In Brief | Oncology | Women's Health | Surgery
Surgical De-escalation Within Gynecologic Oncology
Time to read: 04:23
Time to listen: 08:21
Originally Published: 8 January 2025
Sourced: JAMA Network Open
Type of article: In Brief
MedED Catalogue Reference: MCC002
Category: Oncology
Cross Reference: Surgery, Women's Health
Keywords: oncology, gynaecology, surgical interventions, radiation therapy
Surgical de-escalation in gynaecologic oncology has been found to enhance outcomes, reduce morbidity, and lower costs. However, caution is advised to ensure equitable access, effective implementation, and appropriate training, especially in resource-limited settings with rising cancer rates.
This article is a review of recent studies originally published in JAMA Network Open, 8 January 2025. It does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information.
De-escalation, as defined by the European Society for Medical Oncology Precision Medicine Working Group, involves omitting a segment of standard treatment, shortening the duration of treatment, or both while maintaining survival rates and reducing patient burden.
In the past 15 years, the approach has gained significant traction in medical oncology. The goal is to optimise patient outcomes, reduce the adverse effects of extensive surgical interventions, and improve overall quality of life.
In gynaecologic oncology, surgical de-escalation refers to techniques that minimise tissue injury and preserve tissue integrity during cancer-related operations. Over the past decade, specific approaches, including laparoscopic techniques, sentinel lymph node (SLN) biopsies, and selective organ removal, have demonstrated efficacy in maintaining oncologic outcomes while reducing surgical burden.
Despite these advances, no comprehensive analysis has examined surgical de-escalation trends across the spectrum of procedures performed by gynaecologic oncologists.
Study Purpose
In this study, researchers evaluated the adoption of surgical de-escalation techniques in the field of gynaecologic oncology using data from the American National Cancer Database (NCDB).
A broader understanding of these trends will provide insights into the adoption and effectiveness of de-escalation strategies, paving the way for future research to enhance patient care.
Study Methodology
This cohort study utilised prospectively collected data from the NCDB spanning January 2004 to December 2020.
The study population comprised women in the United States diagnosed with clinical stage I to IV endometrial, ovarian, cervical, or vulvar cancer.
The primary exposure was a diagnosis of these cancers, and the primary outcome was surgical de-escalation. This encompassed the receipt of surgical intervention, the surgical approach, lymph node assessment type, and salvage interventions for disease-affected organs.
To assess trends, a Poisson model estimated the average annual percentage change (AAPC) in surgical treatment rates.
Findings
A total of 1,218,490 patients (mean age at diagnosis: 61.2 years) were included in the study.
Key findings included:
Decreased Surgical Rates
Over the study period, surgery rates declined across all cancer types as follows
Cervical cancer: 47.4% to 39.9% (AAPC: −1.3%).
Ovarian cancer: 72.0% to 67.9% (AAPC: −0.5%).
Endometrial cancer: 83.7% to 79.1% (AAPC: −0.5%).
Vulvar cancer: 81.1% to 72.6% (AAPC: −1.3%).
Increased Use of Minimally Invasive Surgery (MIS)
Endometrial cancer: 45.8% to 82.2% (AAPC: 4.6%)
Ovarian cancer: 13.3% to 37.0% (AAPC: 9.4%)
Adoption of Sentinel Lymph Node Dissection
Endometrial cancer: 0.7% to 39.6% (AAPC: 51.8%)
Cervical cancer: 0.2% to 10.6% (AAPC: 44.0%)
Vulvar cancer: 12.3% to 36.9% (AAPC: 10.7%)
Concurrently, complete lymphadenectomy rates decreased across these groups.
Fertility-Sparing Surgeries
Among cervical cancer patients under 40 years, the rate of fertility-sparing surgeries increased from 17.8% to 28.1% (AAPC: 3.1%).
Discussion
The findings of this study highlight the significant transition in gynaecologic oncology towards surgical de-escalation, reflecting a broader acceptance of less invasive and more conservative management approaches for the treatment of these cases, driven in part by social expectations.
However, the approach is not without its critics, with some pointing to the lack of clinical data regarding the viability of the approach in the absence of additional adjuvant therapies.1
One such study, a 2023 paper on the impact of de-escalation in breast cancer by researchers Banys-Paluchowski & Rubio, questioned the veracity of the results, stating that most clinical trials did not account for adjuvant radiotherapy. This omission leaves uncertainty as to whether the success of these procedures can be attributed solely to de-escalation or whether adjuvant therapies played a significant role.1 Others have argued that as surgical practices are de-implemented, there may be a tendency towards the escalation of these adjuvant therapies.2 The consensus is that the de-escalation of breast cancer surgery must be conducted and monitored within the framework of multidisciplinary care.
