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What is Gynecologic Oncology?
Gynecologic oncologists are physicians committed to the comprehensive treatment of women with cancer. After completing four years of medical school and four years of residency in obstetrics and gynecology, these physicians pursue an additional three to four years of training in gynecologic oncology through a rigorous fellowship program overseen by the American Board of Obstetrics and Gynecology. Gynecologic oncologists are not only trained to be skilled surgeons capable of performing wide-ranging cancer operations, but they are also trained in prescribing the appropriate chemotherapy for those conditions and/or radiation therapy when indicated. Frequently, gynecologic oncologists are involved in research studies and clinical trials that are aimed at finding more effective and less toxic treatments to further advance the field and improve cure rates.
Studies on outcomes from gynecologic cancers demonstrate that women treated by a gynecologic oncologist have a better likelihood of prolonged survival compared to care rendered by non-specialists. Due to their extensive training and expertise, gynecologic oncologists often serve as the “team captain” who coordinates all aspects of a woman’s cancer care and recovery. Gynecologic oncologists understand the impact of cancer and its treatments on all aspects of women’s lives including future childbearing, sexuality, physical and emotional well-being—and the impact cancer can have on the patient’s whole family. How many gynecologic oncologists are there and how can I find one?
There are only about 1000 board-certified gynecologic oncologists in the United States. Most are members of the Society of Gynecologic Oncologists.
Cervical cancer is a complex disease that often requires a multidisciplinary approach to optimize treatment for best outcomes. Because of the years of subspecialty training, the gynecologic oncologist has the unique skill set necessary to properly diagnose, stage and direct the treatment of patients with cervical cancer. For women with early stage cervical cancer, the gynecologic oncologist is uniquely qualified to perform the highly specialized procedure of radical hysterectomy. Gynecologic oncologists have pioneered fertility-sparing minimally invasive surgical approaches, including robotic surgery, to improve the quality of life and minimize side effects of treatment for women with cervical cancer. For women with advanced-stage disease, the gynecologic oncologist has the unique ability and qualifications to individualize care plans while working with the multidisciplinary team, including the radiation oncologist. Gynecologic oncologists are specially trained to prescribe and administer the chemotherapy that is specifically timed with radiation therapy in advanced stage cervical cancer. Lastly, gynecologic oncologists are critical providers of follow-up care for women after treatment for cervical cancer, as early detection of a recurrence in the central pelvic area may be cured with a specialized operation, called a pelvic exenteration, which is the most complex operation for which the gynecologic oncologist is trained. . Gynecologic oncologists are active and productive researchers, and have been the leaders in designing and performing many of the clinical and translational trials that have produced the advances in prevention and treatment that are described in this report.
It is important for women who are found to have a pelvic mass suspicious for cancer to be aware of the specialty of gynecologic oncology. Over the past five years, educational efforts directed towards physicians and the public have focused on raising awareness of the importance of referral of women with known or suspected gynecologic cancer to a gynecologic oncologist. This is critically important for women with ovarian cancer because, as the data demonstrates, women initially treated by a gynecologic oncologist have improved outcomes and are more likely to receive standard therapy.
As described in the first section of this report, a specialist in gynecologic oncology has completed residency training in obstetrics and gynecology and an additional 3-4 year fellowship of subspecialty training in gynecologic oncology. These additional years of subspecialty training provide the unique set of surgical skills required to provide appropriate and comprehensive care for women with gynecologic cancers. The benefits of this specialized training is highlighted in the study results reported below
An analysis of SEER data for patients treated between 1992-1999 by Earle et al., demonstrates the lack of specialist care given to women with ovarian cancer in the United States. Reporting on over 3,000 women aged 65 and older who underwent primary surgery for ovarian cancer, the authors found that only 33 percent were treated by a gynecologic oncologist, while the remainder were operated on by non-specialists in either general gynecology or general surgery. When patients had their initial surgery performed by a gynecologic oncologist, they were more likely to undergo the appropriate and recommended procedures. Surgical treatment of early-stage disease should consist of thorough staging procedures, including lymph node removal and multiple biopsies of peritoneal surfaces. Debulking (cytoreductive) procedures are needed for adequate treatment of patients with advanced stage disease. In addition, this study noted that the administration of postoperative chemotherapy when indicated was significantly more likely to happen when patients had their initial surgery performed by a gynecologic oncologist.
