Background: As part of the residency application process in the United States, many medical specialties now offer applicants the opportunity to send program signals that indicate high interest to a limited number of residency programs. To determine which residency programs to apply to, and which programs to send signals to, applicants need accurate information to determine which programs align with their future training goals. Most applicants use a program's website to review program characteristics and criteria, so describing the current state of residency program websites can inform programs of best practices. Objective: This study aims to characterize information available on obstetrics and gynecology residency program websites and to determine whether there are differences in information available between different types of residency programs. Methods: This was a cross-sectional observational study of all US obstetrics and gynecology residency program website content. The authorship group identified factors that would be useful for residency applicants around program demographics and learner trajectories; application criteria including standardized testing metrics, residency statistics, and benefits; and diversity, equity, and inclusion mission statements and values. Two authors examined all available websites from November 2011 through March 2022. Data analysis consisted of descriptive statistics and one-way ANOVA, with P <.05 considered significant. Results: Among 290 programs, 283 (97.6%) had websites; 238 (82.1%) listed medical schools of current residents; 158 (54.5%) described residency alumni trajectories; 107 (36.9%) included guidance related to the preferred United States Medical Licensing Examination Step 1 scores; 53 (18.3%) included guidance related to the Comprehensive Osteopathic Medical Licensing Examination Level 1 scores; 185 (63.8%) included international applicant guidance; 132 (45.5%) included a program-specific mission statement; 84 (29%) included a diversity, equity, and inclusion statement; and 167 (57.6%) included program-specific media or links to program social media on their websites. University-based programs were more likely to include a variety of information compared to community-based university-affiliated and community-based programs, including medical schools of current residents (113/123, 91.9%, university-based; 85/111, 76.6%, community-based university-affiliated; 40/56, 71.4%, community-based; P <.001); alumni trajectories (90/123, 73.2%, university-based; 51/111, 45.9%, community- based university-affiliated; 17/56, 30.4%, community-based; P <.001); the United States Medical Licensing Examination Step 1 score guidance (58/123, 47.2%, university-based; 36/111, 32.4%, community-based university-affiliated; 13/56, 23.2%, community-based; P =.004); and diversity, equity, and inclusion statements (57/123, 46.3%, university-based; 19/111, 17.1%, community-based university-affiliated; 8/56, 14.3%, community-based; P <.001). Conclusions: There are opportunities to improve the quantity and quality of data on residency websites. From this work, we propose best practices for what information should be included on residency websites that will enable applicants to make informed decisions.

Sometimes I blush when a patient says, “Thank you.” As a medical student, I constantly feel thankful to patients for the opportunity to be part of their care, so I feel a little embarrassed if a patient thanks me first. I also worry that patients may feel obligated to be thankful when the opposite is true—it is my privilege to be involved in their care. Recently, I had a short foray as a patient. After several appointments and mounting pain, I accepted that I had to go to the emergency department for an urgent (but not serious) medical procedure. I was exhausted, worried about setting foot in the emergency room in the midst of a COVID-19 surge, and plagued with stress about how I should have been studying for the United States Medical Licensing Examination Step 1 all day instead. In the emergency department, I was swiftly assigned a bed. I laid on my side wondering if I could squeeze in a nap, but to my surprise, a resident came over quickly. I could have sat up, but before I could manage the painful maneuver, he crouched down to my eye level. I thought about the number of times I had been in his position, squatting precariously in a narrow space, wondering if the patient noticed my awkward positioning. I will never worry about that again; speaking to him directly, as I lay curled up on my side, felt natural and comforting. The procedure was painful. I cried and felt embarrassed. Through puffy eyes I sobbed, “I’m sorry!”