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Maternal COVID-19 vaccine curbs infant infection
a new study shows.
Previous research has confirmed that COVID-19 neutralizing antibodies following maternal vaccination or maternal COVID-19 infection are present in umbilical cord blood, breast milk, and infant serum specimens, wrote Sarah C.J. Jorgensen, PharmD, MPH, of the University of Toronto, and colleagues in their article published in The BMJ.
In the study, the researchers identified maternal and newborn pairs using administrative databases from Canada. The study population included 8,809 infants aged younger than 6 months who were born between May 7, 2021, and March 31, 2022, and who underwent testing for COVID-19 between May 7, 2021, and September 5, 2022.
Maternal vaccination with the primary COVID-19 mRNA monovalent vaccine series was defined as two vaccine doses administered up to 14 days before delivery, with at least one of the doses after the conception date.
Maternal vaccination with the primary series plus one booster was defined as three doses administered up to 14 days before delivery, with at least one of these doses after the conception date.
The primary outcome was the presence of delta or omicron COVID-19 infection or hospital admission of the infants.
The study population included 99 COVID-19 cases with the delta variant (with 4,365 controls) and 1,501 cases with the omicron variant (with 4,847 controls).
Overall, the vaccine effectiveness of maternal doses was 95% against delta infection and 45% against omicron.
The effectiveness against hospital admission in cases of delta and omicron variants were 97% and 53%, respectively.
The effectiveness of three doses was 73% against omicron infant infection and 80% against omicron-related infant hospitalization. Data were not available for the effectiveness of three doses against the delta variant.
The effectiveness of two doses of vaccine against infant omicron infection was highest when mothers received the second dose during the third trimester of pregnancy, compared with during the first trimester or second trimester (53% vs. 47% and 53% vs. 37%, respectively).
Vaccine effectiveness with two doses against infant infection from omicron was highest in the first 8 weeks of life (57%), then decreased to 40% among infants after 16 weeks of age.
Although the study was not designed to assess the mechanism of action of the impact of maternal vaccination on infants, the current study results were consistent with other recent studies showing a reduction in infections and hospitalizations among infants whose mothers received COVID-19 vaccines during pregnancy, the researchers wrote in their discussion.
The findings were limited by several factors including the potential unmeasured confounders not available in databases, such as whether infants were breastfed, the researchers noted. Other limitations included a lack of data on home test results and the inability to assess the waning impact of the vaccine effectiveness against the delta variant because of the small number of delta cases, they said. However, the results suggest that the mRNA COVID-19 vaccine during pregnancy was moderately to highly effective for protection against omicron and delta infection and infection-related hospitalization – especially during the first 8 weeks of life.
Effectiveness is encouraging, but updates are needed
The effectiveness of maternal vaccination to prevent COVID-19 infection and related hospitalizations in infants is promising, especially since those younger than 6 months have no other source of vaccine protection against COVID-19 infection, wrote Dana Danino, MD, of Soroka University Medical Center, Israel, and Ilan Youngster, MD, of Shamir Medical Center, Israel, in an accompanying editorial also published in The BMJ.
They also noted that maternal vaccination during pregnancy is an established method of protecting infants from infections such as influenza and pertussis.
Data from previous studies show that most infants whose mothers were vaccinated against COVID-19 during pregnancy retained maternal antibodies at 6 months, “but evidence for protection against neonatal COVID-19 infection has been deficient,” they said.
The current study findings support the value of vaccination during pregnancy, and the findings were strengthened by the large study population, the editorialists wrote. However, whether the same effectiveness holds for other COVID-19 strains such as BQ.1, BQ.1.1, BF.7, XBB, and XBB.1 remains unknown, they said.
Other areas in need of exploration include the optimal timing of vaccination during pregnancy, the protective effects of a bivalent mRNA vaccine (vs. the primary monovalent vaccine in the current study), and the potential benefits of additional boosters, they added.
“Although Jorgenson and colleagues’ study reinforces the value of maternal vaccination against COVID-19 during pregnancy, more studies are needed to better inform vaccination recommendations in an evolving landscape of new SARS-CoV-2 strains and novel vaccines,” the editorialists concluded.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care; the study also received funding from the Canadian Immunization Research Network and the Public Health Agency of Canada. Dr. Jorgensen and the editorialists had no financial conflicts to disclose.
*This article was updated on 3/2/2023.
a new study shows.
Previous research has confirmed that COVID-19 neutralizing antibodies following maternal vaccination or maternal COVID-19 infection are present in umbilical cord blood, breast milk, and infant serum specimens, wrote Sarah C.J. Jorgensen, PharmD, MPH, of the University of Toronto, and colleagues in their article published in The BMJ.
In the study, the researchers identified maternal and newborn pairs using administrative databases from Canada. The study population included 8,809 infants aged younger than 6 months who were born between May 7, 2021, and March 31, 2022, and who underwent testing for COVID-19 between May 7, 2021, and September 5, 2022.
Maternal vaccination with the primary COVID-19 mRNA monovalent vaccine series was defined as two vaccine doses administered up to 14 days before delivery, with at least one of the doses after the conception date.
Maternal vaccination with the primary series plus one booster was defined as three doses administered up to 14 days before delivery, with at least one of these doses after the conception date.
The primary outcome was the presence of delta or omicron COVID-19 infection or hospital admission of the infants.
The study population included 99 COVID-19 cases with the delta variant (with 4,365 controls) and 1,501 cases with the omicron variant (with 4,847 controls).
Overall, the vaccine effectiveness of maternal doses was 95% against delta infection and 45% against omicron.
The effectiveness against hospital admission in cases of delta and omicron variants were 97% and 53%, respectively.
The effectiveness of three doses was 73% against omicron infant infection and 80% against omicron-related infant hospitalization. Data were not available for the effectiveness of three doses against the delta variant.
The effectiveness of two doses of vaccine against infant omicron infection was highest when mothers received the second dose during the third trimester of pregnancy, compared with during the first trimester or second trimester (53% vs. 47% and 53% vs. 37%, respectively).
Vaccine effectiveness with two doses against infant infection from omicron was highest in the first 8 weeks of life (57%), then decreased to 40% among infants after 16 weeks of age.
