faculty moderator ronald l. levine, md · number of factors. this course provides an overview of...

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Endoscopic Management of the

Adnexal Mass, from Small to Large,

from Benign to Malignant

AAGL acknowledges that it has received support in part by educational grants and equipment (in-kind) from the following companies:

FACULTY

Robert W. Holloway, MD & Yukio Sonoda, MD

MODERATOR

Ronald L. Levine, MD

Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Endoscopic Management of the Adnexal Mass from Small to Large, Benign to Malignant R.W. Holloway, Y. Sonoda ............................................................................................................................ 4 Cultural and Linguistics Competency ......................................................................................................... 13

Surgical Tutorial 4: Endoscopic Management of the Adnexal Mass, from Small to Large,

from Benign to Malignant

Faculty: Robert W. Holloway and Yukio Sonoda Moderator: Ronald L. Levine

Course Description The adnexal mass is a common finding that is encountered in women of all ages by the practicing gynecologist. Preoperative work up and the decision of when to surgically intervene are based on a number of factors. This course provides an overview of management of the adnexal mass from initial presentation to intraoperative surgical management. Surgical videos will be used to help illustrate surgical techniques.

Learning Objectives At the conclusion of this course, the participant will be able to: 1) Explain which patient should undergo surgical assessment of an adnexal mass; Explain which patient should be referred directly to a gynecologic oncologist; 2) identify the key components to intraoperative management of an ovarian malignancy; and 3) identify which patients should and shouldn’t undergo endoscopic management.

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Robert W. Holloway Consultant: Intuitve Surgical Yukio Sonoda* Ronald L. Levine*

2

Asterisk (*) denotes no financial relationships to disclose.

3

Endoscopic Management of the Adnexal Mass

Small to Large, Benign to Malignant

Robert W. Holloway, MDProfessor UCF College of Medicine

Florida Hospital Cancer InstituteGlobal Robotics Institute

Orlando, Florida

Yukio Sonoda, MDAssociate Attending SurgeonMemorial Sloan-Kettering Cancer CenterAssociate Professor Ob/GynWeill Cornell School of MedicineNew York, NY

Disclosure

Robert W. Holloway, M.D.

• Consultant: Intuitive Surgical

Yukio Sonoda, M.D.

• I have no financial relationships to disclose.

Learning Objectives

At the conclusion of this activity, the participant will be able to:

1. Explain which patient should undergo surgical assessment of an adnexal mass.

2. Explain which patient should be referred directly to l i l i ta gynecologic oncologist.

3. Identify the key components to intraoperative management of an ovarian malignancy.

4. Identify which patients should and shouldn’t undergo endoscopic management.

Endoscopic Management of the Adnexal MassSmall to Large, Benign to Malignant (Part I)

Course Introduction Dr Holloway

Pelvic Mass Evaluation Dr Sonoda- Radiology- Tumor Markers

Criteria for Surgery ‘’

ACOG/SGO Referral Guidelines ‘’ACOG/SGO Referral Guidelines

Frozen Section Accuracy Dr Holloway

Intra-operative Rupture ‘’

Approaches to Surgery ‘’

Q & A (5 min)

Endoscopic Management of the Adnexal MassSmall to Large, Benign to Malignant (Part II)

Surgical Management-Video Tutorials

- Laparoscopy* Dr Sonoda

- Robotic-assisted Laparoscopy* Dr Holloway

Q & A (5 min)

*25 min surgical tutorials covering benign and malignant conditions, illustrating state-of-the-art surgical management

Adenexal Surgery Then and Now

QuickTime™ and a decompressor

are needed to see this picture.

1809 2012

4

Adnexal Surgical History Pre‐operative Evaluation of the Adnexal Mass

• Attending Surgeon , Memorial Sloan‐Kettering, NYC

• GW Medical School, SUNY Buffalo Residency

• Fellowships: MSK, Centre Oscar p ,Lambret, Hospital Edouard Herriot, France

• Special interests: Advanced laparoscopic surgery, robotic surgery, radical vaginal surgery, fertility sparing radical trachelectomy

Yukio Sonoda, MD

How accurate are frozen sections in the evaluation of adnexal masses?

• Even when pre‐op physical exam, radiographic evaluations and serum markers predict benign pathology, it is prudent to visually examine the inner aspects of the tumor in the operating suite to determine the need for frozen section (FS) analysis.

• FS allows a determination for the need to proceed with a staging procedure and/or completion hysterectomy in some circumstances.


• A clearly defined surgical plan must be understood by the patient, the family, and the operating team (and documented) .

