.5021/ad.2015.27.1.71
6. Deen IU, Chittal A, Badro N, Jones R, Haas C. Extranodal Rosai-Dorfman Disease- a Review of Diagnostic Testing and Management. J Community Hosp Intern Med Perspect. 2022;12(2):18-22. Published 2022 Apr 12. doi:10.55729/2000-9666.1032
7. Oussama A, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi: 10.1182/blood-2018-03-839753
8. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn Pathol. 1990;7(1):19-73.
9. Gaitonde S. Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Arch Pathol Lab Med. 2007;131(7):1111-1121. doi:10.5858/2007-131-1117-MESHWM
10. Betini N, Munger AM, Rottmann D, Haims A, Costa J, Lindskog DM. Rare presentation of Rosai-Dorfman disease in soft tissue: diagnostic findings and surgical treatment. Case Rep Surg. 2022;2022:8440836. Published 2022 Mar 30. doi:10.1155/2022/8440836
11. Menon MP, Evbuomwan MO, Rosai J, Jaffe ES, Pittaluga S. A subset of Rosai-Dorfman disease cases show increased IgG4-positive plasma cells: another red herring or a true association with IgG4-related disease? Histopathology. 2014;64(3):455-459. doi:10.1111/his.12274
12. Khosroshahi A, Wallace ZS, Crowe JL, et al. International consensus guidance statement on the management and treatment of IgG4-related disease. Arthritis Rheumatol. 2015;67(7):1688-1699. doi:10.1002/art.39132
13. Pulsoni A, Anghel G, Falcucci P, et al. Treatment of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): report of a case and literature review. Am J Hematol. 2002;69(1):67-71. doi:10.1002/ajh.10008
14. Montgomery EA, Meis JM, Firzzera G. Rosai-Dorfman disease of soft tissue. Am J Surg Pathol. 1992;16(2):122-129. doi:10.1097/00000478-199202000-00004
15. Z’Graggen WJ, Sturzenegger M, Mariani L, Keserue B, Kappeler A, Vajtai I. Isolated Rosai-Dorfman disease of intracranial meninges. Pathol Res Pract. 2006;202(3):165-170. doi:10.1016/j.prp.2005.11.004
16. Shulman S, Katzenstein H, Abramowsky C, Broecker J, Wulkan M, Shehata B. Unusual presentation of Rosai-Dorfman disease (RDD) in the bone in adolescents. Fetal Pediatr Pathol. 2011;30(6):442-447. doi:10.3109/15513815.2011.61887317. Ottaviano G, Doro D, Marioni G, et al. Extranodal Rosai-Dorfman disease: involvement of eye, nose and trachea. Acta Otolaryngol. 2006;126(6):657-660. doi:10.1080/00016480500452582
18. Sakallioglu O, Gok F, Kalman S, et al. Minimal change nephropathy in a 7-year-old boy with Rosai-Dorfman disease. J Nephrol. 2006;19(2):211-214.
19. Jabali Y, Smrcka V, Pradna J. Rosai-Dorfman disease: successful long-term results by combination chemotherapy with prednisone, 6-mercaptopurine, methotrexate, and vinblastine: a case report. Int J Surg Pathol. 2005;13(3):285-289. doi:10.1177/106689690501300311
20. Abla O, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi:10.1182/blood-2018-03-839753
21. Konca C, Özkurt ZN, Deger M, Akı Z, Yagcı M. Extranodal multifocal Rosai-Dorfman disease: response to 2-chlorodeoxyadenosine treatment. Int J Hematol. 2009;89(1):58-62. doi:10.1007/s12185-008-0192-2
22. Aouba A, Terrier B, Vasiliu V, et al. Dramatic clinical efficacy of cladribine in Rosai-Dorfman disease and evolution of the cytokine profile: towards a new therapeutic approach. Haematologica. 2006;91(12 Suppl):ECR52.
23. Tasso M, Esquembre C, Blanco E, Moscardó C, Niveiro M, Payá A. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine. Pediatr Blood Cancer. 2006;47(5):612-615. doi:10.1002/pbc.20668
24. Chen E, Pavlidakey P, Sami N. Rosai-Dorfman disease successfully treated with thalidomide. JAAD Case Reports. 2016;2(5):369-372. Published 2016 Sep 28. doi:10.1016/j.jdcr.2016.08.006
25. Rubinstein M, Assal A, Scherba M, et al. Lenalidomide in the treatment of Rosai Dorfman disease-a first in use report. Am J Hematol. 2016;91(2):E1. doi:10.1002/ajh.24225
26. Sandoval-Sus JD, Sandoval-Leon AC, Chapman JR, et al. Rosai-Dorfman disease of the central nervous system: report of 6 cases and review of the literature. Medicine (Baltimore). 2014;93(3):165-175. doi:10.1097/MD.0000000000000030
27. Paryani NN, Daugherty LC, O’Connor MI, Jiang L. Extranodal Rosai-Dorfman disease of the bone treated with surgery and radiotherapy. Rare Tumors. 2014;6(4):5531. Published 2014 Dec 11. doi:10.4081/rt.2014.5531
Rosai Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis first described in 1965 by Destombes and again in 1969 by Rosai and Dorfman to depict patients who presented with massive cervical lymphadenopathy.1 The classification for histiocytosis was revised in 2016 based on new insights into the pathologic, genetic, and molecular features of RDD.2,3 Now, RDD is listed under the R group, which includes familial, sporadic, classical (nodal), extranodal RDD, and other noncutaneous, non-Langerhans cell histiocytosis.3 Cutaneous RDD is classified under the C group and typically presents as painless papules, plaques, or nodules without significant lymphadenopathy, or systemic symptoms usually seen in the presentation of RDD.4
The etiology of RDD is poorly understood, although an underlying infectious or genetic component is suspected.5 Several pathogens—including human herpesvirus 6, parvovirus B19, Epstein-Barr virus, cytomegalovirus, Brucella, and Klebsiella—have all been investigated. A link to kinase mutations has been described in nodal and extranodal RDD; however, the molecular profile of cutaneous RDD remains unknown.2 Histologic findings for RDD typically include cells that are S100 positive, CD68 positive, and CD163 positive, and CD1a and langerin (CD207) negative, thus excluding Langerhans cell histiocytosis.2 The hallmark finding of RDD is emperipolesis, which results from “histiocyte-mediated phagocytosis of intact lymphocytes and other immune cells.”6 Immunoglobulin G (Ig) G4-positive plasma cells are also common, but the significance of this finding is controversial. We present a case of a patient with recurrent RDD within a right medial thigh lipoma and include a literature review to explore the significance of histologic findings and various treatment options in the setting of emerging treatment and diagnostic criteria.
Case Presentation
A 56-year-old African American male was evaluated in the rheumatology clinic at the Central Texas Veterans Affairs Medical Center in Temple, Texas, in 2022 for a cutaneous mass of his right medial thigh. The patient previously reported the onset of a right medial thigh mass in 2005 after he had been deployed in Iraq for about 1 year. A biopsy of the mass from 2005 showed infiltration of plasma cells, lymphocytes, and histiocytes and occasional neutrophils with noted reactivity of S100 protein and CD163, but not CD1a. The patient’s original biopsy report from March 2005 was obtained secondhand from an addendum to a Dermatology Consult note. Surgical excision of the mass was not performed until 2012 and systemic therapy was not initiated.
In 2021, the mass recurred and gradually increased in size, prompting a second surgical removal. Pathology results from the 2021 mass showed a lipoma with areas of fibrosis with a mixed inflammatory cell infiltrate, including abundant lymphocytes, plasma cells, occasional hemosiderin-laden histiocytes, and clusters of enlarged histiocytes with foamy to pale eosinophilic, finely granular cytoplasm, and large, round, vesicular nuclei with prominent nucleoli. Emperipolesis was also present (Figure 1).
Special immunohistochemical staining showed most of the lymphocytes were CD20 positive B-cells with a minority of CD3 positive T-cells. Histiocytes were CD163 positive and CD68 positive with patchy reactivity for S100 protein. The plasma cells were CD138 positive. There were > 125 IgG4-positive plasma cells present in a single high-powered field and the overall IgG4:IgG plasma cell ratio was > 40%. Pertinent imaging included a whole-body positron emission tomography/computed tomography (PET/CT) hypermetabolic activity scan of a small right femoral lymph node (9 mm) and nearby medial right femoral lymph node (13 mm) (Figure 2A). A well-defined mass in the medial aspect of the right thigh (2.5 cm x 3.2 cm x 3.9 cm) and a cutaneous/subcutaneous lesion of the anterior medial aspect of the proximal right thigh superior to the mass (2.9 cm) were also evident on imaging (Figure 2B). Each area of hypermetabolic activity had decreased in size and activity when compared to a previous PET/CT obtained 1 month earlier. There was no evidence of skeletal malignancy. A physical examination did not reveal any other soft tissue masses, palpable lymphadenopathy, or areas of skin involvement. Given the patient’s reassuring imaging findings and a lack of any new physical examination findings, no systemic therapy was initiated, and following shared decision making, the patient agreed to a period of watchful waiting.
Discussion
RDD is rare with a prevalence of 1:200,000. It has been reported that multisystem involvement occurs in 19% of cases and the prognosis of RDD correlates with the number of extranodal systems involved in the disease process.7 Although sporadic RDD is usually self-limited with favorable outcomes, it is estimated that 10% of patients may die of RDD due to direct complications, infections, and amyloidosis.2,7 RDD commonly affects young male children and young adults with a mean age of 20 years and has a higher incidence among African American children.2,7,8 Although patients with RDD present bilateral, painless cervical lymphadenopathy in 90% of cases, about 43% of patients with RDD and associated adenopathy present with ≥ 1 site of extranodal involvement, and only 23% of patients with RDD present with isolated extranodal sites without adenopathy.9 As was the case with our patient, the most common extranodal sites are found in the skin and soft tissue (16%).6,9 However, histopathologic diagnosis of RDD in a lipoma is exceedingly rare. We found only 1 other case report of a patient with a history of multiple lipomas who developed a new solitary nodule that was excised and demonstrated RDD upon immunohistochemical staining.4 There has been no documented association between multiple lipomas and RDD.4
Histologically, RDD is often characterized by emperipolesis (the presence of an intact cell within the cytoplasm of anther cell) and a mixed cell infiltrate that includes S100 positive histiocytes, mononuclear cells, plasma cells, and lymphocytes.10 Despite these shared histologic features among the various phenotypes of RDD, other type-specific characteristics may also be present. When compared to nodal RDD, extranodal disease tends to demonstrate a lack of nodal architecture, more fibrosis and collagen deposition, fewer RDD cells, a lower degree of emperipolesis, and alternating pale (histiocyte rich) and dark (lymphocyte rich) regions with notable polygonal histiocytes arranged in a storiform pattern.5,10
Our patient’s histology showed an overall IgG4:IgG plasma cell ratio > 40%. RDD frequently presents with IgG4-positive plasma cells, which has confounded the diagnosis of IgG4-related diseases and hyper-IgG4 disease.11 Given this association, the Histiocyte Society revised classification recommends that all cases of RDD be evaluated for IgG4-positive cell infiltration.2,3 Further discussion on this matter was recently provided after an expert panel published a consensus statement in 2015 detailing the evaluation of IgG4. The panel advocates for stricter terminology and criteria on this issue, advises that isolated IgG4-positive plasma cells are nonspecific, and states that the diagnosis of IgG4 disease should be based on careful judgment and correlation with the clinical scenario and supportive findings.12 Therefore, while IgG4 positivity continues to be misleading in RDD cases, further evaluation for IgG4 disease is recommended.
Sporadic RDD is usually self-limited with a reported remission rate of up to 50%, according to a case series of 80 patients with RDD.13 This leads to the recommendation of a period of watchful monitoring in patients with limited disease.13 In patients with unifocal extranodal disease, surgical excision has shown positive remission results; however, local recurrence of soft tissue lesions can occur at a rate of 21.4% to 51%.14 Although initiation of systemic therapy should be considered in patients with recurrent disease, there is currently no standardized regimen or medication of choice for treatment. Treatment with steroids, including prednisone 40 to 70 mg daily or dexamethasone 8 to 20 mg daily, have been shown to be effective in reducing the nodal size and symptoms, especially in cases of nonresectable multifocal extranodal disease of the central nervous system, bone, and orbital.7,15,16 However, cases of orbital, tracheal, renal, or soft tissue RDD have reported failure in treatment with steroids.17,18
According to the consensus recommendations for the treatment of RDD released in 2018, treatment with chemotherapy has shown mixed results. Anthracycline and alkylating agents have shown minimal efficacy, but combination regimens with vinca alkaloids, methotrexate, and 6-mercaptopurine have helped patients experience remission.19,20 Due to the rarity of RDD and lack of clinical trials, the exact efficacy of these treatment regimens remains unknown and is largely limited to case reports described within the medical literature. Treatment with nucleoside analogs, such as cladribine 2.1 to 5 mg/m2 or clofarabine 25 mg/m2 per day for 5 days every 28 days for 6 months, have shown promising results and helped achieve complete remission in patients with refractory or recurrent RDD.7,21-23 Immunomodulator therapies including TNF-α inhibitor, such as thalidomide and lenalidomide, have also shown to be effective, particularly in patients with refractory disease.24,25 Low-dose thalidomide (100 mg daily) was effective for cases of refractory cutaneous RDD, though no standard dosing regimen exists. Lenalidomide has shown to be effective in patients with multiple refractory nodal or bone RDD, but is associated with more complications given that it is more myelosuppressive than thalidomide.7 Radiotherapy has also been initiated in patients with refractory soft tissue disease or persistent symptoms after resection and in patients who are not candidates for surgery or systemic therapy, though no standard doses of radiotherapy have been established.7,26,27
Conclusions
RDD is a rare histiocytic disorder that presents in a wide range of age groups, different locations in the body, and with variable disease behavior. Multidisciplinary management of the disease and research for mutations and microenvironment of RDD is needed to better understand its clinicopathological nature and improve targeted novel therapies.