Although the study was not designed to assess the mechanism of action of the impact of maternal vaccination on infants, the current study results were consistent with other recent studies showing a reduction in infections and hospitalizations among infants whose mothers received COVID-19 vaccines during pregnancy, the researchers wrote in their discussion.
The findings were limited by several factors including the potential unmeasured confounders not available in databases, such as whether infants were breastfed, the researchers noted. Other limitations included a lack of data on home test results and the inability to assess the waning impact of the vaccine effectiveness against the delta variant because of the small number of delta cases, they said. However, the results suggest that the mRNA COVID-19 vaccine during pregnancy was moderately to highly effective for protection against omicron and delta infection and infection-related hospitalization – especially during the first 8 weeks of life.
Effectiveness is encouraging, but updates are needed
The effectiveness of maternal vaccination to prevent COVID-19 infection and related hospitalizations in infants is promising, especially since those younger than 6 months have no other source of vaccine protection against COVID-19 infection, wrote Dana Danino, MD, of Soroka University Medical Center, Israel, and Ilan Youngster, MD, of Shamir Medical Center, Israel, in an accompanying editorial also published in The BMJ.
They also noted that maternal vaccination during pregnancy is an established method of protecting infants from infections such as influenza and pertussis.
Data from previous studies show that most infants whose mothers were vaccinated against COVID-19 during pregnancy retained maternal antibodies at 6 months, “but evidence for protection against neonatal COVID-19 infection has been deficient,” they said.
The current study findings support the value of vaccination during pregnancy, and the findings were strengthened by the large study population, the editorialists wrote. However, whether the same effectiveness holds for other COVID-19 strains such as BQ.1, BQ.1.1, BF.7, XBB, and XBB.1 remains unknown, they said.
Other areas in need of exploration include the optimal timing of vaccination during pregnancy, the protective effects of a bivalent mRNA vaccine (vs. the primary monovalent vaccine in the current study), and the potential benefits of additional boosters, they added.
“Although Jorgenson and colleagues’ study reinforces the value of maternal vaccination against COVID-19 during pregnancy, more studies are needed to better inform vaccination recommendations in an evolving landscape of new SARS-CoV-2 strains and novel vaccines,” the editorialists concluded.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care; the study also received funding from the Canadian Immunization Research Network and the Public Health Agency of Canada. Dr. Jorgensen and the editorialists had no financial conflicts to disclose.
*This article was updated on 3/2/2023.
a new study shows.
Previous research has confirmed that COVID-19 neutralizing antibodies following maternal vaccination or maternal COVID-19 infection are present in umbilical cord blood, breast milk, and infant serum specimens, wrote Sarah C.J. Jorgensen, PharmD, MPH, of the University of Toronto, and colleagues in their article published in The BMJ.
In the study, the researchers identified maternal and newborn pairs using administrative databases from Canada. The study population included 8,809 infants aged younger than 6 months who were born between May 7, 2021, and March 31, 2022, and who underwent testing for COVID-19 between May 7, 2021, and September 5, 2022.
Maternal vaccination with the primary COVID-19 mRNA monovalent vaccine series was defined as two vaccine doses administered up to 14 days before delivery, with at least one of the doses after the conception date.
Maternal vaccination with the primary series plus one booster was defined as three doses administered up to 14 days before delivery, with at least one of these doses after the conception date.
The primary outcome was the presence of delta or omicron COVID-19 infection or hospital admission of the infants.
The study population included 99 COVID-19 cases with the delta variant (with 4,365 controls) and 1,501 cases with the omicron variant (with 4,847 controls).
Overall, the vaccine effectiveness of maternal doses was 95% against delta infection and 45% against omicron.
The effectiveness against hospital admission in cases of delta and omicron variants were 97% and 53%, respectively.
The effectiveness of three doses was 73% against omicron infant infection and 80% against omicron-related infant hospitalization. Data were not available for the effectiveness of three doses against the delta variant.
The effectiveness of two doses of vaccine against infant omicron infection was highest when mothers received the second dose during the third trimester of pregnancy, compared with during the first trimester or second trimester (53% vs. 47% and 53% vs. 37%, respectively).
Vaccine effectiveness with two doses against infant infection from omicron was highest in the first 8 weeks of life (57%), then decreased to 40% among infants after 16 weeks of age.
Although the study was not designed to assess the mechanism of action of the impact of maternal vaccination on infants, the current study results were consistent with other recent studies showing a reduction in infections and hospitalizations among infants whose mothers received COVID-19 vaccines during pregnancy, the researchers wrote in their discussion.
The findings were limited by several factors including the potential unmeasured confounders not available in databases, such as whether infants were breastfed, the researchers noted. Other limitations included a lack of data on home test results and the inability to assess the waning impact of the vaccine effectiveness against the delta variant because of the small number of delta cases, they said. However, the results suggest that the mRNA COVID-19 vaccine during pregnancy was moderately to highly effective for protection against omicron and delta infection and infection-related hospitalization – especially during the first 8 weeks of life.
Effectiveness is encouraging, but updates are needed
The effectiveness of maternal vaccination to prevent COVID-19 infection and related hospitalizations in infants is promising, especially since those younger than 6 months have no other source of vaccine protection against COVID-19 infection, wrote Dana Danino, MD, of Soroka University Medical Center, Israel, and Ilan Youngster, MD, of Shamir Medical Center, Israel, in an accompanying editorial also published in The BMJ.
They also noted that maternal vaccination during pregnancy is an established method of protecting infants from infections such as influenza and pertussis.
Data from previous studies show that most infants whose mothers were vaccinated against COVID-19 during pregnancy retained maternal antibodies at 6 months, “but evidence for protection against neonatal COVID-19 infection has been deficient,” they said.
The current study findings support the value of vaccination during pregnancy, and the findings were strengthened by the large study population, the editorialists wrote. However, whether the same effectiveness holds for other COVID-19 strains such as BQ.1, BQ.1.1, BF.7, XBB, and XBB.1 remains unknown, they said.
Other areas in need of exploration include the optimal timing of vaccination during pregnancy, the protective effects of a bivalent mRNA vaccine (vs. the primary monovalent vaccine in the current study), and the potential benefits of additional boosters, they added.