• Understanding the accuracy and limitations of frozen section g yanalysis is key in this process.


Systematic Reviews of Literature

• Geomini P, et al, Gynecol Oncol 2005

18 studies from 1996‐2003, retrospective, correlative

Sensitivity varied between 65% to 97% and specificity 97 to 100%

• Heatly M, Int J Gynecol Pathol 2012y , y

18 retrospective cohort studies from 2005‐2010

Benign v. cancer had best sensitivity and specificity (>95%)

Benign v. Borderline suffers with specificity (70.8%)

Borderline v. Cancer sensitivity and specificity 93.6%/93.1%


Benign v Cancer Benign v Borderline Borderline v Cancer

k 0.964 0.771 0.804

Sensitivity 99.7 98.9 93.6

Specificity 95.8 70.8 93.1Specificity

PPV 97.9 94.9 77.7

NPV 99.5 92.3 98.2

Heatly Mark, Int J Gynecol Pathol, Vol 31, No 2, March 2012

5


Accuracy of frozen section diagnosis of borderline tumor(Shih K, et al, Gynecol Oncol 123, 2011)

• 120 cases, 2000‐2010 at MMSK, with FS diagnosis of borderline tumor

• 104 (86.7%) confirmed on final pathology

• 15 (12.5%) reclassified as invasive OC and 1 (0.8%)as benign

• Reclassification was related to endometriod and clear cell histologies

l f f ll• Reclassification of serous micropapillary type was 42.8% vs 2.8% serous non‐micropapillary type

• Tumor size > 8cm associated with 22.4 % cancer v. 3.2% < 8 cm.

Recommendation: Surgically stage borderline OC > 8cm, endometriod, clear cell, or micropapillary serous histology

What about intra‐operative rupture…. Is

it really an adverse risk factor?

Ovarian Cancer Facts:

• Stage 1 ovarian cancer represents one quarter of all new cases, and the reported overall 5‐year survival ranges between 70‐89%.

• Prognosis is related to histology grade and stage• Prognosis is related to histology, grade, and stage

• Stage Ic includes masses with surface papillary formations, positive ascites, or tumor rupture, and all stage Ic disease is considered “high risk”, requiring adjuvant chemotherapy, irrespective of grade or reason for Ic designation.



Laparoscopy has been reported to have a higher incidence of cyst

rupture than laparotomy (6 to 33% in literature), mostly due to

cystectomy procedures.

Gal, D et al, J Gynecol Surg 1995

‐(7/21 LS v. 2/17 LAP) for cystectomy

‐(1/11 LS v. 1/15 LAP) for adnexectomy ‐( / / ) y

Fauvet, R et al, Ann Oncol 2005

‐358 LMP tumors, 42% LS, 28% conversions

‐Cyst rupture more common LS (P<0.001)

‐Complete staging less with LS (P<0.001)

‐Recurrence associated with conservative

surgery, not surgery type (P<0.001)

What about intra‐operative rupture….

Is it really an adverse risk factor?

Study: Smorgick N et al, Laparoscopic removal of adnexal cysts: Is it possible to decrease inadvertant intraoperative rupture rate?; Am J Obstet Gynecol 2009

• 2002‐2006 retrospective study from Israel, excluding cysts that were intentionally ruptured.

• 256 surgeries

inadvertent rupture of cyst 16 6% adnexectomyinadvertent rupture of cyst 16.6% adnexectomy: 7.4%

cystectomy 29.5% (P< 0.001) correlation with: cystectomy (RR 5.3),

cyst size (RR 1.1, 7.6 vs 6.5 cm) No correlation with: surgeon experience, patient

age, adhesions

Data on the long‐term adverse effects on rupturing a stage‐I EOC are conflicting for several reasons: retrospective studies and confounding

variables including uses of adjuvant therapies.

Con: Sjovall K et al, Int J Gynecol Cancer 1994

• 1974‐1976, Sweden, single hospital, 394 cases stage I EOC

• 27 had preop rupture, 141 intra‐operative tumor spill, and 147 no rupturep p p , p p , p

• No difference in 5‐yr survival for intact v. rupture (78 v 85%, P> 0.05)

• RR death pre‐op rupture/ascites v. intra‐op rupture = 2.91

• Adjuvant therapy: 90% of 141 intra‐operative rupture

77% 147 intact masses



Pro: Vergote et al, Lancet 2001

‐1,545 patients with Stage I EOC

‐Multivariate Risk Analysis for DFS:

G2 v G1 (RR 3.1)

