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Clinical Focus

Robert Dreicer, MD, MS, MACP, FASCO; Neal Shore, MD, FACS; Michael Morris, MD; Alicia K. Morgans, MD, MPH

Medical Crossfire®: How Will Emerging Data Inform Treatment Planning for Patients With Prostate Cancer in the Community?

Howard I. Scher, MD; Scott T. Tagawa, MD, MS, FACP; Mary-Ellen Taplin, MD

Medical Crossfire®: How Does Recent Evidence on PARP Inhibitors and Combinations Inform Treatment Planning for Prostate Cancer Now and In the Future?

Jason Hafron, MD; Aaron D. Berger, MD; Arpeet Shah, MD

Medical Crossfire® in Adjunctive Testing: Charting a New Course in Prostate Cancer Risk Assessment

, discusses the use of vaginal estrogen. Winter is a urologist and sexual medicine expert in Los Angeles, California.

This discussion originally took place during a live X (formerly Twitter) Spaces event held by Urology Times®. To begin the discussion, Winter explains how she first became interested in advocating for this therapy, noting a lack of education in her early training. During the discussion, Winter also shares insight on the conditions that vaginal estrogen can be used to treat, safety data on the medication, and the different forms that may be given to patients.

, or anywhere that podcasts are available.

In this episode of Speaking of Urology®, Ashley G. Winter, MD, discusses the use of vaginal estrogen. 

Speaking of Urology: Dr. Winter on the use of vaginal estrogen

® Assistant Editor Janelle Hart spoke with 

about a study that was presented at the 2022 Society of Women in Urology Annual Clinical Mentoring Conference. The study investigates the quality of information regarding recurrent urinary tract infections on the social media platform Reddit. Malik is an assistant professor of surgery and director of female pelvic medicine and reconstructive surgery at the University of Maryland School of Medicine in Baltimore.

“I think we as urologists have to be proactive in providing information to our patients so that they avoid financial harm and potentially bodily harm from this sort of misinformation,” says Rena D. Malik, MD.

 Dr. Malik evaluates quality of Reddit content on recurrent UTIs

. He discusses the stigmas associated with vaginal mesh surgery, and how it is the urologist’s responsibility to set the expectations for their patients in terms of possible complications with different slings. Blaivas is a professor of urology in the Icahn School of Medicine at Mount Sinai in New York City, New York.

“To me, the overwhelming thing is understanding that treatments are, by and large, effective,” says Jerry G. Blaivas, MD, FACS.

Destigmatizing Urology: Dr. Blaivas discusses vaginal mesh surgery 

In this episode, we continue a series of podcasts on the topic of genitourinary syndrome of menopause, or GSM. Over the course of this series, 

 will discuss why it is important for urology providers to be educated regarding this condition, how to diagnose it in patients, and how to treat it. Rubin is a board-certified urologist with fellowship training in sexual medicine. She is an assistant clinical professor in urology at Georgetown University and has a private practice in the Washington DC area. In this episode, Rubin discusses common symptoms of GSM to look for and how a physical exam for GSM should be conducted. She spoke with 

"Many people do not examine patients who come in with urinary tract infections or overactive bladder symptoms, and it’s a mistake,” says Rachel S. Rubin, MD.

How to diagnose and treat patients with genitourinary syndrome of menopause

They discuss the efficacy of telehealth visits and how their 

 study, “Patient satisfaction and savings, and clinical outcomes of televisits in female pelvic medicine and reconstructive surgery at an urban academic center,” supports a bright future for telemedicine. Abraham is an associate professor and residency director of the department of urology at Montefiore Medical Center, and Shin is a medical student at the Albert Einstein College of Medicine, Bronx, New York.

“Our study strongly suggests that telemedicine can become the mainstay of treatment within FPMRS even after the COVID-19 pandemic has ended,” says Christina Shin, BA.

How FPMRS patients are reacting to televisits

® Managing Editor Ben Saylor spoke with 

 She discusses the safety and feasibility of same-day discharge after female pelvic medicine and reconstructive surgery cases. Zillioux is a urologist at Cleveland Clinic.

“Same-day discharge is safe and feasible across a broad spectrum of FPMRS cases,” says Jacqueline Zillioux, MD.

Dr. Jacqueline Zillioux discusses same-day discharge after FPMRS cases

The company expects the device to become available for US patients with pelvic organ prolapse in September 2024.