“Although Jorgenson and colleagues’ study reinforces the value of maternal vaccination against COVID-19 during pregnancy, more studies are needed to better inform vaccination recommendations in an evolving landscape of new SARS-CoV-2 strains and novel vaccines,” the editorialists concluded.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care; the study also received funding from the Canadian Immunization Research Network and the Public Health Agency of Canada. Dr. Jorgensen and the editorialists had no financial conflicts to disclose.
*This article was updated on 3/2/2023.
FROM THE BMJ
Now trending on social media: Bad birth control info
Add this to the list of social media’s potential health risks: unintended pregnancy.
That’s for women who take birth control advice from influencers, particularly on YouTube, where many talk about stopping hormonal contraception and may give incomplete or inaccurate sexual health information.
In an analysis of 50 YouTube videos, University of Delaware researchers found that nearly three-quarters of influencers talked about discontinuing birth control pills or other forms hormonal birth control. And 40% were using or had used a “natural family planning” method – when women track their cycle, sometimes using an app, to identify days they might get pregnant.
“We know from previous research that these nonhormonal options, such as fertility tracking apps, are not always as accurate as hormonal birth control,” said lead study author Emily Pfender, who reported the findings in Health Communication. “They rely on so many different factors, like body temperature and cervical fluid, that vary widely.”
In fact, this “natural” approach only works when women meticulously follow guidelines like measuring basal body temperature and tracking cervical fluid daily. But many influencers left that part out. Using fertility-tracking methods without the right education and tools could raise the risk of unplanned pregnancy, as failure rates using these methods vary from 2% to 23%, according to the CDC.
Even more alarming: Of the influencers who stopped hormonal birth control, only one-third mentioned replacing it with something else, Ms. Pfender said.
“The message that some of these videos are sending is that discontinuing [hormonal birth control] is good for if you want to improve your mental health and be more natural, but it’s not important to start another form of birth control,” she said. “This places those women at an increased risk of unplanned pregnancy, and possibly sexually transmitted diseases.”
Rise of the health influencer
Taking health advice from influencers is nothing new and appears to be getting more popular.
“People have been sharing health information for decades, even before the internet, but now it is much more prevalent and easier,” said Erin Willis, PhD, an associate professor at the University of Colorado, Boulder, who studies digital media and health communication.
Peer-to-peer health information is very influential, Dr. Willis said. It makes people feel understood, especially if they have the same health condition or share similar experiences or emotions. “The social support is there,” she said. “It is almost like crowdsourcing.”
In her study, Ms. Pfender and another researcher watched 50 YouTube videos posted between December 2019 and December 2021 by influencers with between 20,000 and 2.2 million followers. The top reasons influencers gave for discontinuing birth control included the desire to be more natural and to improve mental health.
Although hormonal birth control, namely the pill, has been used for decades and is considered safe, it has been linked to side effects like depression. And people sharing their experiences with hormonal birth control online may create controversy over whether it’s safe to use.
But Ms. Pfender found that influencers didn’t always share accurate or complete information. For example, some of the influencers talked about using the cycle tracking app Daysy, touting it as highly accurate, but none mentioned that the study backing up how well it worked was retracted in 2019 due to flaws in its research methods.
Not all health influencers give bad information, Dr. Willis said. Many go through ethics and advocacy training and understand the sensitive position and influence they have. Still, people have different levels of “health literacy” – some may understand health information better than others. It’s crucial to analyze the info and sort the good from the bad.
Look for information that is not linked to a particular product, the National Institutes of Health recommends. And cross-check it against reliable websites, such as those ending in “.gov” or “.org.”
A version of this article first appeared on WebMD.com.
Add this to the list of social media’s potential health risks: unintended pregnancy.
That’s for women who take birth control advice from influencers, particularly on YouTube, where many talk about stopping hormonal contraception and may give incomplete or inaccurate sexual health information.
In an analysis of 50 YouTube videos, University of Delaware researchers found that nearly three-quarters of influencers talked about discontinuing birth control pills or other forms hormonal birth control. And 40% were using or had used a “natural family planning” method – when women track their cycle, sometimes using an app, to identify days they might get pregnant.
“We know from previous research that these nonhormonal options, such as fertility tracking apps, are not always as accurate as hormonal birth control,” said lead study author Emily Pfender, who reported the findings in Health Communication. “They rely on so many different factors, like body temperature and cervical fluid, that vary widely.”
In fact, this “natural” approach only works when women meticulously follow guidelines like measuring basal body temperature and tracking cervical fluid daily. But many influencers left that part out. Using fertility-tracking methods without the right education and tools could raise the risk of unplanned pregnancy, as failure rates using these methods vary from 2% to 23%, according to the CDC.
Even more alarming: Of the influencers who stopped hormonal birth control, only one-third mentioned replacing it with something else, Ms. Pfender said.
“The message that some of these videos are sending is that discontinuing [hormonal birth control] is good for if you want to improve your mental health and be more natural, but it’s not important to start another form of birth control,” she said. “This places those women at an increased risk of unplanned pregnancy, and possibly sexually transmitted diseases.”
Rise of the health influencer
Taking health advice from influencers is nothing new and appears to be getting more popular.
“People have been sharing health information for decades, even before the internet, but now it is much more prevalent and easier,” said Erin Willis, PhD, an associate professor at the University of Colorado, Boulder, who studies digital media and health communication.
Peer-to-peer health information is very influential, Dr. Willis said. It makes people feel understood, especially if they have the same health condition or share similar experiences or emotions. “The social support is there,” she said. “It is almost like crowdsourcing.”
In her study, Ms. Pfender and another researcher watched 50 YouTube videos posted between December 2019 and December 2021 by influencers with between 20,000 and 2.2 million followers. The top reasons influencers gave for discontinuing birth control included the desire to be more natural and to improve mental health.
Although hormonal birth control, namely the pill, has been used for decades and is considered safe, it has been linked to side effects like depression. And people sharing their experiences with hormonal birth control online may create controversy over whether it’s safe to use.
But Ms. Pfender found that influencers didn’t always share accurate or complete information. For example, some of the influencers talked about using the cycle tracking app Daysy, touting it as highly accurate, but none mentioned that the study backing up how well it worked was retracted in 2019 due to flaws in its research methods.
