Recently by Pedro Ramirez M.D.

ramirez-Bronto1.jpgUterine cancer is the most common gynecologic malignancy in the United States. There are approximately 43,000 women diagnosed with this disease each year in our country and about 8,000 women die from it annually.

So, why is this disease so common in our country?

The biggest risk factor for uterine cancer is obesity. This isn't difficult to understand, particularly when considering that 65% of adults in the United States are overweight. In Texas, it's estimated that the number of overweight or obese adults will grow to 20 million by 2040.

Why is this important to our patients and why is this becoming a major issue, particularly for young women?

It's estimated that up to 15% of women diagnosed with uterine cancer will be in childbearing years. In other words, many young women who have never had children are being diagnosed with uterine cancer. This is a major problem, since the standard treatment for this disease is a hysterectomy. Options to preserve fertility are limited to hormonal therapy.

Frequently, women diagnosed with gynecologic malignancies wonder who is the ideal doctor to treat their disease. The majority of patients are told of their initial diagnosis by their family practice physician or obstetrician gynecologist. Unfortunately, a large number of patients diagnosed with cervical, uterine or ovarian cancer aren't treated appropriately because they don't have access to a gynecologic oncologist.

Ramirez_surgery.jpgEarly-stage disease    
Many women with early stage ovarian cancer are inadequately staged. Frequently, patients are operated on by surgeons who lack the expertise to perform a lymphadenectomy (removal of the lymph nodes) and a complete staging -- essential procedures in the management of early ovarian cancer.

Previous studies of patients with early-stage ovarian cancer have shown that inadequate staging leads to decreased survival. In addition, it's been shown that up to 30% of women presumed to have early stage ovarian cancer have their disease upstaged during a re-staging procedure.

Several studies that have evaluated the relationship between surgical specialty and survival in patients undergoing initial surgical treatment for epithelial ovarian cancer have found a consistent improvement in outcomes when patients with early stage disease are operated on by a gynecologic oncologist.

One study compared a group of patients who underwent minimal staging performed by a general gynecologist with a group of patients who underwent comprehensive staging performed by a gynecologic oncologist. The authors found the risk of recurrence to be increased for patients operated on by the general gynecologist.

Advanced-stage disease
The majority of patients with ovarian cancer come in for initial treatment with disease that has spread beyond the pelvis, and nearly 75% of them have evidence of extensive upper abdominal disease. The routine recommendation for patients with advanced disease who are surgical candidates is to perform a total hysterectomy, removal of both tubes and ovaries, complete removal of the omentum (a fatty pad of tissue that overlies the bowel), and removal of all visible tumor.

A recent study describing surgery in patients with advanced ovarian cancer revealed that the strongest predictor of improved median survival was the proportion of patients undergoing optimal tumor removal surgery.

At the beginning of the 20th century, women with ovarian cancer were operated on primarily by general surgeons and general gynecologists. It wasn't until the 1970s that subspecialty training in gynecologic oncology was established in the United States.

Similar to the case in patients with early stage disease, there's ample evidence in the literature to support that patients with advanced disease operated on by gynecologic oncologists rather than non-specialists are more likely to have optimal tumor reduction (<1 cm residual disease) and have improved median and overall five-year survival.

It's extremely important for all women diagnosed with an ovarian mass considered to be malignant to be either referred to a gynecologic oncologist or to assure that there's one available at the time of their surgery, in case the intraoperative evaluation of the ovarian mass shows evidence of malignancy.

In patients with suspected advanced ovarian cancer, it's crucial that they're referred to a gynecologic oncologist so that the appropriate surgery and postoperative counseling can be performed.

All women with a suspected diagnosis of ovarian cancer should demand that their doctors refer them to a gynecologic oncologist.

M. D. Anderson Guide for Referring Physicians
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Minimally invasive surgery offers a number of benefits to patients, compared with traditional open surgery. Through the minimally invasive approach, patients are able to recover from their surgery much sooner. Because most patients go home the next day after their surgery, the requirements for pain medication are less and the return of bowel function is quicker, as is the return to normal daily activities.

Robotic surgery is the most advanced technology in gynecologic cancer surgery and it's the newest approach in minimally invasive surgery. Just like laparoscopic surgery in which the procedure is performed through very small incisions in the abdomen, robotic surgery accomplishes the same goals but offers patients even more outstanding benefits. These include less blood loss and lower risks of intraoperative or postoperative complications.

Often, patients will ask, what is the difference between laparoscopy and robotic surgery if they're both considered minimally invasive surgery? The answer is simple and there are several reasons:

  • With the robotic system, the surgeon has a three-dimensional view of the surgical field; in laparoscopy, the visualization is two-dimensional

  • Instruments in robotic surgery have seven degrees of motion, similar to a human wrist; those used in laparoscopy are rigid and offer only three degrees of motion

  • In robotic surgery, the surgeon is sitting down in a comfortable position during the entire procedure; in laparoscopy, the procedure is performed with the surgeon standing, leading to a greater possibility of fatigue

Although many patients are concerned whether the robot or the surgeon is doing the surgery, it should be clear that the robot only reproduces the surgeon's hand movements -- so, it's all done by the surgeon.

Another frequently asked question is about any drawbacks to robotic surgery. Although the benefits are clear, the major drawback to the patient is that the equivalent surgery usually takes longer using the robotic approach than by the open approach.

Most patients undergoing surgery for uterine cancer and early cervical cancer are candidates for robotic surgery. Even patients with early ovarian cancer may qualify for this type of surgery.

All women diagnosed with gynecologic malignancies should ask their doctor if they're candidates for robotic surgery.

Young women with cervical cancer interested in future fertility often face a difficult dilemma. A radical hysterectomy has been the standard approach for many years. Fortunately, this is no longer the case.

Now patients can be treated for their cervical cancer and still maintain fertility. The procedure is called a radical trachelectomy. In this procedure, the cervix is removed but, unlike radical hysterectomy where the uterus is removed along with the cervix, the uterus is kept intact and it's reattached to the vagina so that women can get pregnant afterwards.

Frequently, many women will ask if by undergoing this procedure they're exposed to a higher risk of recurrence or death from this disease. Fortunately, this isn't the case. The recurrence rate and survival is the same or better than for women undergoing radical hysterectomy.

Most women who try to get pregnant after having this procedure will be able to do so spontaneously. Some women will need assisted reproductive technology to become pregnant. The majority of patients who eventually get pregnant also will reach the third trimester and be able to deliver at term.

All women who undergo this procedure require a cerclage placed either at the time of surgery or early in their pregnancy. A cerclage is a suture that's placed in the lower uterus to hold the pregnancy in place. Another important fact is that all women who undergo a radical trachelectomy must deliver by Cesarean section. A number of patients have been able to get pregnant and deliver healthy babies multiple times after undergoing this procedure.

Some problems may arise after having this procedure such as irregular or lack of menstrual cycles, abnormal Pap smears, vaginal discharge or infertility. Fortunately, these are rare complications.

Women should ask their doctors whether they're candidates for this procedure and should seek a consultation with a gynecologic oncologist who's skilled in performing this procedure.

Resources from M. D. Anderson

Listen to Dr. Ramirez talk about the radical trachelectomy procedure


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