Akhter, Maheen F.

Objective Preparation for a career in plastic and reconstructive surgery (PRS) begins long before the residency application process. Given the challenging nature of matching into integrated PRS, the expectations for competitive applicants, including research productivity and networking at conferences, incur significant expenses. Our study is the first to detail the comprehensive costs of pursuing PRS, highlighting many hidden expenses that precede the application process. Design and Setting A branched logic survey was created to inquire about respondents' demographics, personal finances, expenses related to education and research, and opinions on the comprehensive costs of pursuing PRS. Qualitative and quantitative data were collected and analyzed using descriptive statistics. Participants The survey was distributed to PRS residency applicants in the 2023–2024 cycle and to senior members of a virtual PRS research group. The survey achieved a 28.9% response rate. Results Most respondents were fourth-year medical students (57.3%) and attended a school without a home integrated residency program (42.7%). Of students who pursued a research year (37.1%), 40.7% were unpaid, and 53.3% reported living expenses exceeding their income. Most attended more than 5 PRS conferences (29.9%), corresponding to a median total cost of $2000 to $3000. Fourth-year students typically participated in 3 away rotations (40.0%) at a cost of $6000 to $9000. The financial burden of pursuing a career in PRS, including PRS-related extracurricular activities and application-associated costs, is estimated to be $33,400–$45,479. Nearly all respondents (96.6%) believed this cost was too high or excessively high; however, 93.3% determined that it was probably or definitely worth a career in PRS. Conclusions The lofty costs associated with pursuing PRS are unsustainable for many. Additional efforts should be made to reduce financial barriers for PRS applicants. Ensuring funding to all students pursuing a research year, diversifying scholarships for conference attendance and away rotations, increasing loan forgiveness opportunities, and expanding use of lower-cost application options such as the Plastic Surgery Common Application are potential solutions to offset the cost of pursuing PRS.

Background: Poly (ADP-ribose) polymerases (PARPs) are a highly conserved family of enzymes whose main function is to preserve genomic integrity following DNA damage. PARP inhibitors (PARPi) are increasingly used in cancers with deficiencies in homologous recombination. Clinical trials in breast and ovarian cancers have led to several FDA approvals in recent years, and their use in clinical practice is continuing to rise. It is thus necessary to assess their adverse event (AE) profile. Method: Literature search was performed using Ovid MEDLINE, EMBASE, CENTRAL, and Scopus (inception through October 26, 2018). Eligible studies were phase 3, randomized, controlled trials that compared single agent PARPi to placebo or standard treatment. Number of patients treated and AEs reported were recorded. Observed incidence of AE was reported with 95% CI. Heterogeneity was evaluated using Cochran Q statistic and I2 statistics quantified the proportion of heterogeneity not due to chance. Results: Databases revealed 869 references. Of these, 6 were eligible: 2 in breast cancer (OlympiAD, EMBRACA) and 4 in ovarian cancer (NOVA, ARIEL3, SOLO1, SOLO2). PARPi included niraparib (NOVA), olaparib (OlympiAD, SOLO1, SOLO2), rucaparib (ARIEL3), and talazoparib (EMBRACA). Of 1,685 patients who received PARPi, incidence of any AE, regardless of grade, was 98.5% (95% CI, 97.2–99.2%). Common AEs were: nausea (incidence rate, 68.9% and 95% CI, 58.7%–77.5%), fatigue (56.3%, 45.3%–66.8%), anemia (46.3%, 37.2%–55.8%), vomiting (33.7%, 29.5%–38.3%), neutropenia (24.7%, 15.3%–37.4%), headache (23.9%, 19.9%–28.4%), and reduced appetite (21.7%, 19.3%–24.3%). Myeloid neoplasms were rare (1.2%, 0.7%–1.9%). Incidence of grade 3 or higher AE was 44.3% (30.2%–59.5%) and often related to myelosuppression, specifically anemia (24.7%, 15.3%–37.4%), neutropenia (10.7%, 6.6%–16.9%), and thrombocytopenia (5.0%, 1.7%–14.0%). Incidence of serious AE was 24.3% (19.4%–29.9%); dose interruption occurred in 53.3% (41.2%–65.0%) and dose reduction occurred in 39.2% (23.6%–57.4%). 10% (7.4%–13.6%) of patients discontinued therapy due to AE. Death due to AE was rare; less than 1% (0.4%, 0.2%–0.8%) in all trials. Conclusion: Myelosuppression and gastrointestinal toxicities were the most commonly reported AE in 6 randomized phase 3 trials of PARPi for breast and ovarian cancers. Therapy was rarely discontinued due to AE. It remains to be seen whether these results will be reflected in clinical practice.