Not all health influencers give bad information, Dr. Willis said. Many go through ethics and advocacy training and understand the sensitive position and influence they have. Still, people have different levels of “health literacy” – some may understand health information better than others. It’s crucial to analyze the info and sort the good from the bad.
Look for information that is not linked to a particular product, the National Institutes of Health recommends. And cross-check it against reliable websites, such as those ending in “.gov” or “.org.”
A version of this article first appeared on WebMD.com.
Add this to the list of social media’s potential health risks: unintended pregnancy.
That’s for women who take birth control advice from influencers, particularly on YouTube, where many talk about stopping hormonal contraception and may give incomplete or inaccurate sexual health information.
In an analysis of 50 YouTube videos, University of Delaware researchers found that nearly three-quarters of influencers talked about discontinuing birth control pills or other forms hormonal birth control. And 40% were using or had used a “natural family planning” method – when women track their cycle, sometimes using an app, to identify days they might get pregnant.
“We know from previous research that these nonhormonal options, such as fertility tracking apps, are not always as accurate as hormonal birth control,” said lead study author Emily Pfender, who reported the findings in Health Communication. “They rely on so many different factors, like body temperature and cervical fluid, that vary widely.”
In fact, this “natural” approach only works when women meticulously follow guidelines like measuring basal body temperature and tracking cervical fluid daily. But many influencers left that part out. Using fertility-tracking methods without the right education and tools could raise the risk of unplanned pregnancy, as failure rates using these methods vary from 2% to 23%, according to the CDC.
Even more alarming: Of the influencers who stopped hormonal birth control, only one-third mentioned replacing it with something else, Ms. Pfender said.
“The message that some of these videos are sending is that discontinuing [hormonal birth control] is good for if you want to improve your mental health and be more natural, but it’s not important to start another form of birth control,” she said. “This places those women at an increased risk of unplanned pregnancy, and possibly sexually transmitted diseases.”
Rise of the health influencer
Taking health advice from influencers is nothing new and appears to be getting more popular.
“People have been sharing health information for decades, even before the internet, but now it is much more prevalent and easier,” said Erin Willis, PhD, an associate professor at the University of Colorado, Boulder, who studies digital media and health communication.
Peer-to-peer health information is very influential, Dr. Willis said. It makes people feel understood, especially if they have the same health condition or share similar experiences or emotions. “The social support is there,” she said. “It is almost like crowdsourcing.”
In her study, Ms. Pfender and another researcher watched 50 YouTube videos posted between December 2019 and December 2021 by influencers with between 20,000 and 2.2 million followers. The top reasons influencers gave for discontinuing birth control included the desire to be more natural and to improve mental health.
Although hormonal birth control, namely the pill, has been used for decades and is considered safe, it has been linked to side effects like depression. And people sharing their experiences with hormonal birth control online may create controversy over whether it’s safe to use.
But Ms. Pfender found that influencers didn’t always share accurate or complete information. For example, some of the influencers talked about using the cycle tracking app Daysy, touting it as highly accurate, but none mentioned that the study backing up how well it worked was retracted in 2019 due to flaws in its research methods.
Not all health influencers give bad information, Dr. Willis said. Many go through ethics and advocacy training and understand the sensitive position and influence they have. Still, people have different levels of “health literacy” – some may understand health information better than others. It’s crucial to analyze the info and sort the good from the bad.
Look for information that is not linked to a particular product, the National Institutes of Health recommends. And cross-check it against reliable websites, such as those ending in “.gov” or “.org.”
A version of this article first appeared on WebMD.com.
FROM HEALTH COMMUNICATION
Little evidence to support lasers for ‘vaginal rejuvenation’
Laser devices licensed in Canada to treat genitourinary syndrome of menopause (GSM) are often marketed for vaginal rejuvenation with claims that they will tighten the vagina and improve sexual function, despite lack of evidence, a new commentary reveals.
Vaginal lasers heat the vaginal epithelium and cause thermal necrosis. This intervention induces collagen remodeling and synthesis, neovascularization, and elastin formation and may result in improved vaginal elasticity and restoration of premenopausal epithelial function, according to coauthors Blayne Welk, MD, MSc, an associate professor of urologic surgery at Western University, London, Ont., and Erin Kelly, MD, a lecturer in obstetrics and gynecology at the University of Alberta, Edmonton.
Their patients’ questions and experiences with the laser devices prompted the commentary, they told this news organization.
“A large part of my practice involves addressing GSM and urinary incontinence,” said Dr. Kelly. “Many women present to the clinic having heard of vaginal laser procedures, having had vaginal laser procedures, or having been told they need vaginal laser procedures. My impression has been that these procedures are being marketed to women … without rigorous study.”
“Many women are reluctant to have mesh slings for stress incontinence due to some of the potential risks,” and they are looking for less invasive options, said Dr. Welk. Over the past few years, he has had increasing questions from patients about the use of lasers to improve this condition.
The commentary was published online in the Canadian Medical Association Journal.
Transparency needed
The first vaginal energy device was licensed by Health Canada in 2015 to treat GSM. That meant the device was deemed to have met basic safety, effectiveness, and quality criteria. But no controlled studies are required for regulatory approval of such devices, and after licensing, some providers rebranded the device indication from GSM to vaginal rejuvenation, said Dr. Kelly and Dr. Welk.
Vaginal laser therapies are offered throughout Canada, with at least one provider of vaginal rejuvenation procedures in the 10 most populous cities. Under the current system, the number of patients who pay for these procedures and the amount that they pay cannot be tracked. Nor can the number of vaginal laser systems active in Canada be tracked. Patients can refer themselves for the service, and providers’ publicly quoted costs (on websites, for example) are thousands of dollars for treatment.
The rebranding for vaginal rejuvenation “represents a difference between the licensing of a medical device by Health Canada and the way that these devices are used and marketed,” according to the commentary. “A procedure with limited high-quality evidence supporting its efficacy and a potential financial conflict of interest for providers may not be serving the best interests of people in Canada, even if the risk of adverse events is low.”
Updates to Canada’s medical devices action plan, including mandatory reporting of serious incidents and the ability to compel manufacturers to provide information on safety and effectiveness, “represent important progress,” according to Dr. Kelly and Dr. Welk. However, problems persist, including lack of a requirement for peer-reviewed, controlled studies.