Other authors have reported similar findings. Goff reported on over 10,000 women in nine states undergoing surgery for ovarian cancer. Among the most important factors for receiving appropriate surgical management were surgeon specialty of gynecologic oncologist and the volume of cases performed by the surgeon annually. In a separate report, this same author found that the performance of appropriate staging procedures in cases of suspected early stage disease, including lymph node removal, were less likely to occur when women had surgery in a low volume centers and the surgery was performed by a non-gynecologic oncologist.
Current state of the art in the surgical treatment of advanced stage ovarian cancer includes initial surgical resection of the maximal volume of disease in patients who are able to undergo such surgery. This stems from long-held observations and supporting data that indicates the relationship between the smallest amount of residual disease and longest survival. In addition, recent studies also demonstrate the important correlation between the surgical effort and the amount of residual disease—greater surgical effort, including bowel resection and removal of cancer from the upper abdomen, results in smaller residual tumor volumes. Because of the recognized importance of the aggressiveness of the initial surgical resection in advanced ovarian cancer, it is unlikely that a randomized trial will ever be performed on this subject. However, two recent retrospective studies demonstrate the importance of surgical approach to ovarian cancer on the outcomes of both residual disease and overall survival.
Aletti et al., demonstrated the impact of surgeon tendency to employ a more aggressive surgical approach to advanced stage ovarian cancer. The authors found a strong correlation between the use of radical procedures during surgery and the resultant lower volume of residual disease. These procedures include bowel resection, splenectomy and removal of tumor from the diaphragm- procedures requiring the unique surgical skill set acquired in the training of a gynecologic oncologist. For those patients operated on by surgeons who most often tended to use these radical surgical procedures to remove disease, the median survival time was more than twice as long (5.9 years vs. 2.5 years) compared to those women operated on by surgeons least likely to employ such procedures. The authors observed that the primary determinant of overall survival in the subset of patients with most extensive disease was the performance of radical surgical procedures to achieve optimal cytoreduction.
Similar conclusions regarding the impact of a more aggressive surgical approach were reported by Eisenhauer et al., when reporting the effect of altering the surgical approach to ovarian cancer. Beginning in the year 2000, the gynecologic oncologists at one institution made a determined effort to employ upper abdominal surgical resection in the treatment of ovarian cancer. Comparison of the outcomes between patients treated during the 3 years prior to those patients treated during the. 3 years after the change in approach demonstrated significantly higher rates of optimal cytoreduction. More importantly, the group having surgery during the more recent 3 year period also experienced improved overall survival compared to those operated on before the change in approach. These results were obtained with satisfactory outcomes in terms of minor and major operative complications.
Unfortunately, the survival benefit of more radical surgical approaches to ovarian cancer is not currently experienced by most women in the United States. In reporting on 10,432 women with ovarian cancer treated across nine states, Goff found that patients treated by gynecologic oncologists were significantly more likely to undergo cytoreductive procedures compared to those treated by non-specialists. However, only 52 percent of patients were treated by high-volume surgeons who performed at least 10 ovarian cancer cases annually. Moreover, over 30% of patients were not treated by gynecologic oncologists.
In an analysis of state cancer registry data, Chan et al., found only 34 percent of patients received care by a gynecologic oncologist, but those who did had a longer 5 year disease-specific survival compared to those patients who were not treated by a gynecologic oncologist.
In aggregate the data is quite convincing. The specialty of gynecologic oncology has made significant advances in the safe employment of radical surgical procedures aimed at reducing volume of disease even in advanced cases as illustrated in the studies described above. Our specialty has focused intense effort through research and continuing education to improve the rates of complete and optimal cytoreduction for patients nationally. Treatment by the appropriate cancer specialists—a gynecologic oncologist—is the essential first step in ensuring that a woman with ovarian cancer experiences the improved survival afforded by optimal initial surgical effort. Additionally, the likelihood of receiving the recommended standard of care chemotherapy is highest when patients care has included a gynecologic oncologist.
The staging system adopted by the International Federation of Gynecology and Obstetrics in 1988 classifies endometrial cancer by whether tumor has spread to the fallopian tubes and ovaries, lymph nodes, peritoneal cavity or the upper abdomen. Thus accurate staging of endometrial cancer can only be done by surgery that takes washings of the pelvis, removes pelvic and para-aortic lymph nodes, and examines the upper abdomen in addition to removing the uterus, ovaries and tubes. Through their 3 to 4 years of fellowship training, gynecologic oncologists develop the unique surgical skills necessary to perform complete therapeutic and staging surgery for women with endometrial cancer.