Acknowledgments
The authors thank Veterans Affairs Central Texas Health Care Section Chief of Rheumatology, Swastika Jha, MD, for her guidance in this case and Bo Wang, MD, for his preparation of the pathological specimens.
Rosai Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis first described in 1965 by Destombes and again in 1969 by Rosai and Dorfman to depict patients who presented with massive cervical lymphadenopathy.1 The classification for histiocytosis was revised in 2016 based on new insights into the pathologic, genetic, and molecular features of RDD.2,3 Now, RDD is listed under the R group, which includes familial, sporadic, classical (nodal), extranodal RDD, and other noncutaneous, non-Langerhans cell histiocytosis.3 Cutaneous RDD is classified under the C group and typically presents as painless papules, plaques, or nodules without significant lymphadenopathy, or systemic symptoms usually seen in the presentation of RDD.4
The etiology of RDD is poorly understood, although an underlying infectious or genetic component is suspected.5 Several pathogens—including human herpesvirus 6, parvovirus B19, Epstein-Barr virus, cytomegalovirus, Brucella, and Klebsiella—have all been investigated. A link to kinase mutations has been described in nodal and extranodal RDD; however, the molecular profile of cutaneous RDD remains unknown.2 Histologic findings for RDD typically include cells that are S100 positive, CD68 positive, and CD163 positive, and CD1a and langerin (CD207) negative, thus excluding Langerhans cell histiocytosis.2 The hallmark finding of RDD is emperipolesis, which results from “histiocyte-mediated phagocytosis of intact lymphocytes and other immune cells.”6 Immunoglobulin G (Ig) G4-positive plasma cells are also common, but the significance of this finding is controversial. We present a case of a patient with recurrent RDD within a right medial thigh lipoma and include a literature review to explore the significance of histologic findings and various treatment options in the setting of emerging treatment and diagnostic criteria.
Case Presentation
A 56-year-old African American male was evaluated in the rheumatology clinic at the Central Texas Veterans Affairs Medical Center in Temple, Texas, in 2022 for a cutaneous mass of his right medial thigh. The patient previously reported the onset of a right medial thigh mass in 2005 after he had been deployed in Iraq for about 1 year. A biopsy of the mass from 2005 showed infiltration of plasma cells, lymphocytes, and histiocytes and occasional neutrophils with noted reactivity of S100 protein and CD163, but not CD1a. The patient’s original biopsy report from March 2005 was obtained secondhand from an addendum to a Dermatology Consult note. Surgical excision of the mass was not performed until 2012 and systemic therapy was not initiated.
In 2021, the mass recurred and gradually increased in size, prompting a second surgical removal. Pathology results from the 2021 mass showed a lipoma with areas of fibrosis with a mixed inflammatory cell infiltrate, including abundant lymphocytes, plasma cells, occasional hemosiderin-laden histiocytes, and clusters of enlarged histiocytes with foamy to pale eosinophilic, finely granular cytoplasm, and large, round, vesicular nuclei with prominent nucleoli. Emperipolesis was also present (Figure 1).
Special immunohistochemical staining showed most of the lymphocytes were CD20 positive B-cells with a minority of CD3 positive T-cells. Histiocytes were CD163 positive and CD68 positive with patchy reactivity for S100 protein. The plasma cells were CD138 positive. There were > 125 IgG4-positive plasma cells present in a single high-powered field and the overall IgG4:IgG plasma cell ratio was > 40%. Pertinent imaging included a whole-body positron emission tomography/computed tomography (PET/CT) hypermetabolic activity scan of a small right femoral lymph node (9 mm) and nearby medial right femoral lymph node (13 mm) (Figure 2A). A well-defined mass in the medial aspect of the right thigh (2.5 cm x 3.2 cm x 3.9 cm) and a cutaneous/subcutaneous lesion of the anterior medial aspect of the proximal right thigh superior to the mass (2.9 cm) were also evident on imaging (Figure 2B). Each area of hypermetabolic activity had decreased in size and activity when compared to a previous PET/CT obtained 1 month earlier. There was no evidence of skeletal malignancy. A physical examination did not reveal any other soft tissue masses, palpable lymphadenopathy, or areas of skin involvement. Given the patient’s reassuring imaging findings and a lack of any new physical examination findings, no systemic therapy was initiated, and following shared decision making, the patient agreed to a period of watchful waiting.
Discussion
RDD is rare with a prevalence of 1:200,000. It has been reported that multisystem involvement occurs in 19% of cases and the prognosis of RDD correlates with the number of extranodal systems involved in the disease process.7 Although sporadic RDD is usually self-limited with favorable outcomes, it is estimated that 10% of patients may die of RDD due to direct complications, infections, and amyloidosis.2,7 RDD commonly affects young male children and young adults with a mean age of 20 years and has a higher incidence among African American children.2,7,8 Although patients with RDD present bilateral, painless cervical lymphadenopathy in 90% of cases, about 43% of patients with RDD and associated adenopathy present with ≥ 1 site of extranodal involvement, and only 23% of patients with RDD present with isolated extranodal sites without adenopathy.9 As was the case with our patient, the most common extranodal sites are found in the skin and soft tissue (16%).6,9 However, histopathologic diagnosis of RDD in a lipoma is exceedingly rare. We found only 1 other case report of a patient with a history of multiple lipomas who developed a new solitary nodule that was excised and demonstrated RDD upon immunohistochemical staining.4 There has been no documented association between multiple lipomas and RDD.4
Histologically, RDD is often characterized by emperipolesis (the presence of an intact cell within the cytoplasm of anther cell) and a mixed cell infiltrate that includes S100 positive histiocytes, mononuclear cells, plasma cells, and lymphocytes.10 Despite these shared histologic features among the various phenotypes of RDD, other type-specific characteristics may also be present. When compared to nodal RDD, extranodal disease tends to demonstrate a lack of nodal architecture, more fibrosis and collagen deposition, fewer RDD cells, a lower degree of emperipolesis, and alternating pale (histiocyte rich) and dark (lymphocyte rich) regions with notable polygonal histiocytes arranged in a storiform pattern.5,10
Our patient’s histology showed an overall IgG4:IgG plasma cell ratio > 40%. RDD frequently presents with IgG4-positive plasma cells, which has confounded the diagnosis of IgG4-related diseases and hyper-IgG4 disease.11 Given this association, the Histiocyte Society revised classification recommends that all cases of RDD be evaluated for IgG4-positive cell infiltration.2,3 Further discussion on this matter was recently provided after an expert panel published a consensus statement in 2015 detailing the evaluation of IgG4. The panel advocates for stricter terminology and criteria on this issue, advises that isolated IgG4-positive plasma cells are nonspecific, and states that the diagnosis of IgG4 disease should be based on careful judgment and correlation with the clinical scenario and supportive findings.12 Therefore, while IgG4 positivity continues to be misleading in RDD cases, further evaluation for IgG4 disease is recommended.
Sporadic RDD is usually self-limited with a reported remission rate of up to 50%, according to a case series of 80 patients with RDD.13 This leads to the recommendation of a period of watchful monitoring in patients with limited disease.13 In patients with unifocal extranodal disease, surgical excision has shown positive remission results; however, local recurrence of soft tissue lesions can occur at a rate of 21.4% to 51%.14 Although initiation of systemic therapy should be considered in patients with recurrent disease, there is currently no standardized regimen or medication of choice for treatment. Treatment with steroids, including prednisone 40 to 70 mg daily or dexamethasone 8 to 20 mg daily, have been shown to be effective in reducing the nodal size and symptoms, especially in cases of nonresectable multifocal extranodal disease of the central nervous system, bone, and orbital.7,15,16 However, cases of orbital, tracheal, renal, or soft tissue RDD have reported failure in treatment with steroids.17,18
According to the consensus recommendations for the treatment of RDD released in 2018, treatment with chemotherapy has shown mixed results. Anthracycline and alkylating agents have shown minimal efficacy, but combination regimens with vinca alkaloids, methotrexate, and 6-mercaptopurine have helped patients experience remission.19,20 Due to the rarity of RDD and lack of clinical trials, the exact efficacy of these treatment regimens remains unknown and is largely limited to case reports described within the medical literature. Treatment with nucleoside analogs, such as cladribine 2.1 to 5 mg/m2 or clofarabine 25 mg/m2 per day for 5 days every 28 days for 6 months, have shown promising results and helped achieve complete remission in patients with refractory or recurrent RDD.7,21-23 Immunomodulator therapies including TNF-α inhibitor, such as thalidomide and lenalidomide, have also shown to be effective, particularly in patients with refractory disease.24,25 Low-dose thalidomide (100 mg daily) was effective for cases of refractory cutaneous RDD, though no standard dosing regimen exists. Lenalidomide has shown to be effective in patients with multiple refractory nodal or bone RDD, but is associated with more complications given that it is more myelosuppressive than thalidomide.7 Radiotherapy has also been initiated in patients with refractory soft tissue disease or persistent symptoms after resection and in patients who are not candidates for surgery or systemic therapy, though no standard doses of radiotherapy have been established.7,26,27
Conclusions
RDD is a rare histiocytic disorder that presents in a wide range of age groups, different locations in the body, and with variable disease behavior. Multidisciplinary management of the disease and research for mutations and microenvironment of RDD is needed to better understand its clinicopathological nature and improve targeted novel therapies.
Acknowledgments
The authors thank Veterans Affairs Central Texas Health Care Section Chief of Rheumatology, Swastika Jha, MD, for her guidance in this case and Bo Wang, MD, for his preparation of the pathological specimens.
1. Goyal G, Ravindran A, Young JR, et al. Clinicopathological features, treatment approaches, and outcomes in Rosai-Dorfman disease. Haematologica. 2020;105(2):348-357. Published 2020 Jan 31. doi:10.3324/haematol.2019.219626
2. Bruce-Brand C, Schneider JW, Schubert P. Rosai-Dorfman disease: an overview. J Clin Pathol. 2020;73(11):697-705. doi:10.1136/jclinpath-2020-206733
3. Emile JF, Abla O, Fraitag S, et al. Revised classification of histiocytoses and neoplasms of the macrophage-dendritic cell lineages. Blood. 2016;127(22):2672-2681. doi:10.1182/blood-2016-01-690636
4. Farooq U, Chacon AH, Vincek V, Elgart G. Purely cutaneous rosai-dorfman disease with immunohistochemistry. Indian J Dermatol. 2013;58(6):447-450. doi:10.4103/0019-5154.119953
5. Ma H, Zheng Y, Zhu G, Wu J, Lu C, Lai W. Rosai-dorfman disease with massive cutaneous nodule on the shoulder and back. Ann Dermatol. 2015;27(1):71-75. doi:10.5021/ad.2015.27.1.71
6. Deen IU, Chittal A, Badro N, Jones R, Haas C. Extranodal Rosai-Dorfman Disease- a Review of Diagnostic Testing and Management. J Community Hosp Intern Med Perspect. 2022;12(2):18-22. Published 2022 Apr 12. doi:10.55729/2000-9666.1032
7. Oussama A, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi: 10.1182/blood-2018-03-839753
8. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn Pathol. 1990;7(1):19-73.
9. Gaitonde S. Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Arch Pathol Lab Med. 2007;131(7):1111-1121. doi:10.5858/2007-131-1117-MESHWM
10. Betini N, Munger AM, Rottmann D, Haims A, Costa J, Lindskog DM. Rare presentation of Rosai-Dorfman disease in soft tissue: diagnostic findings and surgical treatment. Case Rep Surg. 2022;2022:8440836. Published 2022 Mar 30. doi:10.1155/2022/8440836
11. Menon MP, Evbuomwan MO, Rosai J, Jaffe ES, Pittaluga S. A subset of Rosai-Dorfman disease cases show increased IgG4-positive plasma cells: another red herring or a true association with IgG4-related disease? Histopathology. 2014;64(3):455-459. doi:10.1111/his.12274
12. Khosroshahi A, Wallace ZS, Crowe JL, et al. International consensus guidance statement on the management and treatment of IgG4-related disease. Arthritis Rheumatol. 2015;67(7):1688-1699. doi:10.1002/art.39132
13. Pulsoni A, Anghel G, Falcucci P, et al. Treatment of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): report of a case and literature review. Am J Hematol. 2002;69(1):67-71. doi:10.1002/ajh.10008
14. Montgomery EA, Meis JM, Firzzera G. Rosai-Dorfman disease of soft tissue. Am J Surg Pathol. 1992;16(2):122-129. doi:10.1097/00000478-199202000-00004
15. Z’Graggen WJ, Sturzenegger M, Mariani L, Keserue B, Kappeler A, Vajtai I. Isolated Rosai-Dorfman disease of intracranial meninges. Pathol Res Pract. 2006;202(3):165-170. doi:10.1016/j.prp.2005.11.004
16. Shulman S, Katzenstein H, Abramowsky C, Broecker J, Wulkan M, Shehata B. Unusual presentation of Rosai-Dorfman disease (RDD) in the bone in adolescents. Fetal Pediatr Pathol. 2011;30(6):442-447. doi:10.3109/15513815.2011.61887317. Ottaviano G, Doro D, Marioni G, et al. Extranodal Rosai-Dorfman disease: involvement of eye, nose and trachea. Acta Otolaryngol. 2006;126(6):657-660. doi:10.1080/00016480500452582
18. Sakallioglu O, Gok F, Kalman S, et al. Minimal change nephropathy in a 7-year-old boy with Rosai-Dorfman disease. J Nephrol. 2006;19(2):211-214.
