Transcription:
Minimally Invasive Surgical Innovations in Gynecologic Cancer: Optimizing Outcomes and Safety

Melanie Cole: Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole, and today we're discussing how surgical innovations have improved patient outcomes and safety for treatment of gynecologic cancers. Joining me is Dr. Anna Strohl. She's an Assistant Professor in the Division of Gynecologic Oncology at Northwestern Medicine. Dr. Strohl, it's a pleasure to have you join us today. Can you start by telling us a little bit about yourself and your area of expertise?

Dr. Strohl: My name is Anna Strohl. And as you mentioned, I'm an assistant professor in gynecologic oncology at Northwestern Medicine. As a gynecologic oncologist, I provide comprehensive cancer care for women diagnosed with gynecologic cancers and involved with patient care throughout the entire spectrum of their disease. This includes from diagnosis, surgery, chemotherapy, as well as through survivorship and end of life care. I do have surgical expertise ratings from high volume expertise in advanced ovarian cancer debulking surgery, radical pelvic surgery, Sentinel lymph node techniques, as well as complex minimally invasive surgery using both traditional laparoscopy as well as robotic assisted laparoscopic platforms. And I look forward to talking to you today about how surgical innovations have really improved and changed cancer care for women diagnosed with gynecologic cancers.

Host: They certainly have. And what an exciting time to be in your field. Dr. Strohl, let's start with what type of cancers are considered gynecologic cancers, because sometimes there's a little confusion there.

Dr. Strohl: So gynecologic cancers are cancers that affect the female reproductive organs. So this can include ovarian cancer, fallopian tube cancer, endometrial, or uterine cancers, cervical cancer, vulvar cancer, and vaginal cancers. Within those cancer types. There are many different types of cancer, but any type of cancer that affects these organs are diseases that we take care of as gynecologic oncologists.

Host: Then give us a brief history of how surgical treatments for gynecologic cancers, how they've evolved over the years, and give us a brief update on some of the advances in the treatment of ovarian, cervical, uterine cancers. What had been the option for surgical interventions previously and what's different now.

Dr. Strohl: So, surgery has always played a key role in the diagnosis, staging and treatment of gynecologic cancers and for all cancer types, whether it's ovarian cancer and endometrial, uterine, cervical, or vulvar cancers, surgery remains a mainstay for treatment and plays a key role, not just in treatment, but staging and assessment of pathology. In order to inform additional treatment planning. Traditionally surgery was done with open techniques, meaning a laparotomy or a large incision, or we would do complete lymph node dissections. But over the past few decades, we've learned that we can be a little less aggressive with our approaches and actually achieve similar cancer outcomes, but have better recovery for our patients. Just as surgical technology and techniques have improved in other areas of surgery over the years, gynecologic oncologists have also been adapters of new surgical techniques as they've emerged.

A great example of this is Sentinel lymph node mapping. This technique in which we inject a tumor with a dye or tracer in the Sentinel lymph node, which is the very first lymph node that drains the tumor or affected organ is identified and removed, has been well established for patients with melanoma and breast cancers. And has demonstrated great results in a painting pathologic information required to inform stage and treatment planning while minimizing surgical morbidity for the patient. In gynecologic cancers, the data for Sentinel lymph node mapping initially lagged a bit as we learn more about the technique and had to perform studies that ensured that we could find consistent mapping and apply this to our patients, but now Sentinel lymph node mapping procedures are widely used.

They've been validated in the initial surgical management for endometrial cancer, cervical cancer and vulvar cancers, and is now available for our patients. As gynecologic oncologists, we're also well-known to be early adapters of minimally invasive surgery, both traditional laparoscopic surgery, as well as robotic assisted laparoscopic surgery. In the early two thousands, there was actually a randomized control trial that demonstrated that women undergoing laparoscopic hysterectomy for endometrial cancer had similar cancer outcomes, but improved postoperative outcomes compared to women who had traditional open surgery. And based on this study and others now minimally invasive surgery is really the gold standard for women in our field diagnosed with endometrial cancer

Host:

And for our listeners stay tuned for a podcast on Sentinel lymph node mapping very soon. So you'll have to check that out because it is absolutely fascinating. Speak a little bit more Dr. Strohl about minimally invasive surgery and robotic assisted surgery. Has it changed outcomes and recovery time for gynecologic surgery versus the traditional laparoscopic procedures? How has that impacted your profession?

Dr. Strohl: So, since the FDA approval for robotic surgery and gynecology, the platform of robotic assisted laparoscopic surgery has really taken off and become a main part of gynecologic oncology surgical practice. Some of the benefits of robotic assisted laparoscopy over traditional laparoscopy include advantages of the surgical system itself, including a 3D camera that allows us to have 3D vision, camera stability, improved dexterity with instrument manipulation, similar to the human wrist. So, the instruments actually move 360 degrees rather than with traditional laparoscopy or what we call straight stick laparoscopy, where we have decreased ability to manipulate the instruments. The robotic platform also allows for elimination of this physiologic hand tremor, as well as better ergonomics for the surgeon. Many of these advantages translate to the ability to perform more complex laparoscopic surgery, more efficiently with less blood loss, allows us to push the limits to perform surgeries that we may have traditionally performed open. Now we can perform them minimally invasive with this technology. So less conversion to big open incisions, allowing patients to recover faster with decreased pain and better quality of life.

Host: How have innovations improved techniques for chemotherapy delivery as well?