—a phrase I had heard so many patients say when they did not need to. The attending physician replied that it was okay, I could cry as loud as I needed, and invited me to scream. When the procedure was over, we discussed follow-up instructions, and I admitted to feeling distressed about managing my recovery while studying for Step 1. She looked at me with soft eyes and said, “I’m so sorry … that is so hard.” The words were simple, but her voice communicated her true sympathy. As we wrapped up, my tears were still flowing. I felt overwhelmed with gratitude and blurted out, “Thank you so much!” The warm words bubbled up spontaneously from deep inside. I felt grateful for how the team listened, did not dismiss my outside stressors, and spent precious moments helping me heal. My gratitude was magnified by vulnerability. Usually, I feel control over my body. But then suddenly, I depended on these physicians for care. Saying thank you was a tiny action that I could contribute, and it helped me grasp a sliver of agency. Giving thanks was emotionally soothing because it helped our interaction feel more reciprocal; the exchange of gratitude was an unconscious recognition of partnership. For the first time, I truly empathized with patients in their moments of thanks. As a patient myself, I did not think about the surface-level embarrassment that I had worried about as a student. I did not feel obliged to be thankful, and it certainly did not matter whether the people I thanked were learners or not. My gratitude was not motivated by acknowledgment; it was driven by the profound emotion I felt after caring interactions and my desire for reciprocity. Next time a patient thanks me, I will not let self-conscious worries diminish their words. True thankfulness reflects deep humanistic connection and is unburdened by the hierarchies of medicine. Gracefully appreciating gratitude from others is an important lesson in the art of building a patient relationship. In the future, I will look patients in the eye and fully appreciate that solidification of partnership in the departing moments of a connection. Acknowledgments: The author wishes to thank Dr. Kunal Bailoor, Jean Torres, and Elena Lorenzana.

BACKGROUND & AIMS:Differences in outcomes of hepatocellular carcinoma (HCC) between countries have been largely attributed to variation in the conduct of surveillance and subsequent HCC treatment eligibility. However, differences in outcomes among those detected under surveillance have not been well described. We compared characteristics and prognosis between patients with surveillance-detected HCC from the United States (US) and Japan.METHODS:Patients in whom initial HCC was detected under surveillance between January 2006 and December 2015 from two centers in the US and two from Japan were included. Survival was compared between patients from the US and Japan using multivariable Cox regression analysis and propensity-score matched analysis. We performed subgroup analyses by liver disease etiology, tumor stage, and type of HCC treatment.RESULTS:Of 3788 HCC patients, 1797 (47.4%) were diagnosed under surveillance, 715 from the US and 1082 from Japan. Patients from the US diagnosed under surveillance had worse liver dysfunction and larger tumor burden than those from Japan. In multivariate analysis, US patients with surveillance-detected HCC had significantly worse survival than those from Japan (HR 1.17, 95% CI 1.00-1.35), which was also observed in propensity-score matched analysis. However, this difference was no longer significant after adjusting for treatment type (HR 1.07, 95% CI 0.92-1.25). When stratified by treatment type, survival was comparable between the two countries except lower survival among patients who underwent resection in the US versus Japan.CONCLUSIONS:Prognosis of patients with surveillance-detected HCC is poorer in the US than Japan, primarily driven by differences in treatment delivery. Studies are necessary to elucidate reasons for these differences.

Background Racial/ethnic disparities in prognosis have been reported in patients with hepatocellular carcinoma (HCC); however, few studies have evaluated racial/ethnic disparities in the context of insurance status. Aims Characterize racial/ethnic and insurance status in early tumor detection, receipt of curative therapy and overall survival in a multicenter diverse cohort of HCC patients from the USA. Study We included patients with HCC diagnosed between June 2012 and May 2013 at four centers in the USA. Generalized linear mixed effects models were used to compare early tumor detection (defined using Milan Criteria) and curative treatment receipt (liver transplantation, surgical resection, or local ablation) as a function of patient race/ethnicity and insurance status. A multivariable frailty survival model was used to compare risk of death between patient groups. Results Of 379 HCC patients (52.8% non-Hispanic White, 19.5% Hispanic White, 19.8% Black), 46.4% and 48.0% were found at an early stage and underwent curative therapy, respectively, and median overall survival of the cohort was 25.7 months. Early detection of HCC was associated with gastroenterology subspecialty care and receipt of HCC surveillance but not race/ethnicity or insurance status in adjusted models. However, commercial insurance was significantly associated with higher odds of curative treatment receipt, which in turn was the strongest correlate for overall survival. After adjusting for health system and insurance status, race/ethnicity was not associated with curative treatment receipt or overall survival. Conclusions Insurance status and access to gastroenterology subspecialty care may be important drivers of racial/ethnic disparities in prognosis among HCC patients.