19. Jabali Y, Smrcka V, Pradna J. Rosai-Dorfman disease: successful long-term results by combination chemotherapy with prednisone, 6-mercaptopurine, methotrexate, and vinblastine: a case report. Int J Surg Pathol. 2005;13(3):285-289. doi:10.1177/106689690501300311
20. Abla O, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi:10.1182/blood-2018-03-839753
21. Konca C, Özkurt ZN, Deger M, Akı Z, Yagcı M. Extranodal multifocal Rosai-Dorfman disease: response to 2-chlorodeoxyadenosine treatment. Int J Hematol. 2009;89(1):58-62. doi:10.1007/s12185-008-0192-2
22. Aouba A, Terrier B, Vasiliu V, et al. Dramatic clinical efficacy of cladribine in Rosai-Dorfman disease and evolution of the cytokine profile: towards a new therapeutic approach. Haematologica. 2006;91(12 Suppl):ECR52.
23. Tasso M, Esquembre C, Blanco E, Moscardó C, Niveiro M, Payá A. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine. Pediatr Blood Cancer. 2006;47(5):612-615. doi:10.1002/pbc.20668
24. Chen E, Pavlidakey P, Sami N. Rosai-Dorfman disease successfully treated with thalidomide. JAAD Case Reports. 2016;2(5):369-372. Published 2016 Sep 28. doi:10.1016/j.jdcr.2016.08.006
25. Rubinstein M, Assal A, Scherba M, et al. Lenalidomide in the treatment of Rosai Dorfman disease-a first in use report. Am J Hematol. 2016;91(2):E1. doi:10.1002/ajh.24225
26. Sandoval-Sus JD, Sandoval-Leon AC, Chapman JR, et al. Rosai-Dorfman disease of the central nervous system: report of 6 cases and review of the literature. Medicine (Baltimore). 2014;93(3):165-175. doi:10.1097/MD.0000000000000030
27. Paryani NN, Daugherty LC, O’Connor MI, Jiang L. Extranodal Rosai-Dorfman disease of the bone treated with surgery and radiotherapy. Rare Tumors. 2014;6(4):5531. Published 2014 Dec 11. doi:10.4081/rt.2014.5531
1. Goyal G, Ravindran A, Young JR, et al. Clinicopathological features, treatment approaches, and outcomes in Rosai-Dorfman disease. Haematologica. 2020;105(2):348-357. Published 2020 Jan 31. doi:10.3324/haematol.2019.219626
2. Bruce-Brand C, Schneider JW, Schubert P. Rosai-Dorfman disease: an overview. J Clin Pathol. 2020;73(11):697-705. doi:10.1136/jclinpath-2020-206733
3. Emile JF, Abla O, Fraitag S, et al. Revised classification of histiocytoses and neoplasms of the macrophage-dendritic cell lineages. Blood. 2016;127(22):2672-2681. doi:10.1182/blood-2016-01-690636
4. Farooq U, Chacon AH, Vincek V, Elgart G. Purely cutaneous rosai-dorfman disease with immunohistochemistry. Indian J Dermatol. 2013;58(6):447-450. doi:10.4103/0019-5154.119953
5. Ma H, Zheng Y, Zhu G, Wu J, Lu C, Lai W. Rosai-dorfman disease with massive cutaneous nodule on the shoulder and back. Ann Dermatol. 2015;27(1):71-75. doi:10.5021/ad.2015.27.1.71
6. Deen IU, Chittal A, Badro N, Jones R, Haas C. Extranodal Rosai-Dorfman Disease- a Review of Diagnostic Testing and Management. J Community Hosp Intern Med Perspect. 2022;12(2):18-22. Published 2022 Apr 12. doi:10.55729/2000-9666.1032
7. Oussama A, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi: 10.1182/blood-2018-03-839753
8. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn Pathol. 1990;7(1):19-73.
9. Gaitonde S. Multifocal, extranodal sinus histiocytosis with massive lymphadenopathy: an overview. Arch Pathol Lab Med. 2007;131(7):1111-1121. doi:10.5858/2007-131-1117-MESHWM
10. Betini N, Munger AM, Rottmann D, Haims A, Costa J, Lindskog DM. Rare presentation of Rosai-Dorfman disease in soft tissue: diagnostic findings and surgical treatment. Case Rep Surg. 2022;2022:8440836. Published 2022 Mar 30. doi:10.1155/2022/8440836
11. Menon MP, Evbuomwan MO, Rosai J, Jaffe ES, Pittaluga S. A subset of Rosai-Dorfman disease cases show increased IgG4-positive plasma cells: another red herring or a true association with IgG4-related disease? Histopathology. 2014;64(3):455-459. doi:10.1111/his.12274
12. Khosroshahi A, Wallace ZS, Crowe JL, et al. International consensus guidance statement on the management and treatment of IgG4-related disease. Arthritis Rheumatol. 2015;67(7):1688-1699. doi:10.1002/art.39132
13. Pulsoni A, Anghel G, Falcucci P, et al. Treatment of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): report of a case and literature review. Am J Hematol. 2002;69(1):67-71. doi:10.1002/ajh.10008
14. Montgomery EA, Meis JM, Firzzera G. Rosai-Dorfman disease of soft tissue. Am J Surg Pathol. 1992;16(2):122-129. doi:10.1097/00000478-199202000-00004
15. Z’Graggen WJ, Sturzenegger M, Mariani L, Keserue B, Kappeler A, Vajtai I. Isolated Rosai-Dorfman disease of intracranial meninges. Pathol Res Pract. 2006;202(3):165-170. doi:10.1016/j.prp.2005.11.004
16. Shulman S, Katzenstein H, Abramowsky C, Broecker J, Wulkan M, Shehata B. Unusual presentation of Rosai-Dorfman disease (RDD) in the bone in adolescents. Fetal Pediatr Pathol. 2011;30(6):442-447. doi:10.3109/15513815.2011.61887317. Ottaviano G, Doro D, Marioni G, et al. Extranodal Rosai-Dorfman disease: involvement of eye, nose and trachea. Acta Otolaryngol. 2006;126(6):657-660. doi:10.1080/00016480500452582
18. Sakallioglu O, Gok F, Kalman S, et al. Minimal change nephropathy in a 7-year-old boy with Rosai-Dorfman disease. J Nephrol. 2006;19(2):211-214.
19. Jabali Y, Smrcka V, Pradna J. Rosai-Dorfman disease: successful long-term results by combination chemotherapy with prednisone, 6-mercaptopurine, methotrexate, and vinblastine: a case report. Int J Surg Pathol. 2005;13(3):285-289. doi:10.1177/106689690501300311
20. Abla O, Jacobsen E, Picarsic J, et al. Consensus recommendations for the diagnosis and clinical management of Rosai-Dorfman-Destombes disease. Blood. 2018;131(26):2877-2890. doi:10.1182/blood-2018-03-839753
21. Konca C, Özkurt ZN, Deger M, Akı Z, Yagcı M. Extranodal multifocal Rosai-Dorfman disease: response to 2-chlorodeoxyadenosine treatment. Int J Hematol. 2009;89(1):58-62. doi:10.1007/s12185-008-0192-2
22. Aouba A, Terrier B, Vasiliu V, et al. Dramatic clinical efficacy of cladribine in Rosai-Dorfman disease and evolution of the cytokine profile: towards a new therapeutic approach. Haematologica. 2006;91(12 Suppl):ECR52.
23. Tasso M, Esquembre C, Blanco E, Moscardó C, Niveiro M, Payá A. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine. Pediatr Blood Cancer. 2006;47(5):612-615. doi:10.1002/pbc.20668
24. Chen E, Pavlidakey P, Sami N. Rosai-Dorfman disease successfully treated with thalidomide. JAAD Case Reports. 2016;2(5):369-372. Published 2016 Sep 28. doi:10.1016/j.jdcr.2016.08.006
25. Rubinstein M, Assal A, Scherba M, et al. Lenalidomide in the treatment of Rosai Dorfman disease-a first in use report. Am J Hematol. 2016;91(2):E1. doi:10.1002/ajh.24225
26. Sandoval-Sus JD, Sandoval-Leon AC, Chapman JR, et al. Rosai-Dorfman disease of the central nervous system: report of 6 cases and review of the literature. Medicine (Baltimore). 2014;93(3):165-175. doi:10.1097/MD.0000000000000030
27. Paryani NN, Daugherty LC, O’Connor MI, Jiang L. Extranodal Rosai-Dorfman disease of the bone treated with surgery and radiotherapy. Rare Tumors. 2014;6(4):5531. Published 2014 Dec 11. doi:10.4081/rt.2014.5531
3D Printing for the Development of Palatal Defect Prosthetics
Three-dimensional (3D) printing has become a promising area of innovation in biomedical research.1,2 Previous research in orthopedic surgery has found that customized 3D printed implants, casts, orthoses, and prosthetics (eg, prosthetic hands) matched to an individual’s unique anatomy can result in more precise placement and better surgical outcomes.3-5 Customized prosthetics have also been found to lead to fewer complications.3,6
Recent advances in 3D printing technology has prompted investigation from surgeons to identify how this new tool may be incorporated into patient care.1,7 One of the most common applications of 3D printing is during preoperative planning in which surgeons gain better insight into patient-specific anatomy by using patient-specific printed models.8 Another promising application is the production of customized prosthetics suited to each patient’s unique anatomy.9 As a result, 3D printing has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform the treatment of patients with debilitating musculoskeletal injuries.3,10
The potential surrounding 3D printed prosthetics has led to their adoption by several other specialties, including otolaryngology.11 The most widely used application of 3D printing among otolaryngologists is preoperative planning, and the incorporation of printed prosthetics intoreconstruction of the orbit, nasal septum, auricle, and palate has also been reported.2,12,13 Patient-specific implants might allow otolaryngologists to better rehabilitate, reconstruct, and/or regenerate craniofacial defects using more humane procedures.14
Patients with palatomaxillary cancers are treated by prosthodontists or otolaryngologists. An impression is made with a resin–which can be painful for postoperative patients–and a prosthetic is manufactured and implanted.15-17 Patients with cancer often see many specialists, though reconstructive care is a low priority. Many of these individuals also experience dynamic anatomic functional changes over time, leading to the need for multiple prothesis.
palatomaxillary prosthetics
This program aims to use patients’ previous computed tomography (CT) to tailor customized 3D printed palatomaxillary prosthetics to specifically fit their anatomy. Palatomaxillary defects are a source of profound disability for patients with head and neck cancers who are left with large anatomic defects as a direct result of treatment. Reconstruction of palatal defects poses unique challenges due to the complexity of patient anatomy.18,19
3D printed prosthetics for palatomaxillary defects have not been incorporated into patient care. We reviewed previous imaging research to determine if it could be used to assist patients who struggle with their function and appearance following treatment for head and neck cancers. The primary aim was to investigate whether 3D printing was a feasible strategy for creating patient-specific palatomaxillary prosthetics. The secondary aim is to determine whether these prosthetics should be tested in the future for use in reconstruction of maxillary defects.
Data Acquisition
This study was conducted at the Veterans Affairs Palo Alto Health Care System (VAPAHCS) and was approved by the Stanford University Institutional Review Board (approval #28958, informed consent and patient contact excluded). A retrospective chart review was conducted on all patients with head and neck cancers who were treated at VAPAHCS from 2010 to 2022. Patients aged ≥ 18 years who had a palatomaxillary defect due to cancer treatment, had undergone a palatal resection, and who received treatment at any point from 2010 to 2022 were included in the review. CTs were not a specific inclusion criterion, though the quality of the scans was analyzed for eligible patients. Younger patients and those treated at VAPAHCS prior to 2010 were excluded.
There was no control group; all data was sourced from the US Department of Veterans Affairs (VA) imaging system database. Among the 3595 patients reviewed, 5 met inclusion criteria and the quality of their craniofacial anatomy CTs were analyzed. To maintain accurate craniofacial 3D modeling, CTs require a maximum of 1 mm slice thickness. Of the 5 patients who met the inclusion criteria, 4 were found to have variability in the quality of their CTs and severe defects not suitable for prosthetic reconstruction, which led to their exclusion from the study. One patient was investigated to demonstrate if making these prostheses was feasible. This patient was diagnosed with a malignant neoplasm of the hard palate, underwent a partial maxillectomy, and a palatal obturator was placed to cover the defect.
The primary data collected was patient identifiers as well as the gross anatomy and dimensions of the patients’ craniofacial anatomy, as seen in previous imaging research.20 Before the imaging analysis, all personal health information was removed and the dataset was deidentified to ensure patient anonymity and noninvolvement.
CT Segmentation and 3D Printing
Using CTs of the patient’s craniofacial anatomy, we developed a model of the defects. This was achieved with deidentified CTs imported into the Food and Drug Administration (FDA)-approved computerized aid design (CAD) software, Materialise Mimics. The hard palate was segmented and isolated based off the presented scan and any holes in the image were filled using the CAD software. The model was subsequently mirrored in Materialise 3-matic to replicate an original anatomical hard palate prosthesis. The final product was converted into a 3D model and imported into Formlabs preform software to generate 3D printing supports and orient it for printing. The prosthetic was printed using FDA-approved Biocompatible Denture Base Resin by a Formlabs 3B+ printer at the Palo Alto VA Simulation Center. The 3D printed prosthesis was washed using Formlabs Form Wash 80% ethyl alcohol to remove excess resin and subsequently cured to harden the malleable resin. Supports were later removed, and the prosthesis was sanded.
The primary aim of this study was to investigate whether using CTs to create patient-specific prosthetic renderings for patients with head and neck cancer could be a feasible strategy. The CTs from the patient were successfully used to generate a 3D printed prosthesis, and the prosthesis matched the original craniofacial anatomy seen in the patient's imaging (Figure). These results demonstrate that high quality CTs can be used as a template for 3D printed prostheses for mild to moderate palatomaxillary defects.
