Recent innovations have given new insights into understanding gynaecological cancers, and how gynaecological cancers are treated.
Three of our members working within gynaecological oncology share some of the developments in their field:
- Professor Emma Crosbie, consultant gynaecological oncologist, looks at recent advances in care made possible through the application of genomics to our specialty
- Miss Nahid Gul FRCOG, consultant surgeon in complex gynaecology and oncology, discusses the advancements in using robotic surgery to treat endometrial cancer
- Ms Marielle Nobbenhuis, consultant gynaecological oncology surgeon, explores the current and possible future uses of robotics in early and advanced stage ovarian cancer surgery
Application of genomics to gynaecological cancer screenings
Professor Emma Crosbie, consultant gynaecological oncologist, looks at recent advances in care made possible through the application of genomics to our specialty.
Lynch syndrome is an inherited cancer predisposition syndrome caused by a defective DNA mismatch repair (MMR) system. It is an autosomal dominant condition, meaning that a parent passes it on to approximately half of their children, whether they be girls or boys.
Lynch syndrome increases the risk of certain cancers, particularly colorectal (bowel), endometrial (womb) and ovarian cancer. It is thought to affect around 1 in 300 of the general population, yet only 5% are aware of their diagnosis.
Endometrial cancer may be the first indication that a person has Lynch syndrome and as such offers an important diagnostic opportunity. Knowing that a person has Lynch syndrome allows them to protect themselves and family members against future cancers through bowel cancer screening and aspirin chemoprevention.
Manchester-led research shows for the first time that 3% of endometrial cancers are caused by Lynch syndrome. It showed women want to be tested for Lynch syndrome to protect their family members, and that testing everyone is best.
Restricting testing based on clinical characteristics, for example age or family history, missed cases of Lynch syndrome. Further research showed that a fully integrated clinical testing pathway is cost effective for the NHS.
Following new recommendations by NICE, huge strides are now being made to embed Lynch syndrome testing in routine clinical care pathways and ensure equity of access across the NHS. This will help it achieve its long term plan of 75% of cancers diagnosed at Stages I and II, when cancer survival and quality of life outcomes are best.
Robotic surgery for endometrial cancer
Miss Nahid Gul FRCOG, consultant surgeon in complex gynaecology and oncology, discusses the advancements in using robotic surgery to treat endometrial cancer.
Endometrial cancer (cancer of lining of the womb) is one of the common gynaecological cancers, with 2-3% of cases having a genetic link. It is common in women who have been through the menopause and one of the risk factors is high body mass index (BMI). The most common symptom of endometrial cancer is signs of abnormal bleeding, including bleeding after the menopause, bleeding between periods, or bleeding that is unusually heavy. While there are many other causes of abnormal vaginal bleeding, women should visit their GP if they are experiencing symptoms.
The most common treatment is the surgical removal of womb and cervix (the neck of the womb), called a hysterectomy. This is a successful treatment with early diagnosis. Traditionally hysterectomy has been performed by making cut in the abdomen and full recovery can take up to 3-6months.
Keyhole surgery has enhanced recovery and shortened the hospital stay. Although laparoscopic (keyhole) hysterectomy nowadays is offered in many hospitals across the world, many women still have open surgery, either due to lack of surgical expertise or if the woman is not suitable for laparoscopic hysterectomy due to associated medical complexities such as a high BMI. Advances in technology will enable all patients to have keyhole surgery due to the development of robotic assisted operations.
Robotic assisted hysterectomy can improve outcomes for women. The robotic operation results in less blood loss, less postoperative pain, a shorter hospital stay and less conversion to open operation as compared to laparoscopic surgery. There are numerous studies now available to support the good outcomes after robotic hysterectomy.
Complex procedures are difficult to learn and teach. With robotic assistance surgeon’s learning curve is decreased and enables the surgeon to have better ergonomic position while operating hence physical tiredness is eliminated. Improved surgeon ergonomics helps them to perform a procedure with fewer complications.
The main limiting factor in offering the robotic hysterectomy for endometrial cancer to all women is the cost of the robot. There are now approximately 16 robotic systems developed across the world which will bring the cost down and many more patients within and outside the gynaecology speciality will benefit from this technology.
The use of robotics in ovarian cancer surgery
Ms Marielle Nobbenhuis, consultant gynaecological oncology surgeon, explores the current and possible future uses of robotics in early and advanced stage ovarian cancer surgery.
Ovarian cancer is most common in women post-menopause, but can affect women and people with ovaries at any age. Common symptoms include persistent bloating, abdominal or pelvic pain, no appetite or feeling full quickly, and needing to wee more regularly. Early diagnosis of ovarian cancer can make the cancer more treatable.
Standard treatment for ovarian cancer involves surgery to stage the disease and remove all visible disease. This is often alongside additional chemotherapy. Traditionally this surgery has been performed via a laparotomy (where a surgical incision is made into the abdomen).
Studies have now suggested the feasibility and safety of robotic ovarian cancer surgery in a select group of women. The usage of the robot in minimally invasive staging operations in women with early stage ovarian cancer is widely accepted. Recent feasibility studies have now also identified that the robot can also be used as a tool in more advanced stage ovarian cancer operations.
Incorporating robotic surgery has the potential benefits to decrease length of stay, blood loss, postoperative pain, and aid a quicker return to normal activity. Moreover, if women need chemotherapy there is less risk of any delay in starting this.
A robotic approach can potentially also be used in a select group of women with significant co-morbidities who are at a higher anaesthetic risk when undergoing open surgery. Prospective multicentre studies are currently on the way to establish whether this is also feasible and safe without compromising overall survival in advanced ovarian cancer.
Notes to editors
- Read more about genomics within obstetrics and gynaecology: RCOG Genomics
- Read the RCOG Scientific Impact Paper No. 71: Robotic Surgery in Gynaecology