Surgical De-escalation Increases in Gynecologic Oncology

TOPLINE:

An analysis of over 1.2 million gynecologic cancer cases revealed a trend towards surgical de-escalation, with researchers observing a growing shift to minimally invasive techniques and sentinel lymph node dissection for many but not all procedures.

METHODOLOGY:

• Surgical de-escalation in gynecologic cancers is a strategy to optimize patient outcomes, minimize the adverse effects associated with extensive surgical interventions, and improve patients’ quality of life; however, a comprehensive analysis of de-escalation trends is lacking.
• Researchers evaluated data from the National Cancer Database from January 2004 to December 2020 evaluating 1,218,490 patients with gynecologic cancers, including those with cervical (13.7%), endometrial (56.3%), ovarian (24.7%), and vulvar (5.2%) cancers, between.
• Surgical de-escalation was defined as the use of less invasive surgical approaches or reduction in the extent of surgery.
• Researchers analyzed the surgical de-escalation trends, including the use of minimally invasive surgery and sentinel lymph node dissection, as well as assessments of organ preservation during surgical management.

TAKEAWAY:

• Overall, the percentage of patients undergoing any surgical treatment, including minimally invasive surgery, decreased from 2010 to 2020. In this time, the adoption of minimally invasive surgery increased significantly for endometrial cancer (45.8% to 82.2%) for an average annual percentage change (AAPC) of 4.6%, and ovarian cancer (13.3% to 37.0%; AAPC, 9.4%); however, the use of laparoscopy for cervical cancer fluctuated, peaking at 69.7% in 2017 before declining to 49.9% in 2020.
• Sentinel lymph node dissection rates increased substantially from 0.2% to 10.6% for cervical cancer (AAPC, 44.0%), 0.7% to 39.6% for endometrial cancer (AAPC, 51.8%), and 12.3% to 36.9% for vulvar cancer (AAPC, 10.7%), while rates of complete lymphadenectomy decreased, with annual percentage changes of −1.6% for cervical, −5.8% for endometrial, and −4.3% for cervical cancers.
• From 2012 to 2020, the rates of radical hysterectomy for early-stage cervical cancer with a tumor size under 2 cm increased from 58.1% to 68.8% (AAPC, 2.0%), while the rates of simple hysterectomy decreased from 42.0% to 31.2% (AAPC, −2.8%).
• Fertility-sparing surgery rates increased from 17.8% in 2004 to 28.1% in 2020 (AAPC, 3.1%) in patients with cervical cancer aged less than 40 years; however, among younger patients with endometrial cancer, the rate of ovarian preservation during hysterectomy declined from 20.6% to 6.0% and the rate of ovarian removal increased from 79.5% to 94.0%.

IN PRACTICE:

“This cohort study illustrates a trend toward de-escalation in gynecologic oncology,” characterized by a growing adoption of minimally invasive surgery and sentinel lymph node evaluation, the authors wrote. “However, we observed varying levels of de-escalation in surgical radicality.”

SOURCE:

The study, led by Alexa Kanbergs, MD-ScM, MS, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, was published online in JAMA Network Open.

LIMITATIONS:

The study findings were limited by potential inaccuracies, variability, and underreporting of surgical and treatment codes. While alternative analyses were used to validate the findings in cases of underreporting, certain analyses of surgical trends could not be performed due to limited coding availability for specific disease sites.

DISCLOSURES:

This study received funding support from the National Institutes of Health and National Cancer Institute through multiple awards. Additional funding came from the Department of Defense and Fundación Alfonso Martín Escudero. One author reported receiving personal fees from Guidepoint and Sago outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.