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The role of minimally invasive surgery has evolved in the treatment of gynecologic cancers, with fertility preservation considered a priority.

The treatment paradigms for advanced ovarian cancer and endometrial cancer have changed significantly recently, as Andreas Obermair, MD, of the University of Queensland in Australia, and colleagues explain in a review in the . The authors focused specifically on the controversies in surgical management, including weighing the decision to operate versus waiting.

In the following interview, Obermair, who is director of the Queensland Centre for Gynecological Cancer Research in the Center for Clinical Research, discusses current approaches, along with the pros and cons.

How has the role of minimally invasive surgery evolved for gynecologic cancers?

Obermair: Minimally invasive surgery was pioneered for benign surgery and endometrial cancer. Two large trials, the and the Australian that I pioneered, both showed that endometrial cancer is associated with better recovery and fewer side effects and complications with laparoscopic hysterectomy, and survival outcomes are similar to open surgery. Minimally invasive surgery has become the standard treatment in endometrial cancer.

In the in cervical cancer, a modified LACE protocol surprisingly led to a in patients with cervical cancer. With a higher recurrence rate and worse overall survival with minimally invasive surgery, an open approach should now be the standard of care.

There are no good data for minimally invasive surgery in ovarian cancer. For advanced ovarian cancer, a minimally invasive approach can be used to obtain specimens for histopathologic and genomic diagnosis. Optimal cytoreduction that aims for less than 1 cm residual disease remains the most important prognostic factor for overall survival.

How can clinicians balance disease control and fertility preservation?

Obermair: For patients undergoing surgery for early-stage gynecologic cancer, many safe treatment options exist that mitigate morbidity and loss of fertility without compromising survival. There is consensus across leading gynecologic oncology societies that fertility-sparing treatment for gynecologic cancers must be a research priority, and studies to estimate the effectiveness of these options are underway.

The multicenter, randomized, open-label evaluated a levonorgestrel intrauterine device (IUD) in women with grade 1 endometrial cancer and who did not want to undergo hysterectomy. The IUD treatment was associated with an 85% rate of pathological complete response (pCR) in endometrial hyperplasia. Those with grade 1 disease achieved a 50% pCR. I'm currently running a project to develop predictive factors to determine which patients may respond better.

In cervical cancer, preserving fertility is easier using radical trachelectomy to treat the tumor and leave the uterus intact. In non-epithelial ovarian cancer, fertility preservation is possible already.

What are some of the controversies in the treatment of advanced endometrial cancer and ovarian cancer?

Obermair: In endometrial cancer, the controversies have to do with the sequence and timing of chemotherapy and surgery. Although neoadjuvant chemotherapy has not been established yet, many clinicians offer this to advanced endometrial cancer patients because there is no alternative. Some patients have a good response, but this needs to be confirmed in clinical trials. Also, it is an open question as to and under what circumstances we should use immunomodulators for neoadjuvant treatment of endometrial cancer.

In ovarian cancer, the controversy concerns the number of cycles of chemotherapy and whether surgery should be offered for those who don't respond to neoadjuvant chemotherapy. In the U.S., some clinicians treat patients with three cycles of neoadjuvant chemotherapy followed by interval debulking surgery, whether or not patients respond to neoadjuvant chemotherapy. In Australia, this would be unacceptable. We offer surgery only if the patient shows a response to neoadjuvant chemotherapy, both chemically and via imaging.

What does the future of endometrial cancer look like?

Obermair: The incidence of endometrial cancer has been on a continued upward trajectory over the past four decades. It is the only women's cancer that has also shown rapid increases in mortality rates recently. The concern is that in the future more endometrial cancer patients will die than ovarian cancer patients, and that it will be the number 1 killer in gynecological cancers, which is a definite tragic shift.

Despite the rising mortality rates associated with endometrial cancer and the stark ethnicity-related disparities, National Cancer Institute funding for endometrial cancer research ranked 24th in 2018 and dropped by 18% in 2021 despite an overall increase in budget. More funding for research is urgently required to address current treatment challenges.

What is your main message for practicing oncologists?

Obermair: Gynecologic oncologists should always recognize patient-centered outcomes, including surgical morbidity and fertility preservation, when making treatment recommendations and plans. Shared decision-making requires physicians addressing with patients how these rank in importance, providing them with data supporting or challenging safety, and being open-minded to shaping individual treatment plans to individual patients' values.

Clinicians should enroll appropriate patients into clinical trials to generate evidence whenever possible. Some current standard treatments may not even be supported by randomized evidence.

Read the review here.