Collaboration to advance market launch of ProVate device for pelvic organ prolapse

There were no differences in the number of treatment-related TEAEs in patients who received sildenafil cream vs patients who received placebo. 

Topical sildenafil cream found safe, tolerable in female sexual arousal disorder

Developed by the AUGS Scientific Committee and Research Agenda Writing Group

National Urogynecology Research Agenda: A Path Forward for Advancing the Treatment and Management of Pelvic Floor Disorders

The FDA approval is supported by data from the phase 3 ALLIUM trial, which demonstrated the non-inferiority and superiority of cefepime/enmetazobactam vs piperacillin/tazobactam.

FDA approves cefepime/enmetazobactam for complicated UTI

The aim of this document is to present a framework by which AUGS and its members can address the development of new technology and techniques, particularly in the surgical arena. 

Information and Guidance on the Adoption of Surgical Innovation and Technology in Urogynecology

Shaya Taghechian, MD, offers advice for health care professionals interested in starting/expanding a sexual wellness/aesthetics practice

Expert offers advice on starting a sexual wellness/aesthetics practice

 offers advice for health care professionals interested in starting/expanding a sexual wellness/aesthetics practice. Taghechian is a urologist with Georgia Urology.

What advice do you have for other health care professionals looking to start/expand a sexual wellness and aesthetics practice?

I would say this is unlike normal aesthetic practice. This is not Botox and fillers and things like that. It's very specific to vulva/vagina. If you're interested, first of all, that's fantastic. We need more ambassadors here. But you need to take the time out to find those people who can teach you and train you. And don't just jump into it without knowing what the heck you're doing. Because, again, we're here to serve patients and not to make things worse for them. We want to make things better for them. There are different meetings around the world within the United States. There are cosmetic gynecologists who are available and ready and willing to teach around the US, around the world. It's a very welcoming community, and they want more people to be doing this for patients out there. The number 1 thing is, go get educated. Because there's no formal education. Go and do it, and then bring that to your patients, and just be excited about it. You have to have a passion for it. If you have a passion for it, it's easy to do. You want to go into this for the right reasons, and those reasons are to make your patients’ lives better. This is not something you want to pursue for monetary reasons. That shouldn't be in medicine, period. Do it for the right reasons, and you will be successful.

This transcription was edited for clarity.

Videos

"You have to have a passion for it. If you have a passion for it, it's easy to do," says Shaya Taghechian, MD.

Gamal M. Ghoniem, MD, FACS, ABU/FPMRS, discusses pelvic pain and vesicovaginal fistula. 

Expert discusses pelvic pain and vesicovaginal fistula

 discusses pelvic pain and vesicovaginal fistula. Ghoniem is Emeritus Professor of Urology at UCI School of Medicine.

What are some underreported aspects of female urology?

I think what you don't know, you don't see. That's the principle. I think pelvic pain is 1 of the areas that really needs more attention. And I know many young investigators are looking into that recently, but there is no real breakthrough to control pain, painful bladder and so on. I think that area really needs more attention. I'd like to see also many young urologists in the field go overseas and work on vesicovaginal fistula, to have the experience and to see the extent [of it]. It's a very devastating condition for young women...Having experience in that would be very good for younger urologists and gynecologists in the field. Traveling abroad to the developing countries like in Africa and Asia also. This is a huge problem; the WHO supported efforts in [this area], but women suffering from this is really a big problem. These are young women who get married early and have a baby. And then, as you know, not every area is close to a medical center or a hospital. So they have a problem getting there. Whether they go buy a cart, or whatever, it takes time. So it's a prolonged labor. And that produces pressure on the bottom of the bladder and necrosis, sloughing, and then a fistula happens between the bladder and vagina. It has a lot of effects and social effects. A lot of men will divorce them; [the women] become outcasts in their community. That would be a good area to get trained to do. There are many fistula centers in Africa and Asia and, I encourage [urologists] to look for them.

"I think pelvic pain is 1 of the areas that really needs more attention," says Gamal M. Ghoniem, MD, FACS, ABU/FPMRS.

Shaya Taghechian, MD, gives an overview of her women’s sexual health and cosmetic gynecology practice

Dr. Taghechian on her women’s sexual health practice

 gives an overview of her women’s sexual health and cosmetic gynecology practice. Taghechian is a urologist with Georgia Urology.

Please provide an overview of Aayla, including what conditions are treated and what treatments are provided.