3D Printing Costs
One liter of Denture Base Resin costs $299; prostheses use about 5 mL of resin. The average annual salary of a 3D printing technician in the United States is $42,717, or $20.54 per hour.21 For an experienced 3D printing technician, the time required to segment the hard palate and prepare it for 3D printing is 1 to 2 hours. The process may exceed 2 hours if the technician is presented with a lower quality CT or if the patient has a complex craniofacial anatomy.
The average time it takes to print a palatal prosthetic is 5 hours. An additional hour is needed for postprocessing, which includes washing and sanding. Therefore, the cost of the materials and labor for an average 3D printed prosthetic is about $150. A Formlabs 3B+ printer is competitively priced around $10,000. The cost for Materialise Mimics software varies, but is estimated at $16,000 at VAPAHCS. The prices for these 2 items are not included in our price estimation but should be taken into consideration.
Prosthodontist Process and Cost
The typical process of creating a palatal prosthesis by a prosthodontist begins by examining the patient, creating a stone model, then creating a wax model. Biocompatible materials are selected and processed into a mold that is trimmed and polished to the desired shape. This is followed by another patient visit to ensure the prosthesis fits properly. Follow-up care is also necessary for maintenance and comfort.
The average cost of a palatal prosthesis varies depending on the type needed (ie, metal implant, teeth replacement), the materials used, the region in which the patient is receiving care, and the complexity of the case. For complex and customizable options like those required for patients with cancer, the prostheses typically cost several thousands of dollars. The Healthcare Common Procedure Coding System code for a palatal lift prosthesis (D5955) lists prices ranging from $4000 to $8000 per prosthetic, not including the cost of the prosthodontist visits.22,23
Discussion
This program sought to determine whether imaging studies of maxillary defects are effective templates for developing 3D printed prosthetics and whether these prosthetics should be tested for future use in reconstruction of palatomaxillary defects. Our program illustrated that CTs served as feasible templates for developing hard palate prostheses for patients with palatomaxillary defects. It is important to note the CTs used were from a newer and more modern scanner and therefore yielded detailed palatal structures with higher accuracy more suitable for 3D modeling. Lower-quality CTs from the 4 patients excluded from the program were not suitable for 3D modeling. This suggests that with high-quality imaging, 3D printed prosthesis may be a viable strategy to help patients who struggle with their function following treatment for head and neck cancers.
3D printed prosthesis may also be a more patient centered and convenient option. In the traditional prosthesis creation workflow, the patient must physically bite down onto a resin (alginate or silicone) to make an impression, a very painful postoperative process that is irritating to the raw edges of the surgical bed.15,16 Prosthodontists then create a prosthetic minus the tumor and typically secure it with clips or glue.17 Many patients also experience changes in their anatomy over time requiring them to have a new protheses created. This is particularly important in veterans with palatomaxillary defects since many VA medical centers do not have a prosthodontist on staff, making accessibility to these specialists difficult. 3D printing provides a contactless prosthetic creation process. This convenience may reduce a patient’s pain and the number of visits for which they need a specialist.
Future Directions
Additional research is needed to determine the full potential of 3D printed prosthetics. 3D printed prostheses have been effectively used for patient education in areas of presurgical planning, prosthesis creation, and trainee education.24 This research represents an early step in the development of a new technology for use in otolaryngology. Specifically, many veterans with a history of head and neck cancers have sustained changes to their craniofacial anatomy following treatment. Using imaging to create 3D printed prosthetics could be very effective for these patients. Prosthetics could improve a patient’s quality of life by restoring/approximating their anatomy after cancer treatment.
Significant time and care must be taken by cancer and reconstructive surgeons to properly fit a prosthesis. Improperly fitting prosthetics leads to mucosal ulceration that then may lead to a need for fitting a new prosthetic. The advantage of 3D printed prosthetics is that they may more precisely fit the anatomy of each patient using CT results, thus potentially reducing the time needed to fit the prosthetic as well as the risk associated with an improperly fit prosthetic. 3D printed prosthesis could be used directly in the future, however, clinical trials are needed to verify its efficacy vs prosthodontic options.
Another consideration for potential future use of 3D printed prosthetics is cost. We estimated that the cost of the materials and labor of our 3D printed prosthetic to be about $150. Pricing of current molded prosthetics varies, but is often listed at several thousand dollars. Another consideration is the durability of 3D printed prosthetics vs standard prosthetics. Since we were unable to use the prosthetic in the patient, it was difficult to determine its durability. The significant cost of the 3D printer and software necessary for 3D printed prosthetics must also be considered and may be prohibitive. While many academic hospitals are considering the purchase of 3D printers and licenses, this may be challenging for resource-constrained institutions. 3D printing may also be difficult for groups without any prior experience in the field. Outsourcing to a third party is possible, though doing so adds more cost to the project. While we recognize there is a learning curve associated with adopting any new technology, it’s equally important to note that 3D printing is being rapidly integrated and has already made significant advancements in personalized medicine.8,25,26
Limitations
This program had several limitations. First, we only obtained CTs of sufficient quality from 1 patient to generate a 3D printed prosthesis. Further research with additional patients is necessary to validate this process. Second, we were unable to trial the prosthesis in the patient because we did not have FDA approval. Additionally, it is difficult to calculate a true cost estimate for this process as materials and software costs vary dramatically across institutions as well as over time.
Conclusions
The purpose of this study was to demonstrate the possibility to develop prosthetics for the hard palate for patients suffering from palatomaxillary defects. A 3D printed prosthetic was generated that matched the patient’s craniofacial anatomy. Future research should test the feasibility of these prosthetics in patient care against a traditional prosthodontic impression. Though this is a proof-of-concept study and no prosthetics were implanted as part of this investigation, we showcase the feasibility of printing prosthetics for palatomaxillary defects. The use of 3D printed prosthetics may be a more humane process, potentially lower cost, and be more accessible to veterans.
1. Crafts TD, Ellsperman SE, Wannemuehler TJ, Bellicchi TD, Shipchandler TZ, Mantravadi AV. Three-dimensional printing and its applications in otorhinolaryngology-head and neck surgery. Otolaryngol Head Neck Surg. 2017;156(6):999-1010. doi:10.1177/0194599816678372
2. Virani FR, Chua EC, Timbang MR, Hsieh TY, Senders CW. Three-dimensional printing in cleft care: a systematic review. Cleft Palate Craniofac J. 2022;59(4):484-496. doi:10.1177/10556656211013175
3. Lal H, Patralekh MK. 3D printing and its applications in orthopaedic trauma: A technological marvel. J Clin Orthop Trauma. 2018;9(3):260-268. doi:10.1016/j.jcot.2018.07.022
4. Vujaklija I, Farina D. 3D printed upper limb prosthetics. Expert Rev Med Devices. 2018;15(7):505-512. doi:10.1080/17434440.2018.1494568
5. Ten Kate J, Smit G, Breedveld P. 3D-printed upper limb prostheses: a review. Disabil Rehabil Assist Technol. 2017;12(3):300-314. doi:10.1080/17483107.2016.1253117
6. Thomas CN, Mavrommatis S, Schroder LK, Cole PA. An overview of 3D printing and the orthopaedic application of patient-specific models in malunion surgery. Injury. 2022;53(3):977-983. doi:10.1016/j.injury.2021.11.019
7. Colaco M, Igel DA, Atala A. The potential of 3D printing in urological research and patient care. Nat Rev Urol. 2018;15(4):213-221. doi:10.1038/nrurol.2018.6
8. Meyer-Szary J, Luis MS, Mikulski S, et al. The role of 3D printing in planning complex medical procedures and training of medical professionals-cross-sectional multispecialty review. Int J Environ Res Public Health. 2022;19(6):3331. Published 2022 Mar 11. doi:10.3390/ijerph19063331
9. Moya D, Gobbato B, Valente S, Roca R. Use of preoperative planning and 3D printing in orthopedics and traumatology: entering a new era. Acta Ortop Mex. 2022;36(1):39-47.
10. Wixted CM, Peterson JR, Kadakia RJ, Adams SB. Three-dimensional printing in orthopaedic surgery: current applications and future developments. J Am Acad Orthop Surg Glob Res Rev. 2021;5(4):e20.00230-11. Published 2021 Apr 20. doi:10.5435/JAAOSGlobal-D-20-00230
11. Hong CJ, Giannopoulos AA, Hong BY, et al. Clinical applications of three-dimensional printing in otolaryngology-head and neck surgery: a systematic review. Laryngoscope. 2019;129(9):2045-2052. doi:10.1002/lary.2783112. Sigron GR, Barba M, Chammartin F, Msallem B, Berg BI, Thieringer FM. Functional and cosmetic outcome after reconstruction of isolated, unilateral orbital floor fractures (blow-out fractures) with and without the support of 3D-printed orbital anatomical models. J Clin Med. 2021;10(16):3509. Published 2021 Aug 9. doi:10.3390/jcm10163509
13. Kimura K, Davis S, Thomas E, et al. 3D Customization for microtia repair in hemifacial microsomia. Laryngoscope. 2022;132(3):545-549. doi:10.1002/lary.29823
14. Nyberg EL, Farris AL, Hung BP, et al. 3D-printing technologies for craniofacial rehabilitation, reconstruction, and regeneration. Ann Biomed Eng. 2017;45(1):45-57. doi:10.1007/s10439-016-1668-5
15. Flores-Ruiz R, Castellanos-Cosano L, Serrera-Figallo MA, et al. Evolution of oral cancer treatment in an andalusian population sample: rehabilitation with prosthetic obturation and removable partial prosthesis. J Clin Exp Dent. 2017;9(8):e1008-e1014. doi:10.4317/jced.54023
16. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg. 2003;61(2):174-181. doi:10.1053/joms.2003.50044
17. Pool C, Shokri T, Vincent A, Wang W, Kadakia S, Ducic Y. Prosthetic reconstruction of the maxilla and palate. Semin Plast Surg. 2020;34(2):114-119. doi:10.1055/s-0040-1709143
18. Badhey AK, Khan MN. Palatomaxillary reconstruction: fibula or scapula. Semin Plast Surg. 2020;34(2):86-91. doi:10.1055/s-0040-1709431
19. Jategaonkar AA, Kaul VF, Lee E, Genden EM. Surgery of the palatomaxillary structure. Semin Plast Surg. 2020;34(2):71-76. doi:10.1055/s-0040-1709430
20. Lobb DC, Cottler P, Dart D, Black JS. The use of patient-specific three-dimensional printed surgical models enhances plastic surgery resident education in craniofacial surgery. J Craniofac Surg. 2019;30(2):339-341. doi:10.1097/SCS.0000000000005322
21. 3D printing technician salary in the United States. Accessed February 27, 2024. https://www.salary.com/research/salary/posting/3d-printing-technician-salary22. US Dept of Veterans Affairs. Healthcare Common Procedure Coding System. Outpatient dental professional nationwide charges by HCPCS code. January-December 2020. Accessed February 27, 2024. https://www.va.gov/COMMUNITYCARE/docs/RO/Outpatient-DataTables/v3-27_Table-I.pdf23. Washington State Department of Labor and Industries. Professional services fee schedule HCPCS level II fees. October 1, 2020. Accessed February 27, 2024. https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2020/2020FSHCPCS.pdf24. Low CM, Morris JM, Price DL, et al. Three-dimensional printing: current use in rhinology and endoscopic skull base surgery. Am J Rhinol Allergy. 2019;33(6):770-781. doi:10.1177/1945892419866319
25. Aimar A, Palermo A, Innocenti B. The role of 3D printing in medical applications: a state of the art. J Healthc Eng. 2019;2019:5340616. Published 2019 Mar 21. doi:10.1155/2019/5340616
26. Garcia J, Yang Z, Mongrain R, Leask RL, Lachapelle K. 3D printing materials and their use in medical education: a review of current technology and trends for the future. BMJ Simul Technol Enhanc Learn. 2018;4(1):27-40. doi:10.1136/bmjstel-2017-000234
Three-dimensional (3D) printing has become a promising area of innovation in biomedical research.1,2 Previous research in orthopedic surgery has found that customized 3D printed implants, casts, orthoses, and prosthetics (eg, prosthetic hands) matched to an individual’s unique anatomy can result in more precise placement and better surgical outcomes.3-5 Customized prosthetics have also been found to lead to fewer complications.3,6
Recent advances in 3D printing technology has prompted investigation from surgeons to identify how this new tool may be incorporated into patient care.1,7 One of the most common applications of 3D printing is during preoperative planning in which surgeons gain better insight into patient-specific anatomy by using patient-specific printed models.8 Another promising application is the production of customized prosthetics suited to each patient’s unique anatomy.9 As a result, 3D printing has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform the treatment of patients with debilitating musculoskeletal injuries.3,10
The potential surrounding 3D printed prosthetics has led to their adoption by several other specialties, including otolaryngology.11 The most widely used application of 3D printing among otolaryngologists is preoperative planning, and the incorporation of printed prosthetics intoreconstruction of the orbit, nasal septum, auricle, and palate has also been reported.2,12,13 Patient-specific implants might allow otolaryngologists to better rehabilitate, reconstruct, and/or regenerate craniofacial defects using more humane procedures.14
Patients with palatomaxillary cancers are treated by prosthodontists or otolaryngologists. An impression is made with a resin–which can be painful for postoperative patients–and a prosthetic is manufactured and implanted.15-17 Patients with cancer often see many specialists, though reconstructive care is a low priority. Many of these individuals also experience dynamic anatomic functional changes over time, leading to the need for multiple prothesis.
palatomaxillary prosthetics
This program aims to use patients’ previous computed tomography (CT) to tailor customized 3D printed palatomaxillary prosthetics to specifically fit their anatomy. Palatomaxillary defects are a source of profound disability for patients with head and neck cancers who are left with large anatomic defects as a direct result of treatment. Reconstruction of palatal defects poses unique challenges due to the complexity of patient anatomy.18,19
3D printed prosthetics for palatomaxillary defects have not been incorporated into patient care. We reviewed previous imaging research to determine if it could be used to assist patients who struggle with their function and appearance following treatment for head and neck cancers. The primary aim was to investigate whether 3D printing was a feasible strategy for creating patient-specific palatomaxillary prosthetics. The secondary aim is to determine whether these prosthetics should be tested in the future for use in reconstruction of maxillary defects.