Purpose: To conduct a large single-institution comparison of transarterial chemoembolization (TACE) and stereotactic body radiation therapy (SBRT) outcomes in similar groups of patients with hepatocellular carcinoma (HCC). Methods and Materials: From 2006 to 2014, 209 patients with 1 to 2 tumors underwent TACE (n=84) to 114 tumors or image guided SBRT (n=125) to 173 tumors. Propensity score analysis with inverse probability of treatment weighting was used to compare outcomes between treatments while adjusting for imbalances in treatment assignment. Local control (LC), toxicity, and overall survival (OS) were retrospectively analyzed. Results: The TACE and SBRT groups were similar with respect to the number of tumors treated per patient, underlying liver disease, and baseline liver function. Patients treated with SBRT were older (65 vs 61 years, P=.01), had smaller tumors (2.3 vs 2.9 cm, P<.001), and less frequently underwent liver transplantation (8% vs 18%, P=.01). The 1-and 2-year LC favored SBRT: 97% and 91%, respectively, for SBRT and 47% and 23% for TACE (hazard ratio 66.5, P<.001). For patients treated with TACE, higher alpha-fetoprotein (hazard ratio 1.11 per doubling, P=.008) and segmental portal vein thrombosis (hazard ratio 9.9, P<.001) were associated with worse LC. Predictors associated with LC after SBRT were not identified. Grade 3thorn toxicity occurred after 13% and 8% of TACE and SBRT treatments, respectively (P=.05). There was no difference in OS between patients treated with TACE or SBRT. Conclusions: Stereotactic body radiation therapy is a safe alternative to TACE for 1 to 2 tumors and provides better LC, with no observed difference in OS. Prospective comparative trials of TACE and SBRT are warranted. (C) 2017 Elsevier Inc. All rights reserved.

Hepatocellular carcinoma (HCC) staging guides patient prognosis and treatment allocation; however, there is no universally accepted staging system for HCC. The most widely endorsed staging system is the Barcelona Clinic Liver Cancer (BCLC) system, which incorporates tumor burden, functional status, and liver function.1Llovet J.M. Bru C. Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification.Semin Liver Dis. 1999; 19: 329-338Crossref PubMed Scopus (2940) Google Scholar We aimed to compare the discriminant ability of several staging systems for HCC in a geographically diverse multicenter US cohort. We conducted a retrospective cohort study of patients newly diagnosed with HCC at 4 US health systems between June 1, 2012, and May 31, 2013. Patients were identified by International Classification of Diseases, 9th revision, codes for HCC (155.0 or 155.2), tumor conference lists, and prospectively maintained databases. We adjudicated HCC cases to confirm they met diagnostic criteria, based on published criteria.2Bruix J. Sherman M. Management of hepatocellular carcinoma: an update.Hepatology. 2011; 53: 1020-1022Crossref PubMed Scopus (6606) Google Scholar We excluded patients with missing data for any of the included staging systems. Patient clinical course, including dates of treatment, follow-up imaging, and death, was recorded at each site. Outcomes were recorded from the clinical notes, and in the case of death, all attempts were made to verify the date of death including a search of local obituary listings. Patients were followed up from enrollment to death, referral to hospice care, or the end of the follow-up period. This study was approved by the Institutional Review Boards at each study site. We assessed the prognostic performance of each system (the Italian Liver Cancer, Hong Kong Liver Cancer [HKLC], Cancer of the Liver Italian Program, and the model to estimate survival in ambulatory patients with hepatocellular carcinoma [MESIAH] systems3Yau T. Tang V.Y. Yao T.J. et al.Development of Hong Kong Liver Cancer staging system with treatment stratification for patients with hepatocellular carcinoma.Gastroenterology. 