Big Surgeries and What Matters Most

I have just returned from New Orleans and the 2018 Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer. Between the Super Sunday celebration and birthday beignets, I took in some great lectures. I flew home thinking about big surgeries. Gyn-Oncologists love big surgeries. But we don’t love them when they are not the right thing for the patient. Over the past few years, there has been a movement to minimize morbidity and to perform minimally invasive surgery (MIS) whenever possible. For example, MIS has become the standard of care for endometrial cancer. Epithelial ovarian cancers are managed with debulking surgeries, but there is a trend toward more use of chemotherapy and other methods prior to surgery to minimize morbidity. Early stage cervical cancer is still managed surgically. However, many providers have moved toward MIS. I was expecting more of the same at this year’s conference, but I was surprised.

At the late breaking abstract session, Dr. Pedro Ramirez gave us the first look at the data from the Laparoscopic Approach to Cervical Cancer (LACC) trial. The LACC trial is a large Phase 3 international randomized controlled trial of women with early stage cervical cancer. Seven hundred and forty women were enrolled and randomized to either MIS or open incision for their radical hysterectomy and lymph node assessment. The primary outcome was time to recurrence. The LACC trial had several secondary outcomes including overall survival. I think that we were all expecting that outcomes would be similar. After all, we have a previous trial showing that cancer outcomes were just as good for MIS in endometrial cancer. So, this seemed like a no-brainer. Instead, the trial was closed early. The MIS arm had a higher number of cancer recurrences and deaths. We are still awaiting all of the data and the publication.

In the meantime, though, our specialty is on its heels. Most of us have a patient or two with early stage cervical cancer currently scheduled for an MIS. What do we tell her? What do we tell the next patient? For now, all we can do is tell the truth: there are new data suggesting higher rate of cancer recurrence and death. On the other hand, there are also good data telling us about the benefits of MIS (smaller incisions, lower blood loss, better pain scores, fewer infections, shorter length of stay, fewer readmissions) — all of the stuff that healthcare policies are focusing on these days.

On the same day as that surprise, Dr. William Cliby from Mayo gave a great talk on the many tools for managing the newly diagnosed patient with ovarian cancer. The tried and true approach remains a primary debulking surgery. In the past few years, though, there have been some changes and many Gyn-Oncologists are using more neoadjuvant chemotherapy; chemo before surgery. In fact, Dr. Christina Fotopoulou from the Imperial College of London presented data from Europe this year highlighting that this is becoming extremely common “across the pond.”

In the US, it is also increasing but not quite as quickly. In his talk, Dr. Cliby reinforced the importance of a complete cytoreductive surgery. My favorite of his quotes: “dose reduction does not lend itself well to surgery.” We are to take these patients to the OR and remove all disease. If that is simply not possible, we are to try another approach. We should not do half of a surgery. Dr. Cliby then provided the audience with tools for assessing which patients are which and what to do when the big surgery is not the right option. However, there is concern about the big surgeries and, especially, about the short term outcomes. In this age of MIPS/MACRA and the opioid crisis here in the US, there is great emphasis on length of stay, 30-day readmission rates, and narcotic requirements. Surgeons are feeling the pressure to avoid big surgeries. I was reminded of data presented last year, as well.

At SGO 2017, Dr. Shitanshu Uppal and Dr. Emma Barber had each presented original data on policies around these big ovarian cancer surgeries. Dr. Uppal’s data revealed that the institutions who did lots of the big surgeries for advanced ovarian cancer — and the associated high rates of readmission — also had patients with the best overall survival.6 Dr. Barber then reported that those patients who underwent the big surgery — along with the high rates of readmission — lived longer than the patients who received neoadjuvant chemotherapy. These studies highlight what Gyn-Oncologists already know about advanced ovarian cancer. When possible, your patient has the best chance of longer survival with a primary debulking surgery removing all disease in the abdomen and pelvis — even if it means a longer stay, higher risk of readmission, or greater need for pain management.

So, there are still many big surgeries in my future. I am happy to do them, especially if they give my patients improved overall survival. That is usually what our patients seek. Our next step, however, is going to be to help policymakers understand that many of the short-term outcomes that are currently receiving widespread attention in the US are actually at odds with improved overall survival. I still think that we should measure length of stay, 30-day readmissions, and narcotic requirements. More importantly, we have to keep these in perspective or, even better, think of them as process measures on the way to the outcome measures that matter most — improved overall survival and quality of life.

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