Melanie Cole, MS (Host): [00:00:00] Welcome to the podcast series from the Specialists at Penn Medicine. I'm Melanie Cole. And today, we're highlighting gynecologic oncology at Penn Medicine Princeton Health. Joining me is Dr. Noah Goldman. He's the Medical Director of Cancer Services at Penn Medicine Princeton Health.

Dr. Goldman, thank you so much for joining us today. Give us a little bit of an overview of what you offer at Penn Medicine Princeton, the patients you typically see, and how your services are integrated within the Penn Medicine system as a whole.

Dr. Noah Goldman: Thank you for having me. We offer everything here at Princeton in terms of gynecologic oncology. We see ovary cancer, endometrial cancer, sarcomas, vulvar cancer, cervix cancer. And we are able to treat them both surgically and with chemotherapy and radiation at Penn Medicine Princeton.

The beauty of our system [00:01:00] is that we are integrated with the division of GYN oncology as a whole, and participate in the multidisciplinary tumor conferences to get the latest recommendations on treatments, but the patients have access to those treatments closer to home.

Host: Well, thank you for telling us that, Dr. Goldman. In the near century since Dr. Papanicolaou reported the first findings of what would become the standard Pap test, no other screening tool for other gynecologic cancers have appeared. Given the advent of advances, technology, AI, are we getting any closer to effective screening tests for these gynecologic cancers?

Dr. Noah Goldman: So, the short answer is yes and no. So unfortunately, for cancers like ovary cancer, we have had since the '80s, multiple, different multi-national screening trials, looking at how we can [00:02:00] screen patients. And unfortunately, none of them have shown that there is really effective screening for ovary cancer.

Most of that is because women have ovarian cysts and ovarian masses. And within that screening, patients are taken to surgery, and it's a false positive screen. And so, you end up operating on multiple women who didn't need this surgery to find that one ovary cancer. Even with the use of things like AI, we're finding that AI can predict whether or not an image is malignant or not better than a radiologist, but it's not ready for prime time and we're still seeing unnecessary surgeries on women who had benign cysts that underwent surgery.

And [00:03:00] frankly, there's harm in that. There's the risk of complications. There's the risk of anesthesia. There's the psychological risk of having surgery. And so, we unfortunately haven't really gotten anything yet that's ready for prime time for ovary cancer screening.

In terms of cervical cancer screening, we've really moved away, interestingly enough, from the Pap smear to HPV testing. And so, primary HPV testing has become the standard of care with the fact that a negative HPV test carries a negative predictive value of 99.7%. Meaning that if your HPV test is negative, the likelihood that something bad in the next three to five years is extremely low, less than 1%.

Host: Yeah, that certainly has moved the needle. And with the advent of the HPV vaccine, [00:04:00] that adds another layer to the new recommendations on Pap smears and cervical cancer screening. So, what's to be done other than pelvic ultrasounds, which are sometimes recommended in certain cases? What's to be done in the meantime, Dr. Goldman, to reduce that risk of gynecologic cancers in women at risk? What particularly should women bring to the attention of their gynecologists?

Dr. Noah Goldman: I've always said this throughout my career that the most important thing to do is to listen to your body. Nobody knows their body better than the person themselves. And so, if there is something that feels off, that feels wrong, that needs to be brought to the attention of the primary care physician or the gynecologist, depending on what the symptom is.

The problem is that, especially for something like ovary cancer, and I know I harp on that, but that's the one that we talk about the most, is [00:05:00] the symptoms are very nebulous. So, what I usually tell patients is, if you are having symptoms that aren't going away, right, everybody feels bloated, everybody has a pain every now and then. But if that's persisting for a period of time, even if it's only a few days or a week, that needs to be investigated. And I think that listening to what's going on inside of you is the most important thing.

We do have some screening tools, obviously, cervix cancer, the vaccine screening has all been very favorable. Endometrial cancer, 95% of women are going to have some sort of abnormal bleeding, either postmenopausal bleeding or if they're premenopausal, just a change in their cycle and abnormal bleeding. But ovary cancer is the one that we haven't really figured out in terms of what can we do to prevent.