Furthermore, women who undergo laser treatment for GSM, urinary incontinence, or vaginal rejuvenation may not receive a proper medical evaluation and standard treatments, the authors noted.
“I would like to see more transparency and public-facing information available on approved medical devices,” said Dr. Welk. “Health Canada has an online database of approved devices, but no information around the evidence submitted during the approval process is available, nor are the indications for the various devices.”
In addition, he said, many devices in the registry are listed by a serial number rather than the name that would be familiar to the public, “making it hard to match up information.”
Dr. Kelly added the “encouraging” news that the Canadian Society for Pelvic Medicine is working with Health Canada to “improve knowledge translation when it comes to transparency regarding medical devices.”
Medicine before marketing
“The commentary provides an accurate and evidence-based assessment of the use of vaginal laser treatments,” Jason Abbott, B Med (Hons), PhD, professor of gynecology at the University of New South Wales, Sydney, told this news organization. “The marketing of this device is a case of putting the cart before the horse. It is essential that strong, scientific, and reproducible studies be available on efficacy and safety before there is a direct-to-consumer marketing approach.”
Clinicians should advise patients when the treatment effect is likely to be minimal or risky, especially when there is a financial incentive to the clinician, he said. “Governments, regulators, and medical societies have a duty of care to the public to make sure that the medicine comes before the marketing. Otherwise, we are no better than snake oil sellers.
“Given the size of studies to date, the improvement in symptoms following treatment may be less than a few percent,” he noted. “That may be acceptable to some women. We don’t know.”
Dr. Abbott’s team is conducting research to define what women would want as a minimal level of improvement, the maximum cost, and the maximum risk from the laser procedure.
“In cancer … the benefit of a new treatment may only be a few percent for survival,” he said. “That may be completely acceptable for some or even many patients. What we cannot do, however, is extrapolate those same expectations to a treatment for a benign condition where quality of life is compromised.”
Echoing Dr. Kelly and Dr. Welk, Dr. Abbott said, “It is important that there be transparency in the clinical communication. Patients should be told that the best scientific studies that are judged based on their quality show there is no benefit to laser treatment for GSM or urinary incontinence.”
Although the medical risks may be low, he added, “financial risk also needs to be discussed. Patients should be encouraged to participate in clinical trials where there is no cost to them to gain the information first, before wholesale uptake of the treatment. … Should patients still wish to undergo the procedure once the risks and an honest account of the evidence is given to them, that of course is their choice.” Dr. Kelly, Dr. Welk, and Dr. Abbott had no commercial funding or relevant financial relationships to report.
A version of this article first appeared on Medscape.com.
Laser devices licensed in Canada to treat genitourinary syndrome of menopause (GSM) are often marketed for vaginal rejuvenation with claims that they will tighten the vagina and improve sexual function, despite lack of evidence, a new commentary reveals.
Vaginal lasers heat the vaginal epithelium and cause thermal necrosis. This intervention induces collagen remodeling and synthesis, neovascularization, and elastin formation and may result in improved vaginal elasticity and restoration of premenopausal epithelial function, according to coauthors Blayne Welk, MD, MSc, an associate professor of urologic surgery at Western University, London, Ont., and Erin Kelly, MD, a lecturer in obstetrics and gynecology at the University of Alberta, Edmonton.
Their patients’ questions and experiences with the laser devices prompted the commentary, they told this news organization.
“A large part of my practice involves addressing GSM and urinary incontinence,” said Dr. Kelly. “Many women present to the clinic having heard of vaginal laser procedures, having had vaginal laser procedures, or having been told they need vaginal laser procedures. My impression has been that these procedures are being marketed to women … without rigorous study.”
“Many women are reluctant to have mesh slings for stress incontinence due to some of the potential risks,” and they are looking for less invasive options, said Dr. Welk. Over the past few years, he has had increasing questions from patients about the use of lasers to improve this condition.
The commentary was published online in the Canadian Medical Association Journal.
Transparency needed
The first vaginal energy device was licensed by Health Canada in 2015 to treat GSM. That meant the device was deemed to have met basic safety, effectiveness, and quality criteria. But no controlled studies are required for regulatory approval of such devices, and after licensing, some providers rebranded the device indication from GSM to vaginal rejuvenation, said Dr. Kelly and Dr. Welk.
Vaginal laser therapies are offered throughout Canada, with at least one provider of vaginal rejuvenation procedures in the 10 most populous cities. Under the current system, the number of patients who pay for these procedures and the amount that they pay cannot be tracked. Nor can the number of vaginal laser systems active in Canada be tracked. Patients can refer themselves for the service, and providers’ publicly quoted costs (on websites, for example) are thousands of dollars for treatment.
The rebranding for vaginal rejuvenation “represents a difference between the licensing of a medical device by Health Canada and the way that these devices are used and marketed,” according to the commentary. “A procedure with limited high-quality evidence supporting its efficacy and a potential financial conflict of interest for providers may not be serving the best interests of people in Canada, even if the risk of adverse events is low.”
Updates to Canada’s medical devices action plan, including mandatory reporting of serious incidents and the ability to compel manufacturers to provide information on safety and effectiveness, “represent important progress,” according to Dr. Kelly and Dr. Welk. However, problems persist, including lack of a requirement for peer-reviewed, controlled studies.
Furthermore, women who undergo laser treatment for GSM, urinary incontinence, or vaginal rejuvenation may not receive a proper medical evaluation and standard treatments, the authors noted.
“I would like to see more transparency and public-facing information available on approved medical devices,” said Dr. Welk. “Health Canada has an online database of approved devices, but no information around the evidence submitted during the approval process is available, nor are the indications for the various devices.”
In addition, he said, many devices in the registry are listed by a serial number rather than the name that would be familiar to the public, “making it hard to match up information.”
Dr. Kelly added the “encouraging” news that the Canadian Society for Pelvic Medicine is working with Health Canada to “improve knowledge translation when it comes to transparency regarding medical devices.”
Medicine before marketing
“The commentary provides an accurate and evidence-based assessment of the use of vaginal laser treatments,” Jason Abbott, B Med (Hons), PhD, professor of gynecology at the University of New South Wales, Sydney, told this news organization. “The marketing of this device is a case of putting the cart before the horse. It is essential that strong, scientific, and reproducible studies be available on efficacy and safety before there is a direct-to-consumer marketing approach.”