Dr. Strohl: So that's a great question with a lot of cancers affecting the gynecologic organs. Surgery is not the only treatment. It's the first step towards getting our patients to chemotherapy or other agiment treatments that are necessary for the treatment of their cancer. So by performing complex surgeries with minimally invasive approaches and improving a perioperative recovery for patients, we allow women to recover faster, get back to their baseline strength and prepare for any additional treatment that they may need after surgery so that we can treat their overall cancers. This is critical. We know that delays in additional treatment after surgery can be associated with worse overall survival. So by being able to perform big surgeries with faster recovery for patients, we are able to then get them to additional treatment faster, and this can actually affect their long-term cancer outcomes.

Host: This is also interesting. And how has your surgical practice for gynecologic oncology evolved during the COVID-19 pandemic? How have you utilized tele-health or had to really be creative and innovative in your patient care?

Dr. Strohl: So, we all know that COVID-19 has changed many things in our lives, but through this, we've actually continued to provide high level surgical care for our patients here at Northwestern Medicine, from the surgical piece, we have a fantastic surgical services team that has responded quickly to the surge that happened in the spring and is prepared for any potential surgeries in the future and has allowed us to adapt and prevent surgical delays or disruptions to our patients. So from a surgical piece, we have been providing the same level of surgical care to our patients that we did prior to the pandemic without delays. And we're continuing to push our limits and improve our patient care with the research and quality improvement projects. Even despite the pandemic on the clinical side, we have had to adapt a bit, as you mentioned with telehealth, we have incorporated telehealth and telemedicine visits into our practice. Now for patients that may not live in the city, or may be more hesitant to come into the hospital system during the pandemic, we provide telemedicine visits, we're even able to do surgical consultation visits over the phone, and we're going to reduce the number of visits that a patient needs physically in the hospital prior to either proceeding with surgery or proceeding with treatment for cancer.

Host: And Dr. Strohl, as we're talking about innovations that you feel have led to improved outcomes for women. Speak to us about one of your research interests in exploring health disparities in gynecologic cancers. What are you seeing?

Dr. Strohl: We know that gynecologic cancers affect everybody no matter what your background is, what your race, ethnicity. And so at Northwestern Medicine, we are looking at different ways to not just improve cancer care once you reach our clinics, but how we can improve cancer care in the community. So some of the research projects that we're doing is looking at how women are diagnosed with cancer and how they enter the hospital system. And are there different things that we can do in the community before a woman is diagnosed with cancer to increase the awareness of cancer, increase the awareness of symptoms that may be a sign of cancer, so that we can identify and diagnose cancers earlier. Some of our research is on the individual level, but research projects on the community level are what are really going to impact changes in health disparities and reducing overall disparities in terms of cancer outcomes.

Host: What an important point, what are some of the unique procedures or techniques offered at Northwestern Medicine? And while you're telling us that what's on the horizon in gynecologic cancer care?

Dr. Strohl: So, at Northwestern Medicine, all of our gynecologic oncologists are trained in the most advanced surgical techniques and procedures available to women diagnosed with gynecologic cancers. So this includes both minimally invasive surgery using traditional laparoscopic techniques, as well as robotic surgery for women diagnosed with advanced ovarian cancer. We have developed a program for what's called high-tech chemotherapy or heated intraperitoneal chemotherapy. We are one of the few centers in Illinois to provide this for women, and we have developed this program. So that is as unique to Northwestern Medicine here, we offer robotic surgery with Sentinel lymph node mapping for patients with endometrial cancer.

And similarly, for patients with cervical and vulvar our cancers, we're highly trained in Sentinel lymph node mapping so that we can provide patients with a high level of cancer related care while also focusing on optimizing their quality of life. One of the unique programs we also have here is in addition to the actual surgical technique, we have a program called Enhanced Recovery After Surgery, which is a program aimed at improving the preoperative and postoperative recovery of patients undergoing surgery to help reduce pain and decrease their time to recovery, to get women back on their feet. Either back to their baseline or prepared for any additional treatment that they may need.

Host: ERAS has shown to improve outcomes and recovery for sure. As survivorship continues to grow, where do you see the coordination of care between gynecologic oncologists and other healthcare providers, such as the radiation and medical oncologists, the patient's own OB GYN, fertility specialists to allow for this compliance with cancer follow-up and routine health maintenance that continuum of care?

Dr. Strohl: So, studies have shown time and time again, that the comprehensive team allows for patients to have the best survivorship care and best outcomes. That is the goal for all of our patients who are diagnosed with cancer is to get them through treatment and get them back on their feet and back to their day-to-day lives. And so coordinating care, whether it's clinics, where the patient comes for one visit, and they see every part of their care team during that one visit to allow things to flow more efficiently and for them to stay connected, those are our care models that we're looking into in the future. It certainly is the multidisciplinary team that can help a woman who's diagnosed with gynecologic cancer, get through their treatment and then back on their feet. But this continues through survivorship as well.

Host: Certainly does. As we wrap up Dr. Strohl, what else would you like other providers to know and take forward to their patients to optimize patient outcomes?

Dr. Strohl: I think that it takes a team to get a woman through a cancer diagnosis treatment and onto survivorship. So as you alluded to earlier, it's creating a team, creating a network to provide support for a woman, their families, and looking at the multi-disciplinary aspects of care that help a patient through surgery, through recovery, and looking at each individual piece to see how we can improve it and get women back on their feet and on with their lives.

Host: Absolutely great information. It's so informative. Thank you so much, Dr. Strohl for joining us today. To refer your patient or for more information, please visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.