G3 v G1 (RR 8.9)

cyst rupture prior to surgery (RR 2.65)

cyst rupture during surgery (RR 1.64)

No correlation with ascites, size, surface growth

6



Pro: Bakkum‐Gamez J, et al Obstet and Gynecol 2009

• Mayo Clinic and OSU, 1991‐2007

• 161 Stage I EOC: 74 (46%) intact , (‐) cytology, (‐) surface tumor

61 (38%) intra‐op capsule rupture

33 (20%) (+) cytology

22 (14%) surface tumor

• Multivariate analysis for relapse: capsule rupture HR 4.2 (CI 1.8 ‐ 10.9)

(+) cytology HR 6.4 (CI 2.5‐16.0)

• Stage Ic rupture had an approximately 50% reduction in 5‐year DFS

(80% v. 90%).



The bottom line…

• FIGO staging requires classifying a ruptured tumor mass as Ic, which is included in GOG “early‐stage high risk disease”, eligible for chemotherapy.

• Literature is conflicting, but on balance, indicates an g, ,independent increased risk for recurrence and death associated with intra‐operative rupture.

• Cystectomy has the highest risk for rupture.

• Try to place mass in an endobag and rupture extra‐corporally.

How do we decide the surgical approach…Laparotomy v. MIS?

Laparoscopy v. Robotics?ACOG Practice Bulletin (#83, July 2007)

Management of Adnexal Masses

“If a mass is suspicious for cancer…laparoscopic surgery is considered contra‐indicated, although laparoscopic staging and management of ovarian cancer has been reported”.

“…(laparoscopy is associated with) low complication rates from 0 to 10%. Higher complication rates occur when masses are suspicious for cancer. …the mean conversion rate to laparotomy was 6.4% (range 0‐25%).”

Study n(%) Prior Surg. Dx.

OR TimePelvic Nodes

Aortic Nodes

(%) Up‐staged

(%) Lap.Conversion

Querleu & LeBlanc (1994) 9 100 227 NR 8.6 11.1 0

Childers et al (1995) 14 35.7 120 ‐ 240 NR NR 42.8 0

Pomel et al (1995) 10 100 313 7.1 8.8 10 0

Tozzi et al (2004) 24 45.8 176 19.8 19.6 20.8 0

LeBlanc et al (2004) 42 100 238 14 20 19 2.4

Chi et al (2005) 20 65 321 11.1 6.7 10 0

Spirtos et al (2005) 58 NR 188 18.6 10.3 10.8 22.7

Laparoscopic Staging Ovarian Cancer: Literature Review

Colomer et al (2008) 20 85 223 18 11.3 20 5

Park et al (2008) 19 36.8 221 27.2 6.6 21.1 0

Jung et al (2009) 24 20.8 254 22.5 11 42 0

Nezhat et al (2009) 36 25 229 14.8 12.2 19.4 0

Ghezzi et al (2009) 26 0 348 24.5 9.8 23 0

Total 302

Mean 25.2 55.8 243 17.8 11.4 20.8 2.5

How do we decide the surgical approach…Laparotomy v. MIS?

Laparoscopy v. Robotics?Considerations:

• Risk of malignancy (age, radiology findings, tumor markers, exam)

• Size of the mass (Can I bag it? Intra‐corporeal vs extra‐corporeal drainage?)

• Prior surgical history? (bowel surgery, transplant surgeries, etc)

• Prior history of endometriosis, PID, adhesions?

• Co‐morbid medical conditions? (COPD, valvular heart Dz, pulm. HTN)

• How complex could the surgery be? Need to suture, retroperitoneal dissection?

• What’s my back‐up plan?…Manage patient expectations!

• OR utilization issues/robotic room time considerations

How to Perform a Safe Laparoscopy in a Suspicious Adnexal Mass

1. Surgeons trained and skilled in advanced MIS techniques including oncologic staging procedures available.

2. Strict pre‐operative selection (no metastasis, ascites, fixation on exam)

3. Obtain diaphragm and pelvic washings at the start of procedure.

4. Inspect contralateral ovary and all peritoneal surfaces.

5. Any suspicious areas are biopsied and sent for frozen section.

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How to Perform a Safe Laparoscopy in a Suspicious Adnexal Mass

6. Inadvertent capsular rupture should be followed by copious abdominal irrigation.

7. Mass biopsies and morcellation are never recommended; cyst aspiration may occur inside a bag to aid retrieval.

8. If cancer is diagnosed, proceed to staging laparotomy unless the skills of the laparoscopist are advanced and the patient was informed of the possible i k f d t irisks of understaging.

