Newer surgical, treatment methods look promising for gynecologic cancers

The new president of SGO discusses important gynecologic oncology news from 2009.

Daniel L. Clarke-Pearson, MD, chairman of the department of obstetrics and gynecology and Robert A. Ross Professor at the University of North Carolina School of Medicine, Chapel Hill, was recently elected the 42nd president of the Society of Gynecologic Oncologists. HemOnc Today spoke with Clarke-Pearson about developments in gynecologic oncology in 2009 and important data presented at The Society for Gynecologic Oncologists’ 2010 Annual Meeting.

What were some of the most interesting or important findings presented at this year’s meeting?

There were many interesting abstracts presented at this year’s meeting. The first to come to mind is a follow-up study on the use of laparoscopic surgery to stage and treat endometrial cancer. It was a randomized trial conducted by the Gynecologic Oncology Group. We now have ‘mature’ data that reports treatment results as well as quality-of-life measurements.

According to the data presented at this meeting, long-term survival was the same in patients treated with laparoscopic surgery as compared to those with traditional open surgery. What that means is that minimally invasive surgery did not compromise cancer treatment, which is the most important finding.

Secondly, it was reported that the use of minimally invasive surgery improved quality of life. The patients recovered faster, had less pain and were back to work sooner. In the balance of risk and benefit, there was no additional risk in terms of cancer cure — which is the No. 1 thing we want to achieve — but there was also the benefit of improved quality of life.

Daniel L. Clarke-Pearson

Another important study was presented by researchers from the University of Kentucky. The results were from an ongoing trial that is using ultrasound to screen for ovarian cancer. In the course of the ongoing trial, a large number of ovarian cysts were identified. The researchers looked at these women with ovarian cysts, examined the characteristics of cysts that are found on ultrasound and tried to predict whether the cysts were benign or malignant.

Of approximately 1,300 women with complex cystic ovarian tumors, they found that they were nearly always able to predict whether a cyst was benign vs. malignant based on the ultrasound characteristics. The take-home message of their study is that the great majority of ovarian cysts are not cancer, and if they meet specific ultrasound characteristics (and do not cause the patient pain or symptoms), they do not need to be operated on.

Avoiding unnecessary surgery in a large group of women that have benign cysts, who can instead be followed with ultrasound, is an important finding. It is an issue that gynecologic oncologists are faced with every day.

What other data from the meeting should gynecologic oncologists be paying attention to?

Another paper that came out, which is interesting coming on the heels of the health care reform vote, had to do with funding of clinical trials. A study by researchers at the University of Alabama Birmingham examined what it costs to participate in a clinical trial.

Right now, institutions receive funding through the NCI to reimburse for costs. However, this study found that institutions doing clinical trials for the Gynecologic Oncology Group are only getting reimbursed about 30% of their real costs. That means that the cost of the research nurse and the data manger that I employ are not really being fully funded by NCI.

How do I pay for it? It is paid for mostly out of clinical revenue that I generate by seeing patients and doing surgery. If we participate in a clinical trial, it is an expense taken from other sources in my institution.

Finally, there were two phase-1 trials presented involving intraperitoneal chemotherapy. Gynecologic oncologists continue to explore the use of intraperitoneal chemotherapy. There are three prospective clinical trials that have found that intraperitoneal chemotherapy is more effective for the treatment of ovarian cancer than IV chemotherapy. The downside to intraperitoneal chemotherapy has been that the toxicity and side effects have been worse and the risk for increased toxicity has kept a lot of patients and physicians from using intraperitoneal chemotherapy.

These two phase-1 trials have substituted carboplatin for the more traditionally used cisplatin. It looks as though carboplatin results in less toxicity. What we will have to know down the road is whether carboplatin results in similar response rates and progression-free intervals when compared to cisplatin.

We know that IV cisplatin and carboplatin are equivalent in terms of response rates. Whether it’s the same with intraperitoneal administration has yet to be proven, but certainly the toxicity seems to be less with carboplatin, which hopefully is a step in the right direction.

Does SGO have anything coming down the pipeline as far as treatment guidelines or recommendations?

SGO is beginning to examine quality outcomes in surgery and how these outcomes fit into gynecologic oncologist practice. We have retrospective data that show that gynecologic oncologists perform more complete surgical staging of women with early ovarian cancer and that gynecologic oncologists are able to more completely debulk than general OB/GYNs and general surgeons.

We will examine large databases in order to confirm that these data are true. If so, then one can make the strong and reasonable argument that women with ovarian cancer ought to be taken care of by gynecologic oncologists.

Similarly, we will evaluate the outomes of women with endometrial cancer who are cared for by different groups of surgeons. Today, about two-thirds of women with endometrial cancer are operated on by general OB/GYNs. However, I believe that there are a lot of nuances in taking care of these patients that are best performed by a subspecialist in gynecologic oncology.

In addition to examining these quality outcome measurements, SGO is also beginning to work on a physician statement about the best management for women with atypical hyperplasia of the endometrium, which is a precursor to endometrial cancer. In fact, as many as 40% of women with endometrial hyperplasia with atypia actually have coexisting early endometrial cancer. We are working on guidelines on how to manage these patients so that the gynecologists that make these diagnoses know the best way to treat these women.

What data are physicians in your field looking forward to being released?

There is a highly anticipated paper scheduled to be presented at the 2010 ASCO Annual Meeting: the Gynecologic Oncology Group trial 218, which evaluates bevacizumab (Avastin, Genentech) plus chemotherapy for advanced ovarian cancer. Everyone is anticipating these results. This may be the first significant targeted therapy used in gynecologic oncology. – by Leah Lawrence