Data Acquisition
This study was conducted at the Veterans Affairs Palo Alto Health Care System (VAPAHCS) and was approved by the Stanford University Institutional Review Board (approval #28958, informed consent and patient contact excluded). A retrospective chart review was conducted on all patients with head and neck cancers who were treated at VAPAHCS from 2010 to 2022. Patients aged ≥ 18 years who had a palatomaxillary defect due to cancer treatment, had undergone a palatal resection, and who received treatment at any point from 2010 to 2022 were included in the review. CTs were not a specific inclusion criterion, though the quality of the scans was analyzed for eligible patients. Younger patients and those treated at VAPAHCS prior to 2010 were excluded.
There was no control group; all data was sourced from the US Department of Veterans Affairs (VA) imaging system database. Among the 3595 patients reviewed, 5 met inclusion criteria and the quality of their craniofacial anatomy CTs were analyzed. To maintain accurate craniofacial 3D modeling, CTs require a maximum of 1 mm slice thickness. Of the 5 patients who met the inclusion criteria, 4 were found to have variability in the quality of their CTs and severe defects not suitable for prosthetic reconstruction, which led to their exclusion from the study. One patient was investigated to demonstrate if making these prostheses was feasible. This patient was diagnosed with a malignant neoplasm of the hard palate, underwent a partial maxillectomy, and a palatal obturator was placed to cover the defect.
The primary data collected was patient identifiers as well as the gross anatomy and dimensions of the patients’ craniofacial anatomy, as seen in previous imaging research.20 Before the imaging analysis, all personal health information was removed and the dataset was deidentified to ensure patient anonymity and noninvolvement.
CT Segmentation and 3D Printing
Using CTs of the patient’s craniofacial anatomy, we developed a model of the defects. This was achieved with deidentified CTs imported into the Food and Drug Administration (FDA)-approved computerized aid design (CAD) software, Materialise Mimics. The hard palate was segmented and isolated based off the presented scan and any holes in the image were filled using the CAD software. The model was subsequently mirrored in Materialise 3-matic to replicate an original anatomical hard palate prosthesis. The final product was converted into a 3D model and imported into Formlabs preform software to generate 3D printing supports and orient it for printing. The prosthetic was printed using FDA-approved Biocompatible Denture Base Resin by a Formlabs 3B+ printer at the Palo Alto VA Simulation Center. The 3D printed prosthesis was washed using Formlabs Form Wash 80% ethyl alcohol to remove excess resin and subsequently cured to harden the malleable resin. Supports were later removed, and the prosthesis was sanded.
The primary aim of this study was to investigate whether using CTs to create patient-specific prosthetic renderings for patients with head and neck cancer could be a feasible strategy. The CTs from the patient were successfully used to generate a 3D printed prosthesis, and the prosthesis matched the original craniofacial anatomy seen in the patient's imaging (Figure). These results demonstrate that high quality CTs can be used as a template for 3D printed prostheses for mild to moderate palatomaxillary defects.
3D Printing Costs
One liter of Denture Base Resin costs $299; prostheses use about 5 mL of resin. The average annual salary of a 3D printing technician in the United States is $42,717, or $20.54 per hour.21 For an experienced 3D printing technician, the time required to segment the hard palate and prepare it for 3D printing is 1 to 2 hours. The process may exceed 2 hours if the technician is presented with a lower quality CT or if the patient has a complex craniofacial anatomy.
The average time it takes to print a palatal prosthetic is 5 hours. An additional hour is needed for postprocessing, which includes washing and sanding. Therefore, the cost of the materials and labor for an average 3D printed prosthetic is about $150. A Formlabs 3B+ printer is competitively priced around $10,000. The cost for Materialise Mimics software varies, but is estimated at $16,000 at VAPAHCS. The prices for these 2 items are not included in our price estimation but should be taken into consideration.
Prosthodontist Process and Cost
The typical process of creating a palatal prosthesis by a prosthodontist begins by examining the patient, creating a stone model, then creating a wax model. Biocompatible materials are selected and processed into a mold that is trimmed and polished to the desired shape. This is followed by another patient visit to ensure the prosthesis fits properly. Follow-up care is also necessary for maintenance and comfort.
The average cost of a palatal prosthesis varies depending on the type needed (ie, metal implant, teeth replacement), the materials used, the region in which the patient is receiving care, and the complexity of the case. For complex and customizable options like those required for patients with cancer, the prostheses typically cost several thousands of dollars. The Healthcare Common Procedure Coding System code for a palatal lift prosthesis (D5955) lists prices ranging from $4000 to $8000 per prosthetic, not including the cost of the prosthodontist visits.22,23
Discussion
This program sought to determine whether imaging studies of maxillary defects are effective templates for developing 3D printed prosthetics and whether these prosthetics should be tested for future use in reconstruction of palatomaxillary defects. Our program illustrated that CTs served as feasible templates for developing hard palate prostheses for patients with palatomaxillary defects. It is important to note the CTs used were from a newer and more modern scanner and therefore yielded detailed palatal structures with higher accuracy more suitable for 3D modeling. Lower-quality CTs from the 4 patients excluded from the program were not suitable for 3D modeling. This suggests that with high-quality imaging, 3D printed prosthesis may be a viable strategy to help patients who struggle with their function following treatment for head and neck cancers.
3D printed prosthesis may also be a more patient centered and convenient option. In the traditional prosthesis creation workflow, the patient must physically bite down onto a resin (alginate or silicone) to make an impression, a very painful postoperative process that is irritating to the raw edges of the surgical bed.15,16 Prosthodontists then create a prosthetic minus the tumor and typically secure it with clips or glue.17 Many patients also experience changes in their anatomy over time requiring them to have a new protheses created. This is particularly important in veterans with palatomaxillary defects since many VA medical centers do not have a prosthodontist on staff, making accessibility to these specialists difficult. 3D printing provides a contactless prosthetic creation process. This convenience may reduce a patient’s pain and the number of visits for which they need a specialist.
Future Directions
Additional research is needed to determine the full potential of 3D printed prosthetics. 3D printed prostheses have been effectively used for patient education in areas of presurgical planning, prosthesis creation, and trainee education.24 This research represents an early step in the development of a new technology for use in otolaryngology. Specifically, many veterans with a history of head and neck cancers have sustained changes to their craniofacial anatomy following treatment. Using imaging to create 3D printed prosthetics could be very effective for these patients. Prosthetics could improve a patient’s quality of life by restoring/approximating their anatomy after cancer treatment.
Significant time and care must be taken by cancer and reconstructive surgeons to properly fit a prosthesis. Improperly fitting prosthetics leads to mucosal ulceration that then may lead to a need for fitting a new prosthetic. The advantage of 3D printed prosthetics is that they may more precisely fit the anatomy of each patient using CT results, thus potentially reducing the time needed to fit the prosthetic as well as the risk associated with an improperly fit prosthetic. 3D printed prosthesis could be used directly in the future, however, clinical trials are needed to verify its efficacy vs prosthodontic options.
Another consideration for potential future use of 3D printed prosthetics is cost. We estimated that the cost of the materials and labor of our 3D printed prosthetic to be about $150. Pricing of current molded prosthetics varies, but is often listed at several thousand dollars. Another consideration is the durability of 3D printed prosthetics vs standard prosthetics. Since we were unable to use the prosthetic in the patient, it was difficult to determine its durability. The significant cost of the 3D printer and software necessary for 3D printed prosthetics must also be considered and may be prohibitive. While many academic hospitals are considering the purchase of 3D printers and licenses, this may be challenging for resource-constrained institutions. 3D printing may also be difficult for groups without any prior experience in the field. Outsourcing to a third party is possible, though doing so adds more cost to the project. While we recognize there is a learning curve associated with adopting any new technology, it’s equally important to note that 3D printing is being rapidly integrated and has already made significant advancements in personalized medicine.8,25,26
Limitations
This program had several limitations. First, we only obtained CTs of sufficient quality from 1 patient to generate a 3D printed prosthesis. Further research with additional patients is necessary to validate this process. Second, we were unable to trial the prosthesis in the patient because we did not have FDA approval. Additionally, it is difficult to calculate a true cost estimate for this process as materials and software costs vary dramatically across institutions as well as over time.
Conclusions
The purpose of this study was to demonstrate the possibility to develop prosthetics for the hard palate for patients suffering from palatomaxillary defects. A 3D printed prosthetic was generated that matched the patient’s craniofacial anatomy. Future research should test the feasibility of these prosthetics in patient care against a traditional prosthodontic impression. Though this is a proof-of-concept study and no prosthetics were implanted as part of this investigation, we showcase the feasibility of printing prosthetics for palatomaxillary defects. The use of 3D printed prosthetics may be a more humane process, potentially lower cost, and be more accessible to veterans.
Three-dimensional (3D) printing has become a promising area of innovation in biomedical research.1,2 Previous research in orthopedic surgery has found that customized 3D printed implants, casts, orthoses, and prosthetics (eg, prosthetic hands) matched to an individual’s unique anatomy can result in more precise placement and better surgical outcomes.3-5 Customized prosthetics have also been found to lead to fewer complications.3,6
Recent advances in 3D printing technology has prompted investigation from surgeons to identify how this new tool may be incorporated into patient care.1,7 One of the most common applications of 3D printing is during preoperative planning in which surgeons gain better insight into patient-specific anatomy by using patient-specific printed models.8 Another promising application is the production of customized prosthetics suited to each patient’s unique anatomy.9 As a result, 3D printing has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform the treatment of patients with debilitating musculoskeletal injuries.3,10
The potential surrounding 3D printed prosthetics has led to their adoption by several other specialties, including otolaryngology.11 The most widely used application of 3D printing among otolaryngologists is preoperative planning, and the incorporation of printed prosthetics intoreconstruction of the orbit, nasal septum, auricle, and palate has also been reported.2,12,13 Patient-specific implants might allow otolaryngologists to better rehabilitate, reconstruct, and/or regenerate craniofacial defects using more humane procedures.14
Patients with palatomaxillary cancers are treated by prosthodontists or otolaryngologists. An impression is made with a resin–which can be painful for postoperative patients–and a prosthetic is manufactured and implanted.15-17 Patients with cancer often see many specialists, though reconstructive care is a low priority. Many of these individuals also experience dynamic anatomic functional changes over time, leading to the need for multiple prothesis.
palatomaxillary prosthetics
This program aims to use patients’ previous computed tomography (CT) to tailor customized 3D printed palatomaxillary prosthetics to specifically fit their anatomy. Palatomaxillary defects are a source of profound disability for patients with head and neck cancers who are left with large anatomic defects as a direct result of treatment. Reconstruction of palatal defects poses unique challenges due to the complexity of patient anatomy.18,19
3D printed prosthetics for palatomaxillary defects have not been incorporated into patient care. We reviewed previous imaging research to determine if it could be used to assist patients who struggle with their function and appearance following treatment for head and neck cancers. The primary aim was to investigate whether 3D printing was a feasible strategy for creating patient-specific palatomaxillary prosthetics. The secondary aim is to determine whether these prosthetics should be tested in the future for use in reconstruction of maxillary defects.
Data Acquisition
This study was conducted at the Veterans Affairs Palo Alto Health Care System (VAPAHCS) and was approved by the Stanford University Institutional Review Board (approval #28958, informed consent and patient contact excluded). A retrospective chart review was conducted on all patients with head and neck cancers who were treated at VAPAHCS from 2010 to 2022. Patients aged ≥ 18 years who had a palatomaxillary defect due to cancer treatment, had undergone a palatal resection, and who received treatment at any point from 2010 to 2022 were included in the review. CTs were not a specific inclusion criterion, though the quality of the scans was analyzed for eligible patients. Younger patients and those treated at VAPAHCS prior to 2010 were excluded.
There was no control group; all data was sourced from the US Department of Veterans Affairs (VA) imaging system database. Among the 3595 patients reviewed, 5 met inclusion criteria and the quality of their craniofacial anatomy CTs were analyzed. To maintain accurate craniofacial 3D modeling, CTs require a maximum of 1 mm slice thickness. Of the 5 patients who met the inclusion criteria, 4 were found to have variability in the quality of their CTs and severe defects not suitable for prosthetic reconstruction, which led to their exclusion from the study. One patient was investigated to demonstrate if making these prostheses was feasible. This patient was diagnosed with a malignant neoplasm of the hard palate, underwent a partial maxillectomy, and a palatal obturator was placed to cover the defect.
The primary data collected was patient identifiers as well as the gross anatomy and dimensions of the patients’ craniofacial anatomy, as seen in previous imaging research.20 Before the imaging analysis, all personal health information was removed and the dataset was deidentified to ensure patient anonymity and noninvolvement.