2014; 146: 1691-1700 e3Abstract Full Text Full Text PDF PubMed Scopus (445) Google Scholar, 4A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients: the Cancer of the Liver Italian Program (CLIP) investigators.Hepatology. 1998; 28: 751-755Crossref PubMed Scopus (1195) Google Scholar, 5Yang J.D. Kim W.R. Park K.W. et al.Model to estimate survival in ambulatory patients with hepatocellular carcinoma.Hepatology. 2012; 56: 614-621Crossref PubMed Scopus (66) Google Scholar, 6Farinati F. Vitale A. Spolverato G. et al.Development and validation of a new prognostic system for patients with hepatocellular carcinoma.PLoS Med. 2016; 13: e1002006Crossref PubMed Scopus (90) Google Scholar) based on the Akaike information criterion (AIC),7Stone M. Akaike's criteria. Encyclopedia of biostatistics. John Wiley & Sons, Ltd, London, UK, 2005.Google Scholar the discriminatory ability linear trend chi-square,8Pourhoseingholi M.A. Hajizadeh E. Moghimi Dehkordi B. et al.Comparing Cox regression and parametric models for survival of patients with gastric carcinoma.Asian Pac J Cancer Prev. 2007; 8: 412-416PubMed Google Scholar and the concordance index (C-index).9Steyerberg E.W. Vickers A.J. Cook N.R. et al.Assessing the performance of prediction models: a framework for traditional and novel measures.Epidemiology. 2010; 21: 128-138Crossref PubMed Scopus (2672) Google Scholar We calculated the AIC and the linear trend chi-square based on separate Cox models for each staging system. We resampled the data set with replacement (bootstrap) 1000 times to calculate an empiric distribution for the C-index and the difference between C-indices for each staging system and pair of staging systems. We then used these empiric distributions to estimate a central 95% CI for each C-index and the difference between C-indices. All analyses were completed in SAS v 9.3 (SAS Institute, Cary, NC). In total, 320 patients met inclusion criteria. Baseline characteristics were notable for being predominantly male (75.3%), white (48.8%), and had a mean age of 61.0 ± 9.4 years. The most common liver disease etiology was hepatitis C (48.8%), and the majority of patients had Child–Turcotte–Pugh (CTP) class A liver disease (49.4%; CTP class B, 33.7%; and CTP class C, 16.9%). The median Eastern Cooperative Oncology Group score was 1 (interquartile range [IQR], 0–1). The median number of tumors was 1 (IQR, 1–3), and the median tumor diameter was 3.8 cm (IQR, 2.2–7.5 cm). Vascular invasion and metastases were present in 22.5% and 8.1%, respectively. The mean follow-up period was 382 ± 302 days, and the 1-year survival rate was 58.8%. The MESIAH system had the lowest AIC and the highest discriminatory ability linear trend chi-square, whereas the HKLC showed the highest C-index at 0.769. Notably, the BCLC system had the worst discriminant ability in all measures, including the highest AIC, lowest discriminatory ability linear trend chi-square, and lowest C-statistic. The Cancer of the Liver Italian Program and the Italian Liver Cancer systems were intermediate in their discriminant ability. Bootstrapped comparison of the C-indices of the staging systems is shown in Table 1. Although no staging system showed superiority over the others, both the HKLC and MESIAH had significantly higher C-indices than the BCLC (P = .004 and .026, respectively).Table 1Comparison of the C-Indices for the Staging SystemsABMean C-index difference between staging systems (Column A - Column B)95% CITwo-sided P valueITA.LI.CABCLC0.018-0.010 to 0.044.17HKLC-0.019-0.044 to 0.006.12CLIP0.005-0.019 to 0.030.69MESIAH-0.016-0.039 to 0.006.15BCLCHKLC-0.037-0.065 to -0.011.004CLIP-0.012-0.043 to 0.017.43MESIAH-0.034-0.064 to -0.005.026HKLCCLIP0.024-0.007 to 0.058.16MESIAH0.003-0.027 to 0.035.91CLIPMESIAH-0.021-0.049 to 0.006.1NOTE. Boldface indicates statistical significance.BCLC, Barcelona Clinic