As noted above, an important benefit for the patient is that pathologic information provided by complete and accurate surgical staging is used to determine prognosis and need for additional therapy in women found to have high-risk intrauterine factors for recurrence, or evidence of cancer that has spread outside of the uterus. Perhaps as important as determining which patients do need additional treatment after surgery, thorough surgical staging of an endometrial cancer patient may allow for the avoidance of adjuvant radiation therapy. Cost-effectiveness analysis has demonstrated that avoiding additional treatment, when appropriate for Stage I patients, reduces costs by 31 percent and had minimal effect on survival, but prevents complications from over-treatment.
That primary surgical staging by a gynecologic oncologist in women with endometrial cancer decreases the use of adjuvant radiation therapy was demonstrated in the “real-world” setting by two recent studies. Using data from a community-based health system, Roland et al found that complete surgical staging by a gynecologic oncologist reduced the use of adjuvant radiation therapy by 100% in the patients at lowest risk for recurrence. In a 2005 survey of SGO members that documented that 71 percent of responders performed complete surgical staging of their endometrial cancer patients, Naumann et al also found radiation therapy was recommended less often for endometrial cancer patients by SGO members in 2005 compared to 1999, and vaginal cuff radiation was preferred when necessary.. Thus the balance of risks, benefits and costs for additional treatment after surgery may be best decided by the gynecologic oncologist. The additional 30 minutes required for the thorough surgical staging of an endometrial cancer patient may avoid adjuvant radiation therapy. Without surgical staging, the lack of confidence that the patient truly has only Stage I cancer may lead to over-treatment.
One explanation of why survival is improved after surgical staging by a gynecologic oncologist is the possibility of removal of microscopic metastatic disease that is not detectable by standard pathologic assessment. Three recent retrospective studies, each describing a single institution’s experience, suggest a potential therapeutic benefit of lymphadenectomy in primary surgery for early endometrial cancer based on improved survival observed in hi-risk patients who had complete surgical staging. In a retrospective study of over 12,000 women with early endometrial cancer in the SEER database, Chan and colleagues found extensive lymph node resection was associated with improved survival in intermediate/high risk patients. For women presenting with Stage III or IV endometrial carcinoma, retrospective reports suggest the amount of disease left after primary surgery is an important determinant of survival and an aggressive cytoreductive approach similar to that employed for patients with advanced ovarian carcinoma is recommended.
Gynecologic oncologists have the unique training and skills to provide complete surgical staging for women with early endometrial cancer, and resection of metastatic disease for women who present with advanced disease. In 1999, the Society of Gynecologic Oncology Outcomes Committee documented the ability of gynecologic oncologists to safely and effectively perform complete surgical staging on patients with endometrial cancer. In a pilot project of 300 patients undergoing complete surgical staging, the mean length of stay in the hospital was 3.3 days, the operative time was 119 minutes and 8 patients required blood transfusions. A more recent patterns of care study of a community-based health system found gynecologic oncologists provided care for less than half of over 200 consecutive patients with endometrial cancer, but completed surgical staging more frequently than other providers with similar short hospital stay and low complication rates as was observed in the SGO pilot project.
Having care by a gynecologic oncologist benefits women with endometrial cancer through the provision of comprehensive surgical staging which gives important information about their risk for cancer recurrence. Armed with this knowledge, the patient and her gynecologic oncologist can make informed and appropriate choices about whether to get radiation therapy or chemotherapy after surgery. Gynecologic oncologists have been and will continue to be leaders in clinical trials to expand the use of minimally invasive surgical techniques, and develop new treatments for women with advanced and recurrent disease.
Vaginal cancer is a very rare type of gynecologic cancer that requires special expertise to make the diagnosis, evaluate the extent of disease, and develop a plan for treatment. Gynecologic oncologists go through 3 to 4 years of specialty fellowship training to acquire the skills needed to evaluate and treat all gynecologic cancer including vaginal cancer. Every woman with known or suspected vaginal cancer should seek treatment from the appropriate specialist—a gynecologic oncologist—to ensure she has the best chance for cure.
Gynecologic oncologists spend 3 to 4 years in specially designed fellowship training to acquire the surgical and diagnostic skills to care for women with all gynecologic cancers including vulvar cancer. Because of the rarity of vulvar cancer and the particular challenges with regards to radical surgery on the vulva, including preservation of form and function as well as the requirement for removal of lymph nodes from the groin as part of staging, all women with vulvar cancer should receive care from the appropriate specialist-a gynecologic oncologist- in order to ensure their best chance for cure.