CT Segmentation and 3D Printing
Using CTs of the patient’s craniofacial anatomy, we developed a model of the defects. This was achieved with deidentified CTs imported into the Food and Drug Administration (FDA)-approved computerized aid design (CAD) software, Materialise Mimics. The hard palate was segmented and isolated based off the presented scan and any holes in the image were filled using the CAD software. The model was subsequently mirrored in Materialise 3-matic to replicate an original anatomical hard palate prosthesis. The final product was converted into a 3D model and imported into Formlabs preform software to generate 3D printing supports and orient it for printing. The prosthetic was printed using FDA-approved Biocompatible Denture Base Resin by a Formlabs 3B+ printer at the Palo Alto VA Simulation Center. The 3D printed prosthesis was washed using Formlabs Form Wash 80% ethyl alcohol to remove excess resin and subsequently cured to harden the malleable resin. Supports were later removed, and the prosthesis was sanded.
The primary aim of this study was to investigate whether using CTs to create patient-specific prosthetic renderings for patients with head and neck cancer could be a feasible strategy. The CTs from the patient were successfully used to generate a 3D printed prosthesis, and the prosthesis matched the original craniofacial anatomy seen in the patient's imaging (Figure). These results demonstrate that high quality CTs can be used as a template for 3D printed prostheses for mild to moderate palatomaxillary defects.
3D Printing Costs
One liter of Denture Base Resin costs $299; prostheses use about 5 mL of resin. The average annual salary of a 3D printing technician in the United States is $42,717, or $20.54 per hour.21 For an experienced 3D printing technician, the time required to segment the hard palate and prepare it for 3D printing is 1 to 2 hours. The process may exceed 2 hours if the technician is presented with a lower quality CT or if the patient has a complex craniofacial anatomy.
The average time it takes to print a palatal prosthetic is 5 hours. An additional hour is needed for postprocessing, which includes washing and sanding. Therefore, the cost of the materials and labor for an average 3D printed prosthetic is about $150. A Formlabs 3B+ printer is competitively priced around $10,000. The cost for Materialise Mimics software varies, but is estimated at $16,000 at VAPAHCS. The prices for these 2 items are not included in our price estimation but should be taken into consideration.
Prosthodontist Process and Cost
The typical process of creating a palatal prosthesis by a prosthodontist begins by examining the patient, creating a stone model, then creating a wax model. Biocompatible materials are selected and processed into a mold that is trimmed and polished to the desired shape. This is followed by another patient visit to ensure the prosthesis fits properly. Follow-up care is also necessary for maintenance and comfort.
The average cost of a palatal prosthesis varies depending on the type needed (ie, metal implant, teeth replacement), the materials used, the region in which the patient is receiving care, and the complexity of the case. For complex and customizable options like those required for patients with cancer, the prostheses typically cost several thousands of dollars. The Healthcare Common Procedure Coding System code for a palatal lift prosthesis (D5955) lists prices ranging from $4000 to $8000 per prosthetic, not including the cost of the prosthodontist visits.22,23
Discussion
This program sought to determine whether imaging studies of maxillary defects are effective templates for developing 3D printed prosthetics and whether these prosthetics should be tested for future use in reconstruction of palatomaxillary defects. Our program illustrated that CTs served as feasible templates for developing hard palate prostheses for patients with palatomaxillary defects. It is important to note the CTs used were from a newer and more modern scanner and therefore yielded detailed palatal structures with higher accuracy more suitable for 3D modeling. Lower-quality CTs from the 4 patients excluded from the program were not suitable for 3D modeling. This suggests that with high-quality imaging, 3D printed prosthesis may be a viable strategy to help patients who struggle with their function following treatment for head and neck cancers.
3D printed prosthesis may also be a more patient centered and convenient option. In the traditional prosthesis creation workflow, the patient must physically bite down onto a resin (alginate or silicone) to make an impression, a very painful postoperative process that is irritating to the raw edges of the surgical bed.15,16 Prosthodontists then create a prosthetic minus the tumor and typically secure it with clips or glue.17 Many patients also experience changes in their anatomy over time requiring them to have a new protheses created. This is particularly important in veterans with palatomaxillary defects since many VA medical centers do not have a prosthodontist on staff, making accessibility to these specialists difficult. 3D printing provides a contactless prosthetic creation process. This convenience may reduce a patient’s pain and the number of visits for which they need a specialist.
Future Directions
Additional research is needed to determine the full potential of 3D printed prosthetics. 3D printed prostheses have been effectively used for patient education in areas of presurgical planning, prosthesis creation, and trainee education.24 This research represents an early step in the development of a new technology for use in otolaryngology. Specifically, many veterans with a history of head and neck cancers have sustained changes to their craniofacial anatomy following treatment. Using imaging to create 3D printed prosthetics could be very effective for these patients. Prosthetics could improve a patient’s quality of life by restoring/approximating their anatomy after cancer treatment.
Significant time and care must be taken by cancer and reconstructive surgeons to properly fit a prosthesis. Improperly fitting prosthetics leads to mucosal ulceration that then may lead to a need for fitting a new prosthetic. The advantage of 3D printed prosthetics is that they may more precisely fit the anatomy of each patient using CT results, thus potentially reducing the time needed to fit the prosthetic as well as the risk associated with an improperly fit prosthetic. 3D printed prosthesis could be used directly in the future, however, clinical trials are needed to verify its efficacy vs prosthodontic options.
Another consideration for potential future use of 3D printed prosthetics is cost. We estimated that the cost of the materials and labor of our 3D printed prosthetic to be about $150. Pricing of current molded prosthetics varies, but is often listed at several thousand dollars. Another consideration is the durability of 3D printed prosthetics vs standard prosthetics. Since we were unable to use the prosthetic in the patient, it was difficult to determine its durability. The significant cost of the 3D printer and software necessary for 3D printed prosthetics must also be considered and may be prohibitive. While many academic hospitals are considering the purchase of 3D printers and licenses, this may be challenging for resource-constrained institutions. 3D printing may also be difficult for groups without any prior experience in the field. Outsourcing to a third party is possible, though doing so adds more cost to the project. While we recognize there is a learning curve associated with adopting any new technology, it’s equally important to note that 3D printing is being rapidly integrated and has already made significant advancements in personalized medicine.8,25,26
Limitations
This program had several limitations. First, we only obtained CTs of sufficient quality from 1 patient to generate a 3D printed prosthesis. Further research with additional patients is necessary to validate this process. Second, we were unable to trial the prosthesis in the patient because we did not have FDA approval. Additionally, it is difficult to calculate a true cost estimate for this process as materials and software costs vary dramatically across institutions as well as over time.
Conclusions
The purpose of this study was to demonstrate the possibility to develop prosthetics for the hard palate for patients suffering from palatomaxillary defects. A 3D printed prosthetic was generated that matched the patient’s craniofacial anatomy. Future research should test the feasibility of these prosthetics in patient care against a traditional prosthodontic impression. Though this is a proof-of-concept study and no prosthetics were implanted as part of this investigation, we showcase the feasibility of printing prosthetics for palatomaxillary defects. The use of 3D printed prosthetics may be a more humane process, potentially lower cost, and be more accessible to veterans.
1. Crafts TD, Ellsperman SE, Wannemuehler TJ, Bellicchi TD, Shipchandler TZ, Mantravadi AV. Three-dimensional printing and its applications in otorhinolaryngology-head and neck surgery. Otolaryngol Head Neck Surg. 2017;156(6):999-1010. doi:10.1177/0194599816678372
2. Virani FR, Chua EC, Timbang MR, Hsieh TY, Senders CW. Three-dimensional printing in cleft care: a systematic review. Cleft Palate Craniofac J. 2022;59(4):484-496. doi:10.1177/10556656211013175
3. Lal H, Patralekh MK. 3D printing and its applications in orthopaedic trauma: A technological marvel. J Clin Orthop Trauma. 2018;9(3):260-268. doi:10.1016/j.jcot.2018.07.022
4. Vujaklija I, Farina D. 3D printed upper limb prosthetics. Expert Rev Med Devices. 2018;15(7):505-512. doi:10.1080/17434440.2018.1494568
5. Ten Kate J, Smit G, Breedveld P. 3D-printed upper limb prostheses: a review. Disabil Rehabil Assist Technol. 2017;12(3):300-314. doi:10.1080/17483107.2016.1253117
6. Thomas CN, Mavrommatis S, Schroder LK, Cole PA. An overview of 3D printing and the orthopaedic application of patient-specific models in malunion surgery. Injury. 2022;53(3):977-983. doi:10.1016/j.injury.2021.11.019
7. Colaco M, Igel DA, Atala A. The potential of 3D printing in urological research and patient care. Nat Rev Urol. 2018;15(4):213-221. doi:10.1038/nrurol.2018.6
8. Meyer-Szary J, Luis MS, Mikulski S, et al. The role of 3D printing in planning complex medical procedures and training of medical professionals-cross-sectional multispecialty review. Int J Environ Res Public Health. 2022;19(6):3331. Published 2022 Mar 11. doi:10.3390/ijerph19063331
9. Moya D, Gobbato B, Valente S, Roca R. Use of preoperative planning and 3D printing in orthopedics and traumatology: entering a new era. Acta Ortop Mex. 2022;36(1):39-47.
10. Wixted CM, Peterson JR, Kadakia RJ, Adams SB. Three-dimensional printing in orthopaedic surgery: current applications and future developments. J Am Acad Orthop Surg Glob Res Rev. 2021;5(4):e20.00230-11. Published 2021 Apr 20. doi:10.5435/JAAOSGlobal-D-20-00230
11. Hong CJ, Giannopoulos AA, Hong BY, et al. Clinical applications of three-dimensional printing in otolaryngology-head and neck surgery: a systematic review. Laryngoscope. 2019;129(9):2045-2052. doi:10.1002/lary.2783112. Sigron GR, Barba M, Chammartin F, Msallem B, Berg BI, Thieringer FM. Functional and cosmetic outcome after reconstruction of isolated, unilateral orbital floor fractures (blow-out fractures) with and without the support of 3D-printed orbital anatomical models. J Clin Med. 2021;10(16):3509. Published 2021 Aug 9. doi:10.3390/jcm10163509
13. Kimura K, Davis S, Thomas E, et al. 3D Customization for microtia repair in hemifacial microsomia. Laryngoscope. 2022;132(3):545-549. doi:10.1002/lary.29823
14. Nyberg EL, Farris AL, Hung BP, et al. 3D-printing technologies for craniofacial rehabilitation, reconstruction, and regeneration. Ann Biomed Eng. 2017;45(1):45-57. doi:10.1007/s10439-016-1668-5
15. Flores-Ruiz R, Castellanos-Cosano L, Serrera-Figallo MA, et al. Evolution of oral cancer treatment in an andalusian population sample: rehabilitation with prosthetic obturation and removable partial prosthesis. J Clin Exp Dent. 2017;9(8):e1008-e1014. doi:10.4317/jced.54023
16. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg. 2003;61(2):174-181. doi:10.1053/joms.2003.50044
17. Pool C, Shokri T, Vincent A, Wang W, Kadakia S, Ducic Y. Prosthetic reconstruction of the maxilla and palate. Semin Plast Surg. 2020;34(2):114-119. doi:10.1055/s-0040-1709143
18. Badhey AK, Khan MN. Palatomaxillary reconstruction: fibula or scapula. Semin Plast Surg. 2020;34(2):86-91. doi:10.1055/s-0040-1709431
19. Jategaonkar AA, Kaul VF, Lee E, Genden EM. Surgery of the palatomaxillary structure. Semin Plast Surg. 2020;34(2):71-76. doi:10.1055/s-0040-1709430
20. Lobb DC, Cottler P, Dart D, Black JS. The use of patient-specific three-dimensional printed surgical models enhances plastic surgery resident education in craniofacial surgery. J Craniofac Surg. 2019;30(2):339-341. doi:10.1097/SCS.0000000000005322
21. 3D printing technician salary in the United States. Accessed February 27, 2024. https://www.salary.com/research/salary/posting/3d-printing-technician-salary22. US Dept of Veterans Affairs. Healthcare Common Procedure Coding System. Outpatient dental professional nationwide charges by HCPCS code. January-December 2020. Accessed February 27, 2024. https://www.va.gov/COMMUNITYCARE/docs/RO/Outpatient-DataTables/v3-27_Table-I.pdf23. Washington State Department of Labor and Industries. Professional services fee schedule HCPCS level II fees. October 1, 2020. Accessed February 27, 2024. https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2020/2020FSHCPCS.pdf24. Low CM, Morris JM, Price DL, et al. Three-dimensional printing: current use in rhinology and endoscopic skull base surgery. Am J Rhinol Allergy. 2019;33(6):770-781. doi:10.1177/1945892419866319
25. Aimar A, Palermo A, Innocenti B. The role of 3D printing in medical applications: a state of the art. J Healthc Eng. 2019;2019:5340616. Published 2019 Mar 21. doi:10.1155/2019/5340616
26. Garcia J, Yang Z, Mongrain R, Leask RL, Lachapelle K. 3D printing materials and their use in medical education: a review of current technology and trends for the future. BMJ Simul Technol Enhanc Learn. 2018;4(1):27-40. doi:10.1136/bmjstel-2017-000234
1. Crafts TD, Ellsperman SE, Wannemuehler TJ, Bellicchi TD, Shipchandler TZ, Mantravadi AV. Three-dimensional printing and its applications in otorhinolaryngology-head and neck surgery. Otolaryngol Head Neck Surg. 2017;156(6):999-1010. doi:10.1177/0194599816678372
2. Virani FR, Chua EC, Timbang MR, Hsieh TY, Senders CW. Three-dimensional printing in cleft care: a systematic review. Cleft Palate Craniofac J. 2022;59(4):484-496. doi:10.1177/10556656211013175
3. Lal H, Patralekh MK. 3D printing and its applications in orthopaedic trauma: A technological marvel. J Clin Orthop Trauma. 2018;9(3):260-268. doi:10.1016/j.jcot.2018.07.022
4. Vujaklija I, Farina D. 3D printed upper limb prosthetics. Expert Rev Med Devices. 2018;15(7):505-512. doi:10.1080/17434440.2018.1494568
5. Ten Kate J, Smit G, Breedveld P. 3D-printed upper limb prostheses: a review. Disabil Rehabil Assist Technol. 2017;12(3):300-314. doi:10.1080/17483107.2016.1253117
6. Thomas CN, Mavrommatis S, Schroder LK, Cole PA. An overview of 3D printing and the orthopaedic application of patient-specific models in malunion surgery. Injury. 2022;53(3):977-983. doi:10.1016/j.injury.2021.11.019
7. Colaco M, Igel DA, Atala A. The potential of 3D printing in urological research and patient care. Nat Rev Urol. 2018;15(4):213-221. doi:10.1038/nrurol.2018.6
8. Meyer-Szary J, Luis MS, Mikulski S, et al. The role of 3D printing in planning complex medical procedures and training of medical professionals-cross-sectional multispecialty review. Int J Environ Res Public Health. 2022;19(6):3331. Published 2022 Mar 11. doi:10.3390/ijerph19063331
9. Moya D, Gobbato B, Valente S, Roca R. Use of preoperative planning and 3D printing in orthopedics and traumatology: entering a new era. Acta Ortop Mex. 2022;36(1):39-47.
