Streamlining Surgery to Enhance Outcomes
Rise of de-escalation trends requires educational shift to transform disease management.
Surgical strategies and procedural techniques have historically advanced over time and continue to do so, particularly in oncologic disease management. Only recently have de-escalation trends emerged in gynecologic oncology and, even more recently, been evaluated to understand the impact on physicians and patients.
Alexa Kanbergs, MD-ScM, MS, a gynecologic oncology fellow at MD Anderson Cancer Center in Houston, presented “Surgical de-escalation within gynecologic oncology” yesterday.
Identifying the Trend
The purpose of surgical de-escalation is to make interventions — when needed — less invasive, thereby minimizing damage, reducing risk of complications, and improving patient outcomes. It is a practice that has become more firmly rooted and regulated in other oncology specialties and medical fields, said Dr. Kanbergs.
“Historically, cancer treatment paradigms prioritized maximal surgical resection to ensure oncologic control. The belief was that more extensive surgery correlated with better survival outcomes,” she said.
Innovations in technology have allowed for more precise imaging and defined molecular pathology, Dr. Kanbergs said, as well as a deeper understanding of tumor biology. This progress, along with available targeted drug treatments and immunotherapy, is leading the way to “personalize cancer management.”
Due to the extensive time and cost of surgical trials, this was the first of its kind to research the in-depth impact the revolutionary shift has had on surgeons and their educators.
The study, which was published in JAMA Network Open, analyzed data of 1,218,490 patients from the National Center Database (NCDB) who were diagnosed with clinical stage I-IV endometrial, ovarian, cervical, or vulvar cancer between Jan. 1, 2004, and Dec. 31, 2020.
In the 16-year time period, the clinical researchers observed a decrease in the number of people undergoing oncologic surgeries and an increase in the use of laparoscopic techniques and other minimally invasive methods, confirming the move toward surgical de-escalation. They also saw higher adoption of sentinel lymph node dissection and a reduction in complete lymphadenectomy in all cancer types except for ovarian cancer.
“For me, the most surprising finding was the limited percentage of patients with low-risk endometrial cancer who had ovarian preservation,” Dr. Kanbergs said. “This was unexpected, given current guidelines provide support for ovarian preservation in low-risk cases.”
Filling the Knowledge Gap
These results indicate a strong trend in the right direction in the first two decades of the 21st century. However, according to Dr. Kanbergs, a recent survey assessed the readiness of gynecologic oncology graduates. Approximately three-fourths (76%) of new physicians admitted feeling comfortable to perform a radical hysterectomy, and only 60% said they felt confident to complete a laparoscopic para-aortic lymphadenectomy.
“De-escalation strategies have significant implications. For physicians, it necessitates an evolution in surgical training and daily practice,” she said. “As certain procedures become less common, maintaining proficiency in more radical surgeries becomes a challenge, particularly for trainees and early-career gynecologic oncologists.”
Dr. Kanbergs said more research is required to better grasp the full impact and implementation of surgical de-escalation trends within gynecologic oncology, and she hopes attendees take away this particular call to action.
“As the field shifts toward less invasive techniques, it is essential to ensure that the next generation of gynecologic oncologists is still adequately trained in more complex, rare, or radical procedures,” she said.
Now armed with this base knowledge, researchers can also dedicate future studies to examining the correlation between the trends and patient outcomes, such as safety, adverse events, recovery, quality of life, and satisfaction measures. Equitable access to care is also an important factor to analyze and ensure as surgical de-escalation continues to grow, Dr. Kanbergs said.
