Surgical de-escalation trends in gynecologic oncology

Surgical de-escalation trends in gynecologic oncology | Image Credit: © 9dreamstudio - © 9dreamstudio - stock.adobe.com.

A trend of surgical de-escalation has occurred in the past 15 years of gynecologic oncology, according to a recent study published in JAMA Network Open.¹

The European Society for Medical Oncology Precision Medicine Working Group has defined de-escalation as reducing the duration of treatment or removing a segment without a decline in survival rates.² This strategy has become more common in the field of oncology, and data has highlighted the efficacy of de-escalation in gynecologic oncology.¹

Methods of de-escalation in gynecologic oncology include the laparoscopic technique, sentinel lymph node (SLN) biopsies, and limiting organ removal. Currently, data about trends in the use of these methods remains lacking.

Investigators conducted a cohort study to evaluate trends in de-escalation practices for gynecologic oncology. Data was obtained from the National Cancer Database, which includes data about approximately 70% of US patients with incident cancer.

Participants included women diagnosed with stage 1 to stage 4 ovarian, endometrial, vulvar, or cervical cancer between January 1, 2004, and December 31, 2020. International Classification of Diseases for Oncology, Third Edition codes were used to determine diagnoses.

Exclusion criteria included synchronous or prior malignant neoplasms, noninvasive disease, and missing variables. Surgical de-escalation was identified as reducing the extent of surgery or utilizing a less invasive surgical approach.

Cohorts were created to assess trends in minimally invasive surgery (MIS), SLN biopsy, and limiting organ removal. MIS trends were evaluated in patients receiving surgical treatment for cervical, endometrial, or ovarian cancer at any stage.

Patients were grouped based on receiving only SLN evaluation or receiving a lymphadenectomy regardless of prior SLN dissection (SLND). SLND was defined as assessing less than 4 nymph nodes while lymphadenectomy was the assessment of 4 or more lymph nodes.

Surgical radicality evaluation involved identifying organs preserved during surgical moments of a single cancer type and assessing fertility-sparing surgery trends. Trends in the use of radical vs simple hysterectomy were evaluated in patients with low-risk early-stage disease.

There were 1,218,490 patients included in the final analysis, 13.7% of whom had cervical cancer, 56.3% endometrial cancer, 24.7% ovarian cancer, and 5.2% vulvar cancer. Private insurance was reported in 45.3% and public insurance in 48.8%.

Of participants, 51.3% had stage 1 disease, 81.7% lived in a metropolitan area, and 40.1% received care at an academic center vs 40.1% at a community program. Surgical treatment decreased overall in the study population between 2010 and 2020.

In cervical cancer patients, surgical treatment decreased from 44.7% in 2010 to 39.9% in 2020, vs 72.0% to 67.9% for ovarian cancer, 83.7% to 79.1% for endometrial cancer, and 81.1% to 72.6% for vulvar cancer. This indicated average annual percentage changes (AAPCs) of -1.3%, -0.5%, -0.5%, and -1.3%, respectively.

An increase in SLND use among patients with stage 1 or stage 2A cervical cancer was observed, from 0.2% in 2012 to 10.6% in 2020 for an AAPC of 44%. For complete lymphadenectomy, rates decreased from 99.7% to 89.3% for an AAPC of -1.6%.

The prevalence of evaluating less than 4 lymph nodes increased from 4.2% in 2004 to 17.4% in 2020 in cervical cancer patients. In comparison, a decrease in the prevalence of evaluating 4 or more lymph nodes was reported, from 95.8% to 82.6%.

In patients with endometrial cancer, the SLND rate increased from 0.7% in 2012 to 39.6% in 2020, with an AAPC of 51.8%. The AAPC for complete lymphadenectomy was -5.8%, with a decrease from 99.3% to 60.4%.

In patients with vulvar cancer, the SLND rate increased from 12.3% in 2012 to 36.9% in 2020, with an AAPC of 10.7%. Complete lymphadenectomy rates decreased from 87.7% to 63.1%, with an AAPC of -4.3%.

These results indicated a trend of surgical de-escalation in gynecologic oncology. Investigators recommended further research to determine the impact on patient outcomes.

References

1. Kanbergs A, Melamed A, Viveros-Carreño D, et al. Surgical deescalation within gynecologic oncology. JAMA Netw Open. 2025;8(1):e2453604. doi:10.1001/jamanetworkopen.2024.53604
2. Trapani D, Franzoi MA, Burstein HJ,et al. Risk-adapted modulation through de-intensification of cancer treatments: an ESMO classification.Ann Oncol. 2022;33(7):702-712. doi:10.1016/j.annonc.2022.03.273