9. Avoid delay of more than 10 days if a secondary staging procedure is elected.

Q and A, Part I(5 min)

• ? Pre‐op work up

• Radiology W/U

• Serum Markers

• ? Criteria for surgery

? G id li f f l• ? Guidelines for referral

• ? Mass rupture

• ? Frozen sections

• ? Choice of surgical route

Surgical Tutorial for Adnexal Surgery Traditional Laparoscopy

Dr Yukio Sonoda

Surgical Tutorial for Adnexal SurgeryRobotic‐assisted laparoscopy

Dr. Holloway

Major Surgical CasesMajor Surgical Cases‐‐FHCI Gyn OncFHCI Gyn Onc( 2006 – 2011 )

600

800

1000

1200

of

Cas

es

Total6%

52.5

%

57.3

%

* 8-month data

0

200

400

600

2006 2007 2008 2009 2010 2011

Nu

mb

er

o

Robotics

17.4

%

*

32.4

% 42. 6

FHCI Gyn Onc Robotic Case Mix5/06 – 12/11n = 2,220

600

700

800

900

1000 917

of

Cas

es 740

*includes: Leiomyoma, Ovarian Cystadenoma, Endometrioma, Adenomyosis, Dermoid Cyst, Ovarian Cyst, etc.

**includes: Dysplasia, CIS, CIN, BRCA1, BRCA2, Complex Endometrial Hyperplasia, etc.

CervicalCancer

EndometrialCancer

OvarianCancer

0

100

200

300

400

500

132

320

Benign* Others**

Nu

mb

er o

111

8

Surgical Tutorial for Adnexal SurgeryRobotic‐assisted laparoscopy

• Mature Cystic Teratomas

• Cystadenomas

• Endometriomas/St IV endometriosisEndometriomas/St IV endometriosis

• Early‐stage Ovarian Cancer

“3‐Port” daVinci Pelvic Surgery

side vent

“3‐Port” daVinci Pelvic Surgery “3‐Port” daVinci Hysterectomy

(postoperative week 12)

“3‐port” Robotic‐assisted OophorectomyOvarian Cystectomy and Reconstruction

9

Post‐hysterectomy Retroperitoneal Adnexal Mass

Stage IV Endometriosis

Robotic‐assisted surgery in gynecologic oncology:SGO consensus statement

Clinical Practice Robotics Task Force

• Ovarian Cancer

– … “ only a few isolated cases have been reported using robotic surgery…”

– “Currently, early‐stage disease may be more amendable than more advanced disease to robotic surgery.”

Ramirez PT et al, Gynecologic Oncology 124 (2012) 180‐184

Para‐aortic Lymphadenectomy in Obese Patient

ROBOTIC‐ASSISTED LAPAROSCOPYAortic LymphadenectomyPort Placement S/Si Model

Infra-renal Lymphadenectomy BMI 50

10

Robotic‐assisted Laparoscopic Staging FHCI Database 2006‐2011 (n=66)

Pathology Number (%)

Epithelial ovarian cancer (EOC) 26 (39.4%)

Low malignant‐potential (LMP) 20 (30.3%)

Fallopian Tube 10 (15.2%)Fallopian Tube 10 (15.2%)

Granulosa Cell 19 (13.6%)

Germ cell 1 (1.5%)

Holloway RW et al, AAGL 2011

Robotic Staging EOC/FTC

n = 31

Factors Mean ± SD or Absolute Number

Range or %

Age (years)Age (years) 57 57 ±± 1414 19 19 ‐‐ 8989

Body mass index (kg/mBody mass index (kg/m22)) 26 26 ±± 77 19 19 ‐‐ 4747

Staging for ovarian cancer Staging for ovarian cancer diagnosed with prior surgerydiagnosed with prior surgery

1212 38.7%38.7%

Pre‐op CA‐125 level of primary cases (U/mL)

59 ±± 7777 6 ‐ 299

Tumor size (cm) 6 6 ±± 33 1 ‐ 12

Holloway RW et al, AAGL 2011

Literature Comparison to Current Series

Study n Prior Surg. Dx.