Liver Cancer; CLIP, Cancer of the Liver Italian Program; HKLC, Hong Kong Liver Cancer; ITA.LI.CA, Italian Liver Cancer; MESIAH, Model to Estimate Survival in Ambulatory HCC Patients. Open table in a new tab NOTE. Boldface indicates statistical significance. BCLC, Barcelona Clinic Liver Cancer; CLIP, Cancer of the Liver Italian Program; HKLC, Hong Kong Liver Cancer; ITA.LI.CA, Italian Liver Cancer; MESIAH, Model to Estimate Survival in Ambulatory HCC Patients. Accurate staging is central to prognosticating and allocating treatment in patients with HCC. We report the comparative ability of several HCC staging systems in a multicenter, geographically and demographically diverse cohort in the United States. We found that the HKLC and MESIAH staging systems outperformed the BCLC in discriminant ability. Our study had some notable strengths and weaknesses. First, we captured receipt of all HCC treatments at our institutions, however, there could be ascertainment bias for medical care received at outside institutions. In addition, our study was conducted at 4 academic centers and our results may not be generalized to all practice settings. In conclusion, we have shown that the HKLC and MESIAH staging systems are superior to the widely accepted BCLC in a multicenter US cohort. Notably, the maximum C-index in our cohort was 0.769, which is in the very good range. To improve on this, future staging systems may rely on features such as imaging characteristics or tumor genetic alterations, rather than solely on laboratory and patient-level variables. While better systems are being developed, we have shown that some of the more contemporary systems for HCC staging deserve stronger consideration for more widespread adoption.

4087 Background: TACE is a standard treatment for patients (pts) with HCC. SBRT is a newer, noninvasive therapy. There have been no comparative studies to date. Thus, we examined TACE and SBRT outcomes. Methods: After IRB approval, institutional HCC and radiotherapy databases were queried for pts receiving TACE or SBRT for 1-2 tumors and combined with a diagnosis and billing code query for HCC, TACE, and SBRT. Pts with main branch portal venous (PV) involvement, extrahepatic spread, and Child Pugh C cirrhosis were excluded, since they are not candidates for TACE. Inverse probability weighting, via a propensity score, was used to adjust for imbalances between treatment groups. Local control (LC), overall survival (OS), and toxicity were compared. LC for was defined as no tumor growth within or immediately adjacent to the TACE cavity or original tumor. Results: From 2006-2014, 84 pts with 114 tumors were treated with TACE and 125 pts with 173 tumors with SBRT. Median follow-up was 28 months (1.8-103) and 16 months (0.2-98) for pts treated with TACE or SBRT, respectively (p<0.001). Pts treated with TACE were younger (61 vs 65 yrs, p=0.01) and had slightly larger tumors (2.9 vs 2.3 cm, p<0.001). In propensity adjusted analysis, 1- and 2-yr LC favored SBRT: 97% and 91% for SBRT and 41% and 18%, for TACE (HR 18.8, 95% CI 6.7-52.7, p<0.001). Increasing tumor size (HR 1.2 per cm, 95% CI 1.05 - 1.23, p<0.001) and partial PV tumor thrombus (HR 7, 95% CI 2.73 - 15.2, p<0.001) predicted for worse LC in pts treated with TACE, but not with SBRT. Grade 3+ toxicity occurred after 14% and 7% of TACE and SBRT treatments, respectively (p=0.05). From HCC diagnosis, SBRT was initiated a mean of 9 months later than TACE (p<0.001), and more patients underwent liver transplantation after TACE (18% vs. 8%, p=0.01). After adjustment for baseline liver function and transplantation, overall survival was not significantly different (HR = 0.73, 95% CI 0.48 – 1.12, p =0.15). Conclusions: SBRT is a safe alternative to TACE for 1-2 tumors, and provides better LC, with no difference in OS. Prospective comparative trials of TACE, SBRT, and other ablative therapies are warranted.