Clinicians should advise patients when the treatment effect is likely to be minimal or risky, especially when there is a financial incentive to the clinician, he said. “Governments, regulators, and medical societies have a duty of care to the public to make sure that the medicine comes before the marketing. Otherwise, we are no better than snake oil sellers.
“Given the size of studies to date, the improvement in symptoms following treatment may be less than a few percent,” he noted. “That may be acceptable to some women. We don’t know.”
Dr. Abbott’s team is conducting research to define what women would want as a minimal level of improvement, the maximum cost, and the maximum risk from the laser procedure.
“In cancer … the benefit of a new treatment may only be a few percent for survival,” he said. “That may be completely acceptable for some or even many patients. What we cannot do, however, is extrapolate those same expectations to a treatment for a benign condition where quality of life is compromised.”
Echoing Dr. Kelly and Dr. Welk, Dr. Abbott said, “It is important that there be transparency in the clinical communication. Patients should be told that the best scientific studies that are judged based on their quality show there is no benefit to laser treatment for GSM or urinary incontinence.”
Although the medical risks may be low, he added, “financial risk also needs to be discussed. Patients should be encouraged to participate in clinical trials where there is no cost to them to gain the information first, before wholesale uptake of the treatment. … Should patients still wish to undergo the procedure once the risks and an honest account of the evidence is given to them, that of course is their choice.” Dr. Kelly, Dr. Welk, and Dr. Abbott had no commercial funding or relevant financial relationships to report.
A version of this article first appeared on Medscape.com.
Laser devices licensed in Canada to treat genitourinary syndrome of menopause (GSM) are often marketed for vaginal rejuvenation with claims that they will tighten the vagina and improve sexual function, despite lack of evidence, a new commentary reveals.
Vaginal lasers heat the vaginal epithelium and cause thermal necrosis. This intervention induces collagen remodeling and synthesis, neovascularization, and elastin formation and may result in improved vaginal elasticity and restoration of premenopausal epithelial function, according to coauthors Blayne Welk, MD, MSc, an associate professor of urologic surgery at Western University, London, Ont., and Erin Kelly, MD, a lecturer in obstetrics and gynecology at the University of Alberta, Edmonton.
Their patients’ questions and experiences with the laser devices prompted the commentary, they told this news organization.
“A large part of my practice involves addressing GSM and urinary incontinence,” said Dr. Kelly. “Many women present to the clinic having heard of vaginal laser procedures, having had vaginal laser procedures, or having been told they need vaginal laser procedures. My impression has been that these procedures are being marketed to women … without rigorous study.”
“Many women are reluctant to have mesh slings for stress incontinence due to some of the potential risks,” and they are looking for less invasive options, said Dr. Welk. Over the past few years, he has had increasing questions from patients about the use of lasers to improve this condition.
The commentary was published online in the Canadian Medical Association Journal.
Transparency needed
The first vaginal energy device was licensed by Health Canada in 2015 to treat GSM. That meant the device was deemed to have met basic safety, effectiveness, and quality criteria. But no controlled studies are required for regulatory approval of such devices, and after licensing, some providers rebranded the device indication from GSM to vaginal rejuvenation, said Dr. Kelly and Dr. Welk.
Vaginal laser therapies are offered throughout Canada, with at least one provider of vaginal rejuvenation procedures in the 10 most populous cities. Under the current system, the number of patients who pay for these procedures and the amount that they pay cannot be tracked. Nor can the number of vaginal laser systems active in Canada be tracked. Patients can refer themselves for the service, and providers’ publicly quoted costs (on websites, for example) are thousands of dollars for treatment.
The rebranding for vaginal rejuvenation “represents a difference between the licensing of a medical device by Health Canada and the way that these devices are used and marketed,” according to the commentary. “A procedure with limited high-quality evidence supporting its efficacy and a potential financial conflict of interest for providers may not be serving the best interests of people in Canada, even if the risk of adverse events is low.”
Updates to Canada’s medical devices action plan, including mandatory reporting of serious incidents and the ability to compel manufacturers to provide information on safety and effectiveness, “represent important progress,” according to Dr. Kelly and Dr. Welk. However, problems persist, including lack of a requirement for peer-reviewed, controlled studies.
Furthermore, women who undergo laser treatment for GSM, urinary incontinence, or vaginal rejuvenation may not receive a proper medical evaluation and standard treatments, the authors noted.
“I would like to see more transparency and public-facing information available on approved medical devices,” said Dr. Welk. “Health Canada has an online database of approved devices, but no information around the evidence submitted during the approval process is available, nor are the indications for the various devices.”
In addition, he said, many devices in the registry are listed by a serial number rather than the name that would be familiar to the public, “making it hard to match up information.”
Dr. Kelly added the “encouraging” news that the Canadian Society for Pelvic Medicine is working with Health Canada to “improve knowledge translation when it comes to transparency regarding medical devices.”
Medicine before marketing
“The commentary provides an accurate and evidence-based assessment of the use of vaginal laser treatments,” Jason Abbott, B Med (Hons), PhD, professor of gynecology at the University of New South Wales, Sydney, told this news organization. “The marketing of this device is a case of putting the cart before the horse. It is essential that strong, scientific, and reproducible studies be available on efficacy and safety before there is a direct-to-consumer marketing approach.”
Clinicians should advise patients when the treatment effect is likely to be minimal or risky, especially when there is a financial incentive to the clinician, he said. “Governments, regulators, and medical societies have a duty of care to the public to make sure that the medicine comes before the marketing. Otherwise, we are no better than snake oil sellers.
“Given the size of studies to date, the improvement in symptoms following treatment may be less than a few percent,” he noted. “That may be acceptable to some women. We don’t know.”
Dr. Abbott’s team is conducting research to define what women would want as a minimal level of improvement, the maximum cost, and the maximum risk from the laser procedure.
“In cancer … the benefit of a new treatment may only be a few percent for survival,” he said. “That may be completely acceptable for some or even many patients. What we cannot do, however, is extrapolate those same expectations to a treatment for a benign condition where quality of life is compromised.”