Aayla is dedicated specifically to women's sexual health and I would say some cosmetic gynecology as well. There is a severe lack of treatment when it comes to women's sexual health. There's sort of a lack of ownership in this space. A patient may go to gynecology and may say, "I have a lack of libido, things don't feel the same." And often, I hear, "They did an exam on me, and they said, nothing was wrong. And, this is just the way it's going to be." So nothing happens there. And then they'll come to the urologist, and they may say the same thing, because they may have a female provider and they may feel comfortable speaking with that female provider. But same thing, we say, "We're urologists, [we treat] bladder, kidneys; we don't know what to do." So then nobody takes care of it, even though the patients may have voiced their concern, they're still ignored. A lot of that was happening in my practice. I've been in practice somewhere around 15 years, and it was getting really old. Sometimes, you just have to go out and learn and innovate and bring something into your practice that you didn't learn in medical school, or wasn't out there in residency. So that's how it came about. In terms of cosmetic gynecology, I tell my patients that every vulva is normal. We know that. They come in different shapes, different sizes; there is no "perfect" or "normal." It just doesn't exist. But there are often women who have functional issues with the vulva. [They] have discomfort or pain, because of the way it's shaped or how long labia are. And there are folks out there who offer what's called labiaplasty. But are they qualified to be doing a labiaplasty? Usually, I think it's been plastic surgeons and I am not saying plastic surgeons are bad, horrible people, nothing like that. But honestly, when's the last time a plastic surgeon did a pelvic exam? Do they know what they're looking at? Do they know the structures of the vulva and the vagina, where certain nerves are or how the vagina or vulva age as the patient gets older, like what changes occur? They're not thinking about those things. They're not necessarily trained in those things. And so I don't know if that's the perfect person to be doing cosmetic gynecology. Now, if the patient brings their concerns to the gynecologist, well, they haven't necessarily been trained in plastic surgery either. So there again, is this gap. For me, personally, I thought, who better? I have urologic expertise. I'm in the pelvis all the time. I'm working in the vaginal area all the time, with women who have incontinence, doing surgeries, slings, Bulkamid, what have you. I can learn how to do those plastic surgery procedures. I really enjoyed it. I found people around the world who were already doing it and got trained. It's not that there's nobody doing it. It's a very small world, cosmetic gynecology. So I went and got training and brought that back to my patients, and I love it. And the results are fantastic and the patients are happy. And I feel like we're really doing them a service, making their lives better, not maiming them. There's no "botched" here, because we know what we're doing.

This transcription has been edited for clarity.

"There is a severe lack of treatment when it comes to women's sexual health," says Shaya Taghechian, MD.

Dr. Tabakin on “Vaginal Estrogen Prescribing and Cost Trends Among Medicare Part D Beneficiaries.” 

Expert urges patient education on vaginal estrogen products

paper “Vaginal Estrogen Prescribing and Cost Trends Among Medicare Part D Beneficiaries.” Tabakin is a fellow in female pelvic medicine and reconstructive surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York.

The abstract mentions a subanalysis on OB-GYN-specific trends. Did this subanalysis reveal any significant differences in prescribing patterns compared with other specialties?

We chose to perform a subanalysis on OB-GYN-specific trends because they comprise the majority of all prescribers at about 60%. Surprisingly, we observed similar trends in this group. There was a decrease in the total number of vaginal estrogen claims as well as prescribers. But 1 difference, however, was that the overall median spending per claim decreased during this 5-year study period. When looking at individual vaginal estrogen products prescribed by OB-GYNs, median spending per claim for Vagifem and Yuvafem decreased and median spending per claim increased for Estrace and Estring.

Beyond cost, are there any additional factors you believe might be influencing the utilization and accessibility of vaginal estrogen for Medicare Part D beneficiaries?

Patient education is a really important factor. Currently, the FDA requires that all estrogen-containing products carry a black box warning. When a patient goes to the pharmacy to pick up a vaginal estrogen product, they'll see that the packaging states that there's an increased risk for breast cancer, endometrial cancer, cardiovascular events, probable dementia, and these are the risks for oral estrogen, but they don't pertain to vaginal estrogen because it's not absorbed into the bloodstream in an appreciable manner. There are a lot of data to demonstrate that low-dose vaginal estrogen is safe and isn't associated with these risks. But if patients aren't properly educated, they're going to be less likely to use it.

"When looking at individual vaginal estrogen products prescribed by OB-GYNs median spending per claim for Vagifem and Yuvafem decreased and median spending per claim increased for Estrace and Estring," says Alexandra Tabakin, MD.