OR Time

Pelvic Node Aortic Node (%) Up‐staged

(%) Lap.Conversion

LPS(12 studies ‘94‐

2009)

25.2 55.8% 243 17.8 11.4 20.8 2.5

Holloway et al 31 38 7% 147 14 0± 8 10 0± 6 42 0 6 5Holloway et alEOC/FT Robotic

Database(AAGL‐2011)

31 38.7% 147 14.0 ± 8*61%

Bilateral

10.0 ± 6*54%

Bilateral

42.0 6.5

Retro‐peritoneal Anatomy

1. Vena Cava

2. Renal Vein, L & R

3. Gonadal Arteries

4. Inferior Mesenteric Artery

5. Ureter

6. Common Iliac Vein, L & R

Ovarian Cancer Staging Conclusions

• Robotic‐assisted laparoscopic staging of early ovarian cancer in our preliminary analysis is associated with:

• acceptable OR times , EBL, LOS, node counts

• few laparotomy conversions (6.5%)

• 42% upstaging in FT/EOC cases• 42% upstaging in FT/EOC cases

• Long‐term follow‐up studies are needed for oncologic outcomes in comparison to laparotomy.

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My Recommendations

• Robotic MIS for the “pelvic mass” is acceptable practice with careful pre‐operative evaluations and informed consent about potential risks and benefits.

• General guidelines for robotic surgery:

• No ascites, no upper abdominal metastatic disease

• Complex mass must fit into spleen bag with minimal chance for rupture (12‐14 cm max my preference).

• Complete laparoscopic exam before placing ports and docking to exclude metastatic disease.

Q and A, Part II(5 min)

‐ Laparoscopic Adnexal Surgery

‐ Robotic‐assisted Laparoscopic Adnexal Surgery

*Thanks for your attention and attendance!

Bibliography

1. ACOG Practice Bulletin, # 83 Management of Adnexal Masses; Vol 110, (1) July 2007.2. Bakkum‐Gamez JN., Richardson DL., Seamon LG, Aletti GD, Powless CA, Keeney GL, et al.

Influence of intraoperative capsule rupture on outcomes in stage 1 epithelial ovarian cancer. Obstet Gynecol 2009; 113:11‐17.

3. Fauvet, R Boccara C, Poncelet C, and Darai E. Laparoscopic management of borderline ovarian tumors: results of a French multicenter study. Ann Oncol 2005; (16), 403‐410.

4. Gal D, Lind L, Lovecchio L, and Kohn N. Comparative study of laparoscopy vs. laparotomy for adnexal surgery: efficacy, safety, and cyst rupture. J Gynecol Surg 1995; 11(3): 153‐158.

5 Geomini P Bremer G Kruitwagen R Mol W Diagnostic accuracy of frozen section5. Geomini P, Bremer G, Kruitwagen R, Mol W. Diagnostic accuracy of frozen section diagnosis of the adnexal mass: a metaanalysis. Gynecol Oncol 2005; 96:1‐9.

6. Heatly M. A systematic review of papers examining the use of intraoperative frozen section in predicting the final diagnosis of ovarian lesions. Int J Gynecol Pathol 2012;

31:111‐115.

7. Holloway RW, Ahmad S, Finkler NJ, Bigsby GE, Ghurani GB, Kendrick JE, Brudie LA, Rakowski JA, James JA. Robotic‐assisted laparoscopic surgical staging of patients with clinical stage I adnexal cancers: Peri‐operative outcomes. J. Minim. Invasive Gynecol. 2011; 18 (Suppl.1): A136.

Bibliography

8. Ramirez PT, Adams S, Boggess JF, Burke WM, Frumovitz MM, Gardner GJ, Havrileski LJ, Holloway RW, Lowe MP, Magrina JF, Moore DH, Soliman PT, Yap S. Robotic‐assisted surgery in gynecologic oncology: A Society of Gynecologic Oncology Consensus Statement Developed by the Society of Gynecologic Oncology’s Clinical Practice Robotics Task Force. Gynecol. Oncol. 2012; 124: 180‐184.

9. Shih K, Garg K, Soslow RA, Chi DS, Abu‐Rustum NR, Barakat RR. Accuracy of frozen section diagnosis of borderline tumor. Gynecol Oncol. 2011;123:517‐521

10. Smorgick N, Barel O, Halperin R, Schnieder D, and Pansky M. Laparoscopic removal of adnexal cysts: Is it possible to decrease inadvertant intraoperative rupture rate?. Am J Obstet Gynecol 2009;200: 237.e1‐237.e3.

11. Sjovall K, Nilsson B, Einhorn N. Different types of rupture of the tumor capsule and the impact on survival in early ovarian carcinoma. Int J Gynecol Cancer 1994; 4:333‐336.

12. Vergote I and Trimbos JB. Treatment of patients with early epithelial ovarian cancer. Curr Opin Oncol, 2003; 15: 452

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

faculty moderator ronald l. levine, md · number of factors. this course provides an overview of...

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