Echoing Dr. Kelly and Dr. Welk, Dr. Abbott said, “It is important that there be transparency in the clinical communication. Patients should be told that the best scientific studies that are judged based on their quality show there is no benefit to laser treatment for GSM or urinary incontinence.”
Although the medical risks may be low, he added, “financial risk also needs to be discussed. Patients should be encouraged to participate in clinical trials where there is no cost to them to gain the information first, before wholesale uptake of the treatment. … Should patients still wish to undergo the procedure once the risks and an honest account of the evidence is given to them, that of course is their choice.” Dr. Kelly, Dr. Welk, and Dr. Abbott had no commercial funding or relevant financial relationships to report.
A version of this article first appeared on Medscape.com.
FDA OKs sacituzumab govitecan for HR+ metastatic breast cancer
for patients with unresectable, locally advanced or metastatic hormone receptor (HR)–positive, HER2-negative breast cancer after endocrine-based therapy and at least two additional systemic therapies for metastatic disease.
Label expansion for the Trop-2–directed antibody-drug conjugate was based on the TROPICS-02 trial, which randomized 543 adults 1:1 to either sacituzumab govitecan 10 mg/kg IV on days 1 and 8 of a 21-day cycle or single agent chemotherapy, most often eribulin but also vinorelbine, gemcitabine, or capecitabine.
Median progression free survival was 5.5 months with sacituzumab govitecan versus 4 months with single agent chemotherapy (hazard ratio, 0.66; P = .0003). Median overall survival was 14.4 months in the sacituzumab govitecan group versus 11.2 months with chemotherapy (HR, 0.79), according to an FDA press release announcing the approval.
In a Gilead press release, Hope Rugo, MD, a breast cancer specialist at the University of California, San Francisco, and principal investigator for TROPICS-02, said the approval “is significant for the breast cancer community. We have had limited options to offer patients after endocrine-based therapy and chemotherapy, and to see a clinically meaningful survival benefit of more than 3 months with a quality-of-life benefit for these women is exceptional.”
The most common adverse events associated with sacituzumab govitecan in the trial, occurring in a quarter or more of participants, were decreased leukocyte count, decreased neutrophil count, decreased hemoglobin, decreased lymphocyte count, diarrhea, fatigue, nausea, alopecia, glucose elevation, constipation, and decreased albumin.
Labeling for the agent carries a boxedwarning of severe or life-threatening neutropenia and severe diarrhea.
The recommended dose is the trial dose: 10 mg/kg IV on days 1 and 8 of 21-day cycles until disease progression or unacceptable toxicity.
Sacituzumab govitecan was previously approved for unresectable, locally advanced or metastatic triple-negative breast cancer after two or more prior systemic therapies and locally advanced or metastatic urothelial cancer after platinum-based chemotherapy and either a PD-1 or PD-L1 inhibitor.
A version of this article first appeared on Medscape.com.
for patients with unresectable, locally advanced or metastatic hormone receptor (HR)–positive, HER2-negative breast cancer after endocrine-based therapy and at least two additional systemic therapies for metastatic disease.
Label expansion for the Trop-2–directed antibody-drug conjugate was based on the TROPICS-02 trial, which randomized 543 adults 1:1 to either sacituzumab govitecan 10 mg/kg IV on days 1 and 8 of a 21-day cycle or single agent chemotherapy, most often eribulin but also vinorelbine, gemcitabine, or capecitabine.
Median progression free survival was 5.5 months with sacituzumab govitecan versus 4 months with single agent chemotherapy (hazard ratio, 0.66; P = .0003). Median overall survival was 14.4 months in the sacituzumab govitecan group versus 11.2 months with chemotherapy (HR, 0.79), according to an FDA press release announcing the approval.
In a Gilead press release, Hope Rugo, MD, a breast cancer specialist at the University of California, San Francisco, and principal investigator for TROPICS-02, said the approval “is significant for the breast cancer community. We have had limited options to offer patients after endocrine-based therapy and chemotherapy, and to see a clinically meaningful survival benefit of more than 3 months with a quality-of-life benefit for these women is exceptional.”
The most common adverse events associated with sacituzumab govitecan in the trial, occurring in a quarter or more of participants, were decreased leukocyte count, decreased neutrophil count, decreased hemoglobin, decreased lymphocyte count, diarrhea, fatigue, nausea, alopecia, glucose elevation, constipation, and decreased albumin.
Labeling for the agent carries a boxedwarning of severe or life-threatening neutropenia and severe diarrhea.
The recommended dose is the trial dose: 10 mg/kg IV on days 1 and 8 of 21-day cycles until disease progression or unacceptable toxicity.
Sacituzumab govitecan was previously approved for unresectable, locally advanced or metastatic triple-negative breast cancer after two or more prior systemic therapies and locally advanced or metastatic urothelial cancer after platinum-based chemotherapy and either a PD-1 or PD-L1 inhibitor.
A version of this article first appeared on Medscape.com.
for patients with unresectable, locally advanced or metastatic hormone receptor (HR)–positive, HER2-negative breast cancer after endocrine-based therapy and at least two additional systemic therapies for metastatic disease.
Label expansion for the Trop-2–directed antibody-drug conjugate was based on the TROPICS-02 trial, which randomized 543 adults 1:1 to either sacituzumab govitecan 10 mg/kg IV on days 1 and 8 of a 21-day cycle or single agent chemotherapy, most often eribulin but also vinorelbine, gemcitabine, or capecitabine.
Median progression free survival was 5.5 months with sacituzumab govitecan versus 4 months with single agent chemotherapy (hazard ratio, 0.66; P = .0003). Median overall survival was 14.4 months in the sacituzumab govitecan group versus 11.2 months with chemotherapy (HR, 0.79), according to an FDA press release announcing the approval.
In a Gilead press release, Hope Rugo, MD, a breast cancer specialist at the University of California, San Francisco, and principal investigator for TROPICS-02, said the approval “is significant for the breast cancer community. We have had limited options to offer patients after endocrine-based therapy and chemotherapy, and to see a clinically meaningful survival benefit of more than 3 months with a quality-of-life benefit for these women is exceptional.”
The most common adverse events associated with sacituzumab govitecan in the trial, occurring in a quarter or more of participants, were decreased leukocyte count, decreased neutrophil count, decreased hemoglobin, decreased lymphocyte count, diarrhea, fatigue, nausea, alopecia, glucose elevation, constipation, and decreased albumin.