Raveen Syan, MD, FPMRS, shares her thoughts on the 2024 Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting

Dr. Syan shares her thoughts on SUFU 2024

 shares her thoughts on the 2024 Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting. Syan is an assistant professor in clinical urology at the University of Miami Desai Sethi Urology Institute in Miami, Florida.

SUFU in 24 was another great meeting. The best thing about SUFU is always that you see the young trainees really start to build their skills as speakers and presenting their research. I was moderating the fellows forum, and [there is] really great research coming out of these different institutions. You really see rising stars. [It's] so wonderful to see young trainees getting engaged in the world of urogynecology and pelvic reconstruction. A lot of what they were focusing on were things like quality-of-life outcomes, or outcomes related to new innovations, such as new implantable tibial devices. That was really exciting. It's always good to see the emerging young doctors succeed and have interest. It was very interesting to hear about all these new implantable tibial devices and hear how well they're doing. What's interesting is they're all slightly nuanced, so I think as a provider, it will be a journey to figure out what I would recommend the most, what I think is best for the patient. But at the end of the day, it's nice to have a tailored approach and options available for the individual patient. Other things that stood out to me at the talk [included] the basic science component at SUFU. It starts off the course. It's always great for someone who's not a basic scientist like myself, to hear a really good summary, which is what was done on Friday morning. It was really interesting to hear that apparently umbrella cells are the new hot cell of the bladder, and I am excited to hear more about that, and how that may influence the physiology of the bladder and bladder symptoms. It was also a great hotel; they chose an excellent spot in beautiful Fort Lauderdale. And at the end of the meetings, a lot of us would meet at night, and it was just a great way to interact on an informal level and continue to build our networking and collaboration. It's a really important thing to create that interfacing; that's how new research [and] new ideas are formulated. One of the very interesting talks was the SOTA Lecture, where Dr. Andrew C. Peterson describes the end stage bladder, and it's always great to hear from experts and experienced clinicians about how they handle these very difficult cases. And I think that's one of the things SUFU does best, which is showcase these challenging, difficult-to-treat situations and really helps contextualize it. He did a great job of explaining how should we define the end stage bladder? Because that's a little vague. And then how do we talk to patients about it, and most importantly, what do patients have to say? And he shared a beautiful video by a patient who talked about how difficult that decision was to do some major surgery and how incredibly impactful in a positive way undergoing that surgery was. So it was great to hear, as a younger clinician, how others talk to patients, how patients do, how do we face these difficult challenges. SUFU is a fantastic organization where they're very much focused on partnership between all stages of your career: research, clinical care, outcomes. And SUFU really leads the nation in terms of defining urogynecologic problems and how we should treat [them] expertly with care and with attention to what's important to patients. It's a meeting I look forward to every year because I learn so much. I have the opportunity, I feel, to share what I am learning and every time I leave the meeting, I just feel reinvigorated, refreshed, and excited about this field that we're a part of.

"Every time I leave the meeting, I just feel reinvigorated, refreshed, and excited about this field that we're a part of," says Raveen Syan, MD, FPMRS.

Cassandra K. Kisby, MD, MS, discusses the Urogynecology study “Impact of Severe Obesity on Major Perioperative Complications for Prolapse Surgery.” 

BMI may increase complications for prolapse surgery

 discusses the take-home message from the 

study “Impact of Severe Obesity on Major Perioperative Complications for Prolapse Surgery.” Kisby is an assistant professor of obstetrics and gynecology, obstetrics and gynecology, and urogynecology at Duke University in Durham, North Carolina.

What are some next steps following this research?

I don't want to overstate our outcomes, because this really is a national database study. It's a good place to start, but I think it would be optimal to have a multicenter prospective study looking to see if there's a similar association. Furthermore, we use BMI as a dichotomous variable, and there are some statistical downsides to that. There are a lot of more complex modeling techniques that I think could be utilized to evaluate associations.

What is the take-home message for the practicing urologist?

I don't think 1 database study creates dogma, but I do think we can share these data with our patients and talk to them about treatment options and risk, have that difficult conversation about how BMI may be associated with that risk. For some patients, this will be motivating. They might opt for lifestyle changes prior to their prolapse surgery. However, [for] patients who do have a BMI over 40 [and] opt for laparoscopic or robotic surgery for their prolapse, I would thoroughly counsel them on risks as well as involve their primary care providers or any subspecialist providers who are caring for them to optimize any of their medical comorbidities.