Ultrasounds, again, [00:06:00] sometimes do more harm than good. And in fact, most of the societies don't recommend screening because the predictive value is just so low.

Host: Well then, one thing that we do have in our toolbox is genetic counseling to identify women that might be at higher risk. And we've learned more about the BRCA gene mutation over the years, Dr. Goldman. But what about the prerequisites for genetic counseling and the women that you see? What typically are you looking for, particularly in younger women at risk, whether it's an Ashkenazi Jew or whether there's a family history? Tell us a little bit about that.

Dr. Noah Goldman: Family history is the key to genetic testing, although I was just on a meeting and the qualifications for testing someone has expanded exponentially over the last five years, ten years. I remember when I first started, it really was [00:07:00] all about you needed to have multiple people with ovary cancer or breast cancer to get BRCA gene testing. That has really expanded to include a larger number of patients. But family history is the key. Anyone who has a family history or personal history of ovarian cancer qualifies for genetic testing.

Similarly, the recommendations for testing for breast cancer have expanded to include younger patients with a personal history, patients with multiple family members. And so, I think, that it's going to be very soon that we start just testing everybody for germline mutations, because the process has gotten very expansive.

Host: Yeah, I see that. And Dr. Goldman, you perform robotic gynecologic surgeries. What's the robotic platform brought to these procedures? What are you most excited about?

Dr. Noah Goldman: I was [00:08:00] doing laparoscopic surgery long before 2006, when robotic surgery was first approved for GYN procedures. And it is just opened up a whole new level. You're operating with three or four hands as opposed to just your two hands. You're able to do more complex surgeries. You are able to be much more facile and dexterous because of the operating mechanisms of the robot. And it's allowed really a conversion of minimally invasive surgery from maximally or open surgery.

And so, what we see is where we used to do the majority of our cases open and only a few laparoscopic, that ratio has flipped. And in fact, about 80% of our surgeries at Penn Medicine Princeton, for GYN and GYN oncology are done in a minimally invasive fashion. And only about [00:09:00] 20% require an open surgery.

Host: Wow. I mean, it's pretty exciting time in your field. And when we think of gynecologic oncology as a whole, how has the utilization of a multidisciplinary team been really ideal for managing some of these complex patients? And how are you utilizing collaboration at Penn Medicine Princeton Health?

Dr. Noah Goldman: So, it's been really fantastic. The wonderful thing about the division of GYN oncology is it's truly a systemic division that includes all six hospitals of the Penn Medicine system. And so, when I have a patient who has a complex problem, I am able to ask of the other GYN oncologists what their recommendation might be, what they think about my plan. Sometimes even those patients can be transferred downtown [00:10:00] for surgical intervention or clinical trial, and then return back up to me afterwards for surveillance and follow up. We don't need to do that a lot, but that's available to us. And so, there's been a really great collaboration between the multitude of physicians that make up the division of GYN oncology. And it's allowed for really streamlined patient care.

Host: Well, that's so important for women going through this. And as we wrap up, Dr. Goldman, I'd like you to summarize the great work that you're doing at Penn Medicine Princeton Health. And for referring physicians, what's the most important part that you'd like them to take away from this episode today about the work that you're doing and the exciting advances.

Dr. Noah Goldman: I think the biggest thing is that Penn Medicine Princeton Health is part of the Penn Medicine community. We have all of the options that are available in the downtown [00:11:00] facilities in Philadelphia. But it is going to be closer to home. We are building a new 200,000-square foot, four-story cancer center to house our cancer program. And that will be a regional leader in cancer care in the central New Jersey area.

Host: Thank you so much, Dr. Goldman, for joining us today and sharing your expertise and to highlight all the great work that you're doing. Thank you again. And to refer your patient to Dr. Goldman at Penn Medicine, Princeton Health, please call our 24/7 provider-only line at 877-937-PENN, or you can submit your referral via our secure online referral form by visiting our website at pennmedicine.org/refer. That concludes this episode from the specialists at Penn Medicine. I'm Melanie Cole.