Labeling for the agent carries a boxedwarning of severe or life-threatening neutropenia and severe diarrhea.
The recommended dose is the trial dose: 10 mg/kg IV on days 1 and 8 of 21-day cycles until disease progression or unacceptable toxicity.
Sacituzumab govitecan was previously approved for unresectable, locally advanced or metastatic triple-negative breast cancer after two or more prior systemic therapies and locally advanced or metastatic urothelial cancer after platinum-based chemotherapy and either a PD-1 or PD-L1 inhibitor.
A version of this article first appeared on Medscape.com.
Race and geography tied to breast cancer care delays
suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.
Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.
“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.
Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.
However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.
In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.
The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.
Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).
Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).
On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).
The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.
Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.
“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.
Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.
In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.
This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.
“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”
Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.
“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”
The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.
Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.
“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.
Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.
However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.
In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.
The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.
Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).
Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).
On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).
The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.
Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.
“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.
Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.
In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.
This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.
“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”
Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.
“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”
The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.
Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.
“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.
Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.
However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.
In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.
The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.
Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).
Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).
On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).
The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.
Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.
“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.
Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.
In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.
This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.
“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”
Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.
“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”
The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CANCER
Commenting on weight’s not rude. It’s dangerous.
It was the start of the fall semester of my sophomore year of college.
At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.
In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.
The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.
Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.
My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.
Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.
In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.
Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
Common weight bias assumptions
“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.
Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.
“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.
It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
Ways to reduce clinical weight bias
How do you reduce clinical weight bias?
Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.
Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.
Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.
Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.
Addressing weight bias needs to extend beyond the individual level.
Systemically, health care needs to address the following:
Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”
Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.
Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.
We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”
S*: Initial has been changed to protect privacy.
Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.
It was the start of the fall semester of my sophomore year of college.
At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.
In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.
The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.
Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.
My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.
Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.
In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.
Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
Common weight bias assumptions
“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.
Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.
“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.
It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
Ways to reduce clinical weight bias
How do you reduce clinical weight bias?
Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.
Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.
Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.
Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.
Addressing weight bias needs to extend beyond the individual level.
Systemically, health care needs to address the following:
Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”
Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.
Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.
We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”
S*: Initial has been changed to protect privacy.
Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.
It was the start of the fall semester of my sophomore year of college.
At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.
In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.
The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.
Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.
My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.
Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.
In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.
Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
Common weight bias assumptions
“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.
Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.
“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.
It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
Ways to reduce clinical weight bias
How do you reduce clinical weight bias?
Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.
Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.
Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.
Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.
Addressing weight bias needs to extend beyond the individual level.
Systemically, health care needs to address the following:
Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”
Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.
Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.
We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”
S*: Initial has been changed to protect privacy.
Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.
Bacterial vaginosis linked with persistent HPV infections
Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix.
At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
Striking a balance
Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.
Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.
Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
Vaginosis and HPV
When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.
These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.
What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix.
At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
Striking a balance
Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.
Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.
Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
Vaginosis and HPV
When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.
These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.
What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix.
At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
Striking a balance
Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.
Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.
Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
Vaginosis and HPV
When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.
These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.
What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Pandemic pregnancy-linked deaths up 35% from 2019
Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.
The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.
The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.
The findings were published online in JAMA Open Network.
Drug-related deaths up 55.3%
During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.
“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.
The findings align with deaths in the general population in that time frame, they added.
Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.
According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”
Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
Prevention opportunities missed
“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.
Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.
They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.
Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.
Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.
Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.
“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.
The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”
Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.
*This story was updated on 2/1.
Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.
The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.
The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.
The findings were published online in JAMA Open Network.
Drug-related deaths up 55.3%
During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.
“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.
The findings align with deaths in the general population in that time frame, they added.
Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.
According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”
Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
Prevention opportunities missed
“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.
Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.
They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.
Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.
Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.
Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.
“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.
The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”
Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.
*This story was updated on 2/1.
Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.
The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.
The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.
The findings were published online in JAMA Open Network.
Drug-related deaths up 55.3%
During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.
“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.
The findings align with deaths in the general population in that time frame, they added.
Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.
According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”
Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
Prevention opportunities missed
“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.
Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.
They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.
Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.
Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.
Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.
“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.
The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”
Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.
*This story was updated on 2/1.
FROM JAMA NETWORK OPEN
Difficulty fitting family into career: Female oncologists
In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.
The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.
One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.
The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),
These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.
The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston.
In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.
“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.
“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
Survey details
The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.
Most respondents (84.4%) were married, and 71% were currently working full-time.
About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.
A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.
Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).
Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.
The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.
When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.
However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”
“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.
The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.
The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.
Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.
The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.
One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.
The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),
These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.
The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston.
In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.
“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.
“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
Survey details
The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.
Most respondents (84.4%) were married, and 71% were currently working full-time.
About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.
A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.
Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).
Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.
The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.
When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.
However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”
“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.
The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.
The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.
Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.
The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.
One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.
The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),
These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.
The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston.
In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.
“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.
“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
Survey details
The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.
Most respondents (84.4%) were married, and 71% were currently working full-time.
About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.
A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.
Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).
Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.
The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.
When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.
However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”
“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.
The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.
The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.
Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Female doctors have higher infertility rates and riskier pregnancies: What can be done?
In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.
“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.
Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.
“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”
Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.
Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.
Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
The barriers to starting a family
Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”
In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”
“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”
It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.
When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.
There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”
The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
The physical consequences
Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.
Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.
Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.
Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”
Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.”
Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.
“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
Hope for the future
Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.
Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.
In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”
Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.
A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.
Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.
Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”
Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.
“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”
A version of this article first appeared on Medscape.com.
In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.
“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.
Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.
“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”
Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.
Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.
Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
The barriers to starting a family
Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”
In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”
“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”
It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.
When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.
There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”
The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
The physical consequences
Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.
Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.
Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.
Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”
Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.”
Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.
“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
Hope for the future
Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.
Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.
In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”
Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.
A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.
Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.
Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”
Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.
“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”
A version of this article first appeared on Medscape.com.
In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.
“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.
Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.
“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”
Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.
Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.
Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
The barriers to starting a family
Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”
In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”
“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”
It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.
When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.
There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”
The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
The physical consequences
Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.
Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.
Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.
Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”
Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.”
Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.
“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
Hope for the future
Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.
Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.
In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”
Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.
A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.
Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.
Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”
Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.
“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”
A version of this article first appeared on Medscape.com.