Hope on the Horizon: Evolving Strategies in Gynecologic Cancer Surgery

Each year, more than 100,000 women in the United States are diagnosed with gynecologic cancers — those that start in the uterus, ovaries, cervix, fallopian tubes, vagina or vulva. Gynecologic oncology is seeing pivotal shifts, driven by breakthrough research, emerging data and clinical trials. Together, these are redefining treatment with an emphasis on more-precise patient-centered care.

For September’s Gynecologic Cancer Awareness Month, two experts from Baptist Health Cancer Care, Thomas Morrissey, M.D., director of gynecologic oncology at Lynn Cancer Institute and Ryan Kahn, M.D., a gynecologic oncologist at Miami Cancer Institute, recently discussed advances in care.

“It’s clear that we’re moving into a new era of gynecologic cancer care,” Dr. Morrissey says. “We’re learning when to scale back, when to be aggressive and how to tailor treatments in smarter, more targeted ways. It’s not just about survival anymore. It’s about quality of life, long-term outcomes, and making each decision count.”

In Ovarian Cancer, Which Treatment Comes First?

Ovarian cancer is the fifth leading cause of cancer deaths among women and the most fatal gynecologic malignancy in the U.S. Due to the asymptomatic nature of early-stage ovarian cancer and the lack of effective population-wide early screening methods, about 80 percent of women with ovarian cancer present with advanced disease. For these patients, surgical cytoreduction and systemic chemotherapy is standard of care; however, the timing of which strategy to use first remains controversial.

The breakthrough TRUST trial presented earlier this year evaluated strategies for the most effective treatment strategy for ovarian cancer. “The TRUST study looks to answer which patients may benefit most from upfront surgery and which may benefit most from neoadjuvant chemotherapy, which is chemotherapy before surgery to shrink the tumors,’” Dr. Kahn explains.

According to the study, patients did the best when doctors were able to remove all visible cancer at surgery, no matter when the surgery happened. However, the group that had surgery first tended to stay cancer-free longer before the disease came back. Overall survival was also slightly better in the surgery-first group, although this was not shown to be statistically significant.

Where You Have Your Surgery Matters, Too

The study demonstrates that the scheduling of surgery may not be as important as previously thought — however, what matters most is the quality of the surgery and where it is performed, Dr. Kahn says. Research has demonstrated that specialized centers with experienced teams like Miami Cancer Institute and Lynn Cancer Institute have better patient outcomes.

“Patients need to see a gynecologic oncologist at a center that has the ability to make the maximal attempt at an initial surgery, because that gives the patient the best overall outcome,” Dr. Morrissey says. “If you do a big operation but you’re only able to remove 80 or 90 percent of the tumor, you’re really not helping them very much, based on data that we have when following those patients.”

Starting with chemotherapy followed by surgery is still a good option for certain patients — for example, if the cancer is very widespread or if the patient has other health issues. But if it’s possible and safe, surgery first with complete removal of the cancer is usually the best option.

Who Is Most Likely to Benefit From Surgery?

One of the big challenges in ovarian cancer surgery is figuring out which patients will benefit from surgery first. Scans like CTs and PETs are good, but they can miss tiny spots of cancer, especially in tricky areas like the bowel or the lining of the abdomen.

As a fellow at Memorial Sloan Kettering Cancer Center, Dr. Kahn participated in improving upon a scoring algorithm that combines scan results with patient information to predict whether a surgeon will likely be able to remove all visible cancer. Using this system, the team was able to remove all visible cancer in more than 80 percent of patients, he says, while avoiding unnecessary big surgeries in almost all others.

“The goal isn’t perfection — it’s to get as close as possible. And with new technology, including artificial intelligence and better data analysis, these tools will only keep improving in the future,” Dr. Kahn says.

Reducing Radical Surgery for Cervical Cancer

Depending on the stage, standard treatment for certain cervical cancers is a radical or modified radical hysterectomy, which removes the uterus, fallopian tubes, cervix and surrounding tissue called the parametria. Radical surgery can cause side effects, especially affecting bladder function.

A recent study called the SHAPE trial investigated the use of a simple hysterectomy (also called an extrafascial hysterectomy) that spared some of the surrounding tissue in cases of small, low-risk tumors.Results showed that cancer survival was the same as with radical surgery, but with fewer side effects and less urinary problems.

This is good news for patients and doctors, who are always looking for ways to treat cancer effectively while reducing side effects. “We’re always trying to get better in what we do, and to do better for our patients. Sometimes that’s dialing down the surgery,” Dr. Kahn says. “This is another thing that we’re seeing over time, and this could be a great option for our patients.”

Recent studies suggest that minimally invasive laparoscopic or robotic-assisted radical hysterectomies for cervical cancer have a slightly higher risk of the cancer coming back compared to open surgery, with worse survival outcomes.

For example, the ROCC trial, in which Miami Cancer Institute is a participating site, is investigating techniques to contain the cancer during minimally invasive surgery to see if outcomes are similar to open surgery. This has the potential to lead to reduced post-operative pain and expedited recovery.

“That would be a much better option for patients as far as recovery and a shorter hospital stay if it can be proven that the minimally invasive approach could have similar outcomes,” Dr. Morrissey says.

New Options In Gynecological Oncology

Very promising advances in gynecologic cancer care are also occurring outside the operating room.

Dr. Morrissey and Dr. Kahn note the success being achieved with targeted checkpoint inhibitor immunotherapy medications that help the patient’s own immune system fight cancer cells, as well as antibody-drug conjugates (ADCs) that target tumors directly with a payload of chemotherapy medication while sparing healthy tissue.

“These medications are making a difference for our patients and extending survival,” Dr. Kahn says. “I think it’s setting a kind of blueprint for the future of systematic therapies. The more tools we have as physicians to help our patients, the better.”

Thomas Morrissey, M.D., director of gynecologic oncology at Lynn Cancer Institute, part of Baptist Health, at Boca Raton Regional Hospital

Ryan Kahn, M.D., a gynecologic oncologist at Baptist Health Miami Cancer Institute