It's our job and we took an oath to do no harm, and we as surgeons, we really want to fix things, we want to fix the prolapse. We need to have the hard conversations about some sensitive topics though around surgery, things like weight and perioperative morbidity. And when these things are broached very gracefully, patients often appreciate it and are thankful for the information.

"I don't think 1 database study creates dogma, but I do think we can share these data with our patients and talk to them about treatment options and risk, have that difficult conversation about how BMI may be associated with that risk," says Cassandra K. Kisby, MD, MS.

Cassandra K. Kisby, MD, MS, discusses the Urogynecology study “Impact of Severe Obesity on Major Perioperative Complications for Prolapse Surgery.”

Dr. Kisby on obesity in patients undergoing prolapse surgery

 shares the background and notable findings from the 

Please describe the background for this study.

We have an increasing body of literature on surgical outcomes for patients with pelvic organ prolapse, including data on vaginal or native tissue procedures as well as laparoscopic and robotic procedures for prolapse. I think it's important to also take a step back and not only look at outcomes, but also look at safety of these procedures, particularly in a changing population. There are 2 major changes happening in our patient population. One is the overall size of the elderly population. This is growing, and we know that prolapse is most common in patients over age 60. The other concurrent trend that's happening is also the number of patients with an elevated body mass index or BMI. We don't have a lot of good data about BMI in patients undergoing prolapse surgery. The data that we do have that does exist in literature oftentimes uses the WHO definition for obesity, which is a BMI of 30. Clinically, I really noticed a difference in surgical morbidity once we're looking more at BMIs around the 40 range or even higher. That's where this study came from; I wanted to know where the inflection point was for BMI and surgical or perioperative complications. I was also curious if there was a difference between vaginal approaches to prolapse surgery vs laparoscopic and robotic approaches to surgery. To answer this question, we used a large national database that many people are familiar with—the NSQIP database. This looks at 30-day major complications or morbidity around surgery. And so we looked at major complications in particular, so things like surgical site infection, sepsis, VTE, acute renal injury, and things like that.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

The most important thing that I think came out of this study is really the BMI inflection point for complications. We saw an abrupt rise in complications around a BMI of 40. This makes sense; things like cardiac morbidity and difficulty ventilating a patient, the risk of comorbid conditions like hypertension and diabetes, are pretty common among [patients with] higher BMIs. Using that inflection point, we found that the odds of a major complication were 1.8 times higher for women with a higher BMI, so women with a BMI over 40. And then we looked between surgical approaches. Women who underwent a laparoscopic or robotic approach to surgery were 6 times more likely to have a major complication, and that was the really big surprise for us. We didn't expect it to be such a big difference.

"The most important thing that I think came out of this study is really the BMI inflection point for complications. We saw an abrupt rise in complications around a BMI of 40," says Cassandra K. Kisby, MD, MS.

Vikas Desai, MD, describes his clinical practice and the different types of urinary incontinence

Dr. Vikas Desai discusses urinary incontinence in women

describes his clinical practice and the different types of urinary incontinence. Desai is a urologist with Northwestern Medical Group in Winfield, Illinois.

Please provide an overview of your clinical practice.

I feel that my practice is more based in restorative urology. I like to use the word restorative because I kind of bring back things people have lost over the years. In terms of conditions that I treat, specific to female incontinence, I would say is overactive bladder, which sometimes can overlap into urinary urgency or urge incontinence and then stress urinary incontinence.

What types of incontinence do you treat? How are they similar and how do they differ?

The 2 main types of incontinence are stress incontinence and urge incontinence. And so it's kind of a big dichotomy that we try to really discern out when a patient presents where I try to figure out what's more important? Some people will come in with mixed incontinence, which is stress and urge together, but a lot of times they have one overarching incontinence that's more bothersome, and I really try to tailor the focus on that. If we get that better, they're going to be better off and happier, and then we can always focus on the other one secondarily. Stress incontinence, typically, I would say, is leaking when you cough, sneeze, or with activity. It prevents you from playing pickleball, maybe doing some yoga, working out. And so it can can be very debilitating, especially over the last few years with COVID people getting these coughs and stuff and things that might have not been so bothersome getting these exacerbating factors, or even during this time of year, when people's bronchitis or asthma start acting up. So it's something that's definitely bothersome. I would say stress incontinence, more times than not, we'll see in females of childbearing age, shortly after they've had childbirth down the line. So their pelvic floor muscles basically have just gotten weakened over time. And so those muscles are weak, and so they just can't hold the urine that they used to. In terms of urinary urge incontinence or overactive bladder, which I would say is kind of a progression of overactive bladder. Overactive bladder is going to the bathroom more often than usual. Typically, someone goes to the bathroom about 6 to 7 times a day, but they would be going more than 6 to 7 times, so maybe more like every 2 to 3 hours. And that can progress where they have no control of their urine and urge incontinence. And so that sometimes happens because the bladder muscle itself is weak; the bladder muscle can get weak as you get older, so developing urinary incontinence or urgency is very common as you get older, but there are other precipitating factors that we can go through that cause some of those symptoms.