On this basis, this study underscores the importance of further exploration into the long-term outcomes of surgical de-escalation. Areas such as disease control, patient quality of life, and equitable access to these innovative surgical approaches warrant deeper investigation. Moreover, these shifts necessitate adjustments in surgical training programmes to equip future surgeons with the skills required for these techniques.
Conclusion
Over the past 15 years, oncology has embraced surgical de-escalation for the treatment of gynaecological cancers. These trends signify a progressive move towards optimising patient outcomes while minimising surgical trauma. However, continued research is essential to understand the implications of these changes fully and to ensure that equitable access and quality of care are maintained.
Importance of this study for South Africa
The incidence of cancer in South Africa is projected to nearly double between 2019 and 2030, with 80–90% of cases occurring in the resource-constrained public sector.4
Breast cancer remains the most common cancer among women, with significantly higher rates in the private sector (110.1 per 100,000 in 2020) compared to the public sector (59.5 per 100,000). Cervical cancer ranks as the second most prevalent cancer among women.4 While precise figures are challenging to determine, occult cancers are estimated to account for 0.1–1% of breast cancers, 1.44% of uterine cancers, 0.60% of cervical cancers, and 0.19% of ovarian cancers.6,3
The shift towards surgical de-escalation has had significant implications for gynaecologic oncology, aligning with the goals of improving patient outcomes, minimising treatment-related morbidity, and reducing procedural costs.
However, for these approaches to achieve their full potential, adjustments to surgical training programmes will be essential to equip future surgeons with the specialised skills required for these techniques.
Furthermore, caution is necessary to ensure that these strategies are implemented effectively and responsibly within diverse healthcare settings.
Access the original study
Additional References
1. Banys-Paluchowski M, Rubio IT, Ditsch N, Krug D, Gentilini OD, Kühn T. Real de-escalation or escalation in disguise? Breast. 2023 Jun;69:249-257. doi: 10.1016/j.breast.2023.03.001. Epub 2023 Mar 4. PMID: 36898258; PMCID: PMC10017412.
2. Shubeck SP, Morrow M, Dossett LA. De-escalation in breast cancer surgery. NPJ Breast Cancer. 2022 Feb 23;8(1):25. doi: 10.1038/s41523-022-00383-4. PMID: 35197478; PMCID: PMC8866473.
3. Desai, V. B., Wright, J. D., Schwartz, P. E., et al. (2018). Occult Gynecologic Cancer in Women Undergoing Hysterectomy or Myomectomy for Benign Indications. Obstetrics and gynecology, 131(4), 642–651. https://doi.org/10.1097/AOG.0000000000002521
4. Finestone, E., & Wishnia, J. (2022). Estimating the burden of cancer in South Africa. SA Journal of Oncology, 6(1). https://hdl.handle.net/10520/ejc-sajo_v6_i0_a220
5. Ismail, S. (2021). Radioguided occult lesion localisation (ROLL) as a diagnostic and therapeutic procedure: Clinical review at a single tertiary hospital in South Africa [Master's thesis, Cape Peninsula University of Technology]. Cape Peninsula University of Technology Institutional Repository. https://etd.cput.ac.za/handle/20.500.11838/3618
6. Zhang D, Zhai J, Li L, Wu Y, Ma F, Xu B. Prognostic Factors and a Model for Occult Breast Cancer: A Population-Based Cohort Study. J Clin Med. 2022 Nov 17;11(22):6804. doi: 10.3390/jcm11226804. PMID: 36431280; PMCID: PMC9698700
Disclaimer
This article is compiled from several resources researched and compiled by the contributor. It is in no way presented as an original work. Every effort has been made to attribute quotes and content correctly. Where possible all information has been independently verified. The Medical Education Network bears no responsibility for any inaccuracies which may occur from the use of third-party sources. If you have any queries regarding this article contact us
Fact-checking Policy
The Medical Education Network makes every effort to review and fact-check the articles used as source material in our summaries and original material. We have strict guidelines in relation to the publications we use as our source data, favouring peer-reviewed research wherever possible. Every effort is made to ensure that the information contained here is an accurate reflection of the original material. Should you find inaccuracies, out of date content or have any additional issues with our articles, please make use of the contact us form to notify us.