10. Wixted CM, Peterson JR, Kadakia RJ, Adams SB. Three-dimensional printing in orthopaedic surgery: current applications and future developments. J Am Acad Orthop Surg Glob Res Rev. 2021;5(4):e20.00230-11. Published 2021 Apr 20. doi:10.5435/JAAOSGlobal-D-20-00230
11. Hong CJ, Giannopoulos AA, Hong BY, et al. Clinical applications of three-dimensional printing in otolaryngology-head and neck surgery: a systematic review. Laryngoscope. 2019;129(9):2045-2052. doi:10.1002/lary.2783112. Sigron GR, Barba M, Chammartin F, Msallem B, Berg BI, Thieringer FM. Functional and cosmetic outcome after reconstruction of isolated, unilateral orbital floor fractures (blow-out fractures) with and without the support of 3D-printed orbital anatomical models. J Clin Med. 2021;10(16):3509. Published 2021 Aug 9. doi:10.3390/jcm10163509
13. Kimura K, Davis S, Thomas E, et al. 3D Customization for microtia repair in hemifacial microsomia. Laryngoscope. 2022;132(3):545-549. doi:10.1002/lary.29823
14. Nyberg EL, Farris AL, Hung BP, et al. 3D-printing technologies for craniofacial rehabilitation, reconstruction, and regeneration. Ann Biomed Eng. 2017;45(1):45-57. doi:10.1007/s10439-016-1668-5
15. Flores-Ruiz R, Castellanos-Cosano L, Serrera-Figallo MA, et al. Evolution of oral cancer treatment in an andalusian population sample: rehabilitation with prosthetic obturation and removable partial prosthesis. J Clin Exp Dent. 2017;9(8):e1008-e1014. doi:10.4317/jced.54023
16. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg. 2003;61(2):174-181. doi:10.1053/joms.2003.50044
17. Pool C, Shokri T, Vincent A, Wang W, Kadakia S, Ducic Y. Prosthetic reconstruction of the maxilla and palate. Semin Plast Surg. 2020;34(2):114-119. doi:10.1055/s-0040-1709143
18. Badhey AK, Khan MN. Palatomaxillary reconstruction: fibula or scapula. Semin Plast Surg. 2020;34(2):86-91. doi:10.1055/s-0040-1709431
19. Jategaonkar AA, Kaul VF, Lee E, Genden EM. Surgery of the palatomaxillary structure. Semin Plast Surg. 2020;34(2):71-76. doi:10.1055/s-0040-1709430
20. Lobb DC, Cottler P, Dart D, Black JS. The use of patient-specific three-dimensional printed surgical models enhances plastic surgery resident education in craniofacial surgery. J Craniofac Surg. 2019;30(2):339-341. doi:10.1097/SCS.0000000000005322
21. 3D printing technician salary in the United States. Accessed February 27, 2024. https://www.salary.com/research/salary/posting/3d-printing-technician-salary22. US Dept of Veterans Affairs. Healthcare Common Procedure Coding System. Outpatient dental professional nationwide charges by HCPCS code. January-December 2020. Accessed February 27, 2024. https://www.va.gov/COMMUNITYCARE/docs/RO/Outpatient-DataTables/v3-27_Table-I.pdf23. Washington State Department of Labor and Industries. Professional services fee schedule HCPCS level II fees. October 1, 2020. Accessed February 27, 2024. https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2020/2020FSHCPCS.pdf24. Low CM, Morris JM, Price DL, et al. Three-dimensional printing: current use in rhinology and endoscopic skull base surgery. Am J Rhinol Allergy. 2019;33(6):770-781. doi:10.1177/1945892419866319
25. Aimar A, Palermo A, Innocenti B. The role of 3D printing in medical applications: a state of the art. J Healthc Eng. 2019;2019:5340616. Published 2019 Mar 21. doi:10.1155/2019/5340616
26. Garcia J, Yang Z, Mongrain R, Leask RL, Lachapelle K. 3D printing materials and their use in medical education: a review of current technology and trends for the future. BMJ Simul Technol Enhanc Learn. 2018;4(1):27-40. doi:10.1136/bmjstel-2017-000234
Are Direct-to-Consumer Microbiome Tests Clinically Useful?
Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.
“We analyze the trillions of microbes in your gut microflora and craft a unique formula for your unique gut needs,” one says. “Get actionable dietary, supplement, and lifestyle recommendations from our microbiome experts based on your results, tailored to mom and baby’s biomarkers. ... Any family member like dads or siblings are welcome too,” says another.
The companies assert that they can improve gut health by offering individuals personalized treatments based on their gut microbiome test results. The trouble is, no provider, company, or technology can reliably do that yet.
Clinical Implications, Not Applications
The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.
Although knowledge is increasing on the oral, cutaneous, and vaginal microbiomes, the gut microbiome is arguably the most studied. However, while research is increasingly demonstrating that the gut microbiome has clinical implications, much work needs to be done before reliable applications based on that research are available.
But , Erik C. von Rosenvinge, MD, AGAF, a professor at the University of Maryland School of Medicine and chief of gastroenterology at the VA Maryland Health Care System, Baltimore, said in an interview.
“If you go to their websites, even if it’s not stated overtly, these companies at least give the impression that they’re providing actionable, useful information,” he said. “The sites recommend microbiome testing, and often supplements, probiotics, or other products that they sell. And consumers are told they need to be tested again once they start taking any of these products to see if they’re receiving any benefit.”
Dr. von Rosenvinge and colleagues authored a recent article in Science arguing that DTC microbiome tests “lack analytical and clinical validity” — and yet regulation of the industry has been “generally ignored.” They identified 31 companies globally, 17 of which are based in the United States, claiming to have products and/or services aimed at changing the intestinal microbiome.
Unreliable, Unregulated
The lack of reliability has been shown by experts who have tested the tests.
“People have taken the same stool sample, sent it to multiple companies, and gotten different results back,” Dr. von Rosenvinge said. “People also have taken a stool sample and sent it to the same company under two different names and received two different results. If the test is unreliable at its foundational level, it’s hard to use it in any clinical way.”
Test users’ methods and the companies’ procedures can affect the results, Dina Kao, MD, a professor at the University of Alberta, Edmonton, Alberta, Canada, said in an interview.
“So many biases can be introduced at every single step of the way, starting from how the stool sample was collected and how it’s preserved or not being preserved, because that can introduce a lot of noise that would change the analyses. Which primer they’re using to amplify the signals and which bioinformatic pipeline they use are also important,” said Dr. Kao, who presented at the recent Gut Microbiota for Health World Summit, organized by the American Gastroenterological Association (AGA) and the European Society of Neurogastroenterology and Motility (ESNM).
Different investigators and companies use different technologies, so it’s very difficult to compare them and to create a standard, said Mahmoud Ghannoum, PhD, a professor in the dermatology and pathology departments at Case Western Reserve University School of Medicine and director of the Center for Medical Mycology at University Hospitals in Cleveland.
The complexity of the gut microbiome makes test standardization more difficult than it is when just one organism is involved, Dr. Ghannoum, who chaired the antifungal subcommittee at the Clinical and Laboratory Standards Institute, said in an interview.
“Even though many researchers are focusing on bacteria, we also have fungi and viruses. We need standardization of methods for testing these organisms if we want to have regulations,” said Dr. Ghannoum, a cofounder of BIOHM, a microbiome company that offers nondiagnostic tests and markets a variety of probiotics, prebiotics, and immunity supplements. BIOHM is one of the 31 companies identified by Dr. von Rosenvinge and colleagues, as noted above.
Dr. Ghannoum believes that taking a systematic approach could facilitate standardization and, ultimately, regulation of the DTC microbiome testing products. He and his colleagues described such an approach by outlining the stages for designing probiotics capable of modulating the microbiome in chronic diseases, using Crohn’s disease as a model. Their strategy involved the following steps:
- Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
- Gaining insight into the interactions among the identified pathogens.
- Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
- Creating a prototype formulation for testing.
- Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
- Conducting clinical testing.
Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”
Potential Pitfalls
Whether test results from commercial companies are positioned as wellness aids or diagnostic tools, providing advice based on the results “is where the danger can really come in,” Dr. Kao said. “There is still so much we don’t know about which microbial signatures are associated with each condition.”
“Even when we have a solution, like the Crohn’s exclusion diet, a physician doesn’t know enough of the nuances to give advice to a patient,” she said. “That really should be done under the guidance of an expert dietitian. And if a company is selling probiotics, I personally feel that’s not ethical. I’m pretty sure there’s always going to be some kind of conflict of interest.”
Supplements and probiotics are generally safe, but negative consequences can occur, Dr. von Rosenvinge noted.
“We occasionally see people who end up with liver problems as a result of certain supplements, and rarely, probiotics have been associated with infections from those organisms, usually in those with a compromised immune system,” he said.
Other risks include people taking supplements or probiotics when they actually have a medically treatable condition or delays in diagnosis of a potentially serious underlying condition, such as colon cancer, he said. Some patients may stop taking their traditional medication in favor of taking supplements or may experience a drug-supplement interaction if they take both.
What to Tell Patients
“Doctors should be advising against this testing for their patients,” gastroenterologist Colleen R. Kelly, MD, AGAF, Brigham and Women’s Hospital, Boston, said in an interview. “I explain to patients that these tests are not validated and are clinically meaningless data and not worth the money. There is a reason they are not covered by insurance.
“Recommendations to purchase probiotics or supplements manufactured by the testing company to ‘restore a balanced or healthy microbiome’ clearly seem like a scam,” she added. “I believe some of these companies are capitalizing on patients who are desperate for answers to explain chronic symptoms, such as bloating in irritable bowel syndrome.”
Dr. von Rosenvinge said that the message to patients “is that the science isn’t there yet to support using the results of these tests in a meaningful way. We believe the microbiome is very important in health and disease, but the tests themselves in their current state are not as reliable and reproducible as we would like.”
When patients come in with test results, the first question a clinician should ask is what led them to seek out this type of information in the first place, Dr. von Rosenvinge said.
“Our patient focus groups suggested that many have not gotten clear, satisfactory answers from traditional medicine,” he said. “We don’t have a single test that says, yes, you have irritable bowel syndrome, or no, you don’t. We might suggest things that are helpful for some people and are less helpful for others.”
Dr. Kelly said she worries that “there are snake oil salesmen and cons out there who will gladly take your money. These may be smart people, capable of doing very high-level testing, and even producing very detailed and accurate results, but that doesn’t mean we know what to do with them.”
She hopes to see a microbiome-based diagnostic test in the future, particularly if the ability to therapeutically manipulate the gut microbiome in various diseases becomes a reality.
Educate Clinicians, Companies
More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.
“The microbiome never came up when I was going through my medical education,” she said. But we, and the next generation of physicians, “need to at least be able to understand the basics.
“Hopefully, one day, we will be in a position where we can have meaningful interpretations of the test results and make some kind of meaningful dietary interventions,” Dr. Kao added.
As for clinicians who are currently ordering these tests and products directly from the DTC companies, Dr. Kao said, “I roll my eyes.”
Dr. Ghannoum reiterated that companies offering microbiome tests and products also need to be educated and encouraged to use systematic approaches to product development and interpretation.
“Companies should be open to calls from clinicians and be ready to explain findings on a report, as well as the basis for any recommendations,” he said.
Dr. von Rosenvinge, Dr. Kao, and Dr. Kelly had no relevant conflicts of interest. Dr. Ghannoum is a cofounder of BIOHM.
A version of this article appeared on Medscape.com.
Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.
“We analyze the trillions of microbes in your gut microflora and craft a unique formula for your unique gut needs,” one says. “Get actionable dietary, supplement, and lifestyle recommendations from our microbiome experts based on your results, tailored to mom and baby’s biomarkers. ... Any family member like dads or siblings are welcome too,” says another.
The companies assert that they can improve gut health by offering individuals personalized treatments based on their gut microbiome test results. The trouble is, no provider, company, or technology can reliably do that yet.
Clinical Implications, Not Applications
The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.
Although knowledge is increasing on the oral, cutaneous, and vaginal microbiomes, the gut microbiome is arguably the most studied. However, while research is increasingly demonstrating that the gut microbiome has clinical implications, much work needs to be done before reliable applications based on that research are available.
But , Erik C. von Rosenvinge, MD, AGAF, a professor at the University of Maryland School of Medicine and chief of gastroenterology at the VA Maryland Health Care System, Baltimore, said in an interview.