“The bladder muscle can get weak as you get older, so developing urinary incontinence or ur-gency is very common as you get older,” says Vikas Desai, MD.

In this video, Bree Duncan, RN, BSN, shares her experiences working with female patients with bladder cancer.

Care coordinator discusses working with female patients with bladder cancer

 shares her experiences working with female patients with bladder cancer. Duncan is the Gail Kraemer Care Coordinator for Female Bladder Cancer Patients at Vanderbilt University Medical Center in Nashville, Tennessee.

Can you share some clinical experiences or case studies of patients you have cared for?

Typically, the patient population is a little bit older, just in general. But we have had some patients that are younger. And I think being younger and going through something so scary, I think it's been really important to her to have someone with her throughout the whole process. And sometimes things don't also go as smooth as everyone hopes when you're dealing with surgery and cancer. And so sometimes there's a lot of extra stuff that's involved and things that maybe feel a little bit more urgent, because you're hoping to get answers back quickly about things. And I think having a role like this where I am so readily accessible, being able to call my office and I'm going to either answer, or I'm going to call you back within probably a couple hours is really big for these people. Because that's just not something you get here at Vanderbilt, unfortunately. I wish we could offer that, but we are just so big that things go through an answering service, and things get funneled out that way. So for these patients to have access to me so closely, has, I think, eased a lot of their fears, especially like I said, when you're dealing with patients that have some more complications. A lot of patients just maybe need some more emotional support too along the way—someone that they can hug and cry with because they're scared of everything that's happening. And we create these relationships along the way, and they feel comfortable sharing their fears and concerns and stuff with me. I feel very lucky to actually be a part of it, and be that person. It's been really special, especially because of how it was all created. This one patient creating it and I had a really close relationship with her and to be able to carry this out and help other women in her honor has been really cool.

“I think being younger and going through something so scary, I think it's been really important to her to have someone with her throughout the whole process,” says Bree Duncan, RN, BSN.

Bree Duncan, RN, BSN, discusses the challenges female patients with bladder cancer face 

Bree Duncan, RN, BSN, on challenges faced by female patients with bladder cancer

 discusses the challenges female patients with bladder cancer face and offers advice on establishing a care coordination role in bladder cancer in women. Duncan is the Gail Kraemer Care Coordinator for Female Bladder Cancer Patients at Vanderbilt University Medical Center in Nashville, Tennessee.

What are some challenges female patients with bladder cancer specifically face?

It's a much smaller population compared with the men. And so, there are a lot of questions and issues regarding [topics] like body image and sexual function, and things like that, that also, being a woman in this role, I feel like they feel comfortable asking me those questions. I've gotten questions like that, from patients who, even though the doctors are wonderful, they might not feel comfortable asking those specific questions to them, especially the male providers. And so I'll get those questions. And I might not know the answers to all of them, so I'll be that middle person to get the answers for them. But I think as a woman, it's easier to relate to another woman. Even if I haven't been through the cancer journey, I'm there with them for it.

What advice would you give others looking to implement a similar role?

I would say it's a learning process along the way, just to see how best to help the specific patients. We started this a little over a year ago, and it's definitely been a journey where it's kind of changed courses a couple times. [We're] documenting what we're doing along the way, what things we could do better. I meet with Dr. Chang regularly, and let him know what I've been up to, the feedback I've been getting. And we just come up with different ideas of ways that I can better assist patients. The goal is also not to only help our patients but help the rest of the staff and the providers. Having 1 person who has so much interaction with these women, it's easier than trying to be like, "who spoke to that patient last about this?" If I can be that one that a lot of it funnels through, the goal is to help ease the load on some of the clinic nurses and be there to help communicate with the providers.

"There are a lot of questions and issues regarding [topics] like body image and sexual function, and things like that, that also, being a woman in this role, I feel like they feel comfortable asking me those questions," says Bree Duncan, RN, BSN.

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