“If you go to their websites, even if it’s not stated overtly, these companies at least give the impression that they’re providing actionable, useful information,” he said. “The sites recommend microbiome testing, and often supplements, probiotics, or other products that they sell. And consumers are told they need to be tested again once they start taking any of these products to see if they’re receiving any benefit.”
Dr. von Rosenvinge and colleagues authored a recent article in Science arguing that DTC microbiome tests “lack analytical and clinical validity” — and yet regulation of the industry has been “generally ignored.” They identified 31 companies globally, 17 of which are based in the United States, claiming to have products and/or services aimed at changing the intestinal microbiome.
Unreliable, Unregulated
The lack of reliability has been shown by experts who have tested the tests.
“People have taken the same stool sample, sent it to multiple companies, and gotten different results back,” Dr. von Rosenvinge said. “People also have taken a stool sample and sent it to the same company under two different names and received two different results. If the test is unreliable at its foundational level, it’s hard to use it in any clinical way.”
Test users’ methods and the companies’ procedures can affect the results, Dina Kao, MD, a professor at the University of Alberta, Edmonton, Alberta, Canada, said in an interview.
“So many biases can be introduced at every single step of the way, starting from how the stool sample was collected and how it’s preserved or not being preserved, because that can introduce a lot of noise that would change the analyses. Which primer they’re using to amplify the signals and which bioinformatic pipeline they use are also important,” said Dr. Kao, who presented at the recent Gut Microbiota for Health World Summit, organized by the American Gastroenterological Association (AGA) and the European Society of Neurogastroenterology and Motility (ESNM).
Different investigators and companies use different technologies, so it’s very difficult to compare them and to create a standard, said Mahmoud Ghannoum, PhD, a professor in the dermatology and pathology departments at Case Western Reserve University School of Medicine and director of the Center for Medical Mycology at University Hospitals in Cleveland.
The complexity of the gut microbiome makes test standardization more difficult than it is when just one organism is involved, Dr. Ghannoum, who chaired the antifungal subcommittee at the Clinical and Laboratory Standards Institute, said in an interview.
“Even though many researchers are focusing on bacteria, we also have fungi and viruses. We need standardization of methods for testing these organisms if we want to have regulations,” said Dr. Ghannoum, a cofounder of BIOHM, a microbiome company that offers nondiagnostic tests and markets a variety of probiotics, prebiotics, and immunity supplements. BIOHM is one of the 31 companies identified by Dr. von Rosenvinge and colleagues, as noted above.
Dr. Ghannoum believes that taking a systematic approach could facilitate standardization and, ultimately, regulation of the DTC microbiome testing products. He and his colleagues described such an approach by outlining the stages for designing probiotics capable of modulating the microbiome in chronic diseases, using Crohn’s disease as a model. Their strategy involved the following steps:
- Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
- Gaining insight into the interactions among the identified pathogens.
- Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
- Creating a prototype formulation for testing.
- Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
- Conducting clinical testing.
Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”
Potential Pitfalls
Whether test results from commercial companies are positioned as wellness aids or diagnostic tools, providing advice based on the results “is where the danger can really come in,” Dr. Kao said. “There is still so much we don’t know about which microbial signatures are associated with each condition.”
“Even when we have a solution, like the Crohn’s exclusion diet, a physician doesn’t know enough of the nuances to give advice to a patient,” she said. “That really should be done under the guidance of an expert dietitian. And if a company is selling probiotics, I personally feel that’s not ethical. I’m pretty sure there’s always going to be some kind of conflict of interest.”
Supplements and probiotics are generally safe, but negative consequences can occur, Dr. von Rosenvinge noted.
“We occasionally see people who end up with liver problems as a result of certain supplements, and rarely, probiotics have been associated with infections from those organisms, usually in those with a compromised immune system,” he said.
Other risks include people taking supplements or probiotics when they actually have a medically treatable condition or delays in diagnosis of a potentially serious underlying condition, such as colon cancer, he said. Some patients may stop taking their traditional medication in favor of taking supplements or may experience a drug-supplement interaction if they take both.
What to Tell Patients
“Doctors should be advising against this testing for their patients,” gastroenterologist Colleen R. Kelly, MD, AGAF, Brigham and Women’s Hospital, Boston, said in an interview. “I explain to patients that these tests are not validated and are clinically meaningless data and not worth the money. There is a reason they are not covered by insurance.
“Recommendations to purchase probiotics or supplements manufactured by the testing company to ‘restore a balanced or healthy microbiome’ clearly seem like a scam,” she added. “I believe some of these companies are capitalizing on patients who are desperate for answers to explain chronic symptoms, such as bloating in irritable bowel syndrome.”
Dr. von Rosenvinge said that the message to patients “is that the science isn’t there yet to support using the results of these tests in a meaningful way. We believe the microbiome is very important in health and disease, but the tests themselves in their current state are not as reliable and reproducible as we would like.”
When patients come in with test results, the first question a clinician should ask is what led them to seek out this type of information in the first place, Dr. von Rosenvinge said.
“Our patient focus groups suggested that many have not gotten clear, satisfactory answers from traditional medicine,” he said. “We don’t have a single test that says, yes, you have irritable bowel syndrome, or no, you don’t. We might suggest things that are helpful for some people and are less helpful for others.”
Dr. Kelly said she worries that “there are snake oil salesmen and cons out there who will gladly take your money. These may be smart people, capable of doing very high-level testing, and even producing very detailed and accurate results, but that doesn’t mean we know what to do with them.”
She hopes to see a microbiome-based diagnostic test in the future, particularly if the ability to therapeutically manipulate the gut microbiome in various diseases becomes a reality.
Educate Clinicians, Companies
More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.
“The microbiome never came up when I was going through my medical education,” she said. But we, and the next generation of physicians, “need to at least be able to understand the basics.
“Hopefully, one day, we will be in a position where we can have meaningful interpretations of the test results and make some kind of meaningful dietary interventions,” Dr. Kao added.
As for clinicians who are currently ordering these tests and products directly from the DTC companies, Dr. Kao said, “I roll my eyes.”
Dr. Ghannoum reiterated that companies offering microbiome tests and products also need to be educated and encouraged to use systematic approaches to product development and interpretation.
“Companies should be open to calls from clinicians and be ready to explain findings on a report, as well as the basis for any recommendations,” he said.
Dr. von Rosenvinge, Dr. Kao, and Dr. Kelly had no relevant conflicts of interest. Dr. Ghannoum is a cofounder of BIOHM.
A version of this article appeared on Medscape.com.
Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.
“We analyze the trillions of microbes in your gut microflora and craft a unique formula for your unique gut needs,” one says. “Get actionable dietary, supplement, and lifestyle recommendations from our microbiome experts based on your results, tailored to mom and baby’s biomarkers. ... Any family member like dads or siblings are welcome too,” says another.
The companies assert that they can improve gut health by offering individuals personalized treatments based on their gut microbiome test results. The trouble is, no provider, company, or technology can reliably do that yet.
Clinical Implications, Not Applications
The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.
Although knowledge is increasing on the oral, cutaneous, and vaginal microbiomes, the gut microbiome is arguably the most studied. However, while research is increasingly demonstrating that the gut microbiome has clinical implications, much work needs to be done before reliable applications based on that research are available.
But , Erik C. von Rosenvinge, MD, AGAF, a professor at the University of Maryland School of Medicine and chief of gastroenterology at the VA Maryland Health Care System, Baltimore, said in an interview.
“If you go to their websites, even if it’s not stated overtly, these companies at least give the impression that they’re providing actionable, useful information,” he said. “The sites recommend microbiome testing, and often supplements, probiotics, or other products that they sell. And consumers are told they need to be tested again once they start taking any of these products to see if they’re receiving any benefit.”
Dr. von Rosenvinge and colleagues authored a recent article in Science arguing that DTC microbiome tests “lack analytical and clinical validity” — and yet regulation of the industry has been “generally ignored.” They identified 31 companies globally, 17 of which are based in the United States, claiming to have products and/or services aimed at changing the intestinal microbiome.
Unreliable, Unregulated
The lack of reliability has been shown by experts who have tested the tests.
“People have taken the same stool sample, sent it to multiple companies, and gotten different results back,” Dr. von Rosenvinge said. “People also have taken a stool sample and sent it to the same company under two different names and received two different results. If the test is unreliable at its foundational level, it’s hard to use it in any clinical way.”
Test users’ methods and the companies’ procedures can affect the results, Dina Kao, MD, a professor at the University of Alberta, Edmonton, Alberta, Canada, said in an interview.
“So many biases can be introduced at every single step of the way, starting from how the stool sample was collected and how it’s preserved or not being preserved, because that can introduce a lot of noise that would change the analyses. Which primer they’re using to amplify the signals and which bioinformatic pipeline they use are also important,” said Dr. Kao, who presented at the recent Gut Microbiota for Health World Summit, organized by the American Gastroenterological Association (AGA) and the European Society of Neurogastroenterology and Motility (ESNM).
Different investigators and companies use different technologies, so it’s very difficult to compare them and to create a standard, said Mahmoud Ghannoum, PhD, a professor in the dermatology and pathology departments at Case Western Reserve University School of Medicine and director of the Center for Medical Mycology at University Hospitals in Cleveland.
The complexity of the gut microbiome makes test standardization more difficult than it is when just one organism is involved, Dr. Ghannoum, who chaired the antifungal subcommittee at the Clinical and Laboratory Standards Institute, said in an interview.
“Even though many researchers are focusing on bacteria, we also have fungi and viruses. We need standardization of methods for testing these organisms if we want to have regulations,” said Dr. Ghannoum, a cofounder of BIOHM, a microbiome company that offers nondiagnostic tests and markets a variety of probiotics, prebiotics, and immunity supplements. BIOHM is one of the 31 companies identified by Dr. von Rosenvinge and colleagues, as noted above.
Dr. Ghannoum believes that taking a systematic approach could facilitate standardization and, ultimately, regulation of the DTC microbiome testing products. He and his colleagues described such an approach by outlining the stages for designing probiotics capable of modulating the microbiome in chronic diseases, using Crohn’s disease as a model. Their strategy involved the following steps:
- Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
- Gaining insight into the interactions among the identified pathogens.
- Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
- Creating a prototype formulation for testing.
- Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
- Conducting clinical testing.
Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”
Potential Pitfalls
Whether test results from commercial companies are positioned as wellness aids or diagnostic tools, providing advice based on the results “is where the danger can really come in,” Dr. Kao said. “There is still so much we don’t know about which microbial signatures are associated with each condition.”
“Even when we have a solution, like the Crohn’s exclusion diet, a physician doesn’t know enough of the nuances to give advice to a patient,” she said. “That really should be done under the guidance of an expert dietitian. And if a company is selling probiotics, I personally feel that’s not ethical. I’m pretty sure there’s always going to be some kind of conflict of interest.”
Supplements and probiotics are generally safe, but negative consequences can occur, Dr. von Rosenvinge noted.
“We occasionally see people who end up with liver problems as a result of certain supplements, and rarely, probiotics have been associated with infections from those organisms, usually in those with a compromised immune system,” he said.
Other risks include people taking supplements or probiotics when they actually have a medically treatable condition or delays in diagnosis of a potentially serious underlying condition, such as colon cancer, he said. Some patients may stop taking their traditional medication in favor of taking supplements or may experience a drug-supplement interaction if they take both.
What to Tell Patients
“Doctors should be advising against this testing for their patients,” gastroenterologist Colleen R. Kelly, MD, AGAF, Brigham and Women’s Hospital, Boston, said in an interview. “I explain to patients that these tests are not validated and are clinically meaningless data and not worth the money. There is a reason they are not covered by insurance.
“Recommendations to purchase probiotics or supplements manufactured by the testing company to ‘restore a balanced or healthy microbiome’ clearly seem like a scam,” she added. “I believe some of these companies are capitalizing on patients who are desperate for answers to explain chronic symptoms, such as bloating in irritable bowel syndrome.”
Dr. von Rosenvinge said that the message to patients “is that the science isn’t there yet to support using the results of these tests in a meaningful way. We believe the microbiome is very important in health and disease, but the tests themselves in their current state are not as reliable and reproducible as we would like.”
When patients come in with test results, the first question a clinician should ask is what led them to seek out this type of information in the first place, Dr. von Rosenvinge said.
“Our patient focus groups suggested that many have not gotten clear, satisfactory answers from traditional medicine,” he said. “We don’t have a single test that says, yes, you have irritable bowel syndrome, or no, you don’t. We might suggest things that are helpful for some people and are less helpful for others.”
Dr. Kelly said she worries that “there are snake oil salesmen and cons out there who will gladly take your money. These may be smart people, capable of doing very high-level testing, and even producing very detailed and accurate results, but that doesn’t mean we know what to do with them.”
She hopes to see a microbiome-based diagnostic test in the future, particularly if the ability to therapeutically manipulate the gut microbiome in various diseases becomes a reality.
Educate Clinicians, Companies
More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.
“The microbiome never came up when I was going through my medical education,” she said. But we, and the next generation of physicians, “need to at least be able to understand the basics.
“Hopefully, one day, we will be in a position where we can have meaningful interpretations of the test results and make some kind of meaningful dietary interventions,” Dr. Kao added.
As for clinicians who are currently ordering these tests and products directly from the DTC companies, Dr. Kao said, “I roll my eyes.”
Dr. Ghannoum reiterated that companies offering microbiome tests and products also need to be educated and encouraged to use systematic approaches to product development and interpretation.
“Companies should be open to calls from clinicians and be ready to explain findings on a report, as well as the basis for any recommendations,” he said.
Dr. von Rosenvinge, Dr. Kao, and Dr. Kelly had no relevant conflicts of interest. Dr. Ghannoum is a cofounder of BIOHM.
A version of this article appeared on Medscape.com.