It was only after a recent sabbatical trip to France to observe the work of Denis Querleu (an outstanding gynaecological oncologist working in Toulouse) and his colleagues that I made the realisation that this working relationship has not come about by accident, but rather by the forward-thinking and active planning of my Australian colleagues before me.
In France, and indeed in many other European countries, despite the huge advancement in surgical techniques and development of state-of-the-art cancer centres, the development of gynaecological oncology as a recognised subspecialty remains in its infancy. For a number of reasons, there is a reluctance of gynaecologists to refer women with a diagnosis of, or suspicion of cancer.
The women I saw in theatres and on the wards during my visit there were often referred only after they had already had primary surgery with incomplete staging, or no adjuvant treatment, or after their cancer had recurred. The unit itself has established a significant reputation for radical and exenterative-type surgery, but one of the reasons for this was the lack of appropriate screening, optimal surgery or adjuvant treatment for its patients in the first instance. The unit was like a shining pinnacle of a mountain with no foundation.
An historical perspective is necessary to understand how we ‘got it right’ in Australia. The current relationship that exists in our country between the specialist gynaecologist and the subspecialist gynaecological oncologist began to develop almost 30 years ago. In the early 1980s, it was recognised that the best standard of care for women with gynaecological cancer could realistically only be provided by setting up specialised units, where surgical expertise could be focused and provided within a specialised cancer centre. A number of young gynaecologists were sent to train overseas to learn the expert surgical skills needed to spearhead these units.
On their return, they brought with them not only the surgical expertise and specialised knowledge needed, but also the philosophy of multidisciplinary care that has been the foundation of our current gynaecological cancer centres. Gynaecological oncologists were one of the first surgical craft groups in Australia to introduce regular multidisciplinary ‘tumour conferences’. Each week, in each unit in Australia, we meet with our colleagues with expertise in the areas of gynaecological pathology, medical and radiation oncology, palliative care, and specialist nurses and allied health staff. We discuss each woman diagnosed with cancer, with the aim of developing an integrated treatment plan based on the most current evidence-based treatments. We rely heavily on expert opinions of our colleagues, who themselves could be seen as ‘subspecialists’ in their own specialties.
All cancer groups have subsequently taken up this philosophy. It is now expected that a woman with breast cancer, or a man with colorectal or prostate cancer, for instance, should receive their surgery and treatment within the framework of similar multidisciplinary care groups. This has been shown not only to improve outcomes for patients with cancer, but allows access to current clinical trials and fosters ongoing clinical research.
There appears to be rapid changes on the horizon for gynaecological oncology as a subspecialty and although we must be ready and willing to embrace change, we must also be aware of the constant need to prove that such change will improve the survival and quality of life of our patients. Most gynaecological oncologists are now accepting of the expanding role of minimal invasive surgery for the treatment and staging of borderline ovarian tumours, early endometrial cancer and some cervical cancers. Our trainees are now working in endogynaecology units at some time during their training. Most trainees will have developed advanced skills in laparoscopic surgery by the time they have completed their Certification in Gynaecological Oncology (CGO).
Simultaneously, there is a current trend to more radical debulking surgery in women with advanced ovarian cancer. In some units, this means that the gynaecological oncologist is performing difficult upper abdominal surgery such as diaphragmatic stripping, gastrectomy and distal pancreatectomy. This has called for a close working relationship with our colleagues in other surgical disciplines such as upper abdominal or surgical oncology. With this type of radical surgery comes the need for a high level of post-operative care and expertise in caring for critically ill surgical patients. Indeed, it may mean the development of even more ‘specialised’ subspecialty units, as not all centres may be able to provide this level of care.
Another positive change has been a major shift in terms of addressing aspects of ‘survivorship’ in our patients. Women treated for cancer have many ongoing problems as a result of the diagnosis and outcome of treatment for their disease. Issues such as loss of fertility, premature menopause, lymphoedema, and social and psychological adjustment are just a few. We are fortunate to work in centres that can provide specialised care for these problems. We have access to physiotherapists, psychologists and social workers with special knowledge and skills. We also have direct links with other subspecialty gynaecologists in the areas of endocrinology, menopause and reproductive medicine to assist us in managing these problems.
So where does that leave us in terms of the future of the relationship between gynaecological oncologists and the ‘general’ gynaecologist? Any relationship, no matter how functional, can always be improved. I believe gynaecological oncologists should have a greater role in the training of our gynaecologists. In the age of advanced laparoscopic surgery, the opportunity for our trainees to be exposed to the pelvis through an incision greater than a centimetre is likewise getting smaller. Our units must provide positions for gynaecological surgical trainees to develop open surgical techniques. This is not with the intention of creating ‘mini’ gynaecological oncologists who could then work outside of the current units, but to share our skills with gynaecologists in order that they can perform the more difficult benign procedures and to give them the confidence to convert difficult laparoscopic procedures to less difficult and safer open procedures when the need arises.
I would also like to see gynaecologists sharing a greater role in the follow-up of women after they have been treated for cancer. In most instances, women could have a shared arrangement for follow-up between their own community-based gynaecologist and the oncology unit. This would foster communication between the professional groups and give back to the woman a sense of ‘normality’ after her treatment.
Complementary to this, the referral basis from our gynaecologist colleagues to the oncology unit could be improved. There are still many women in Australia diagnosed with ovarian malignancy who have not had their primary surgery performed by a gynaecological oncologist. A wider acceptance and use of the Risk of Malignancy Index would mean more appropriate referral of women with an adnexal mass. If in doubt of whether or not to refer, we are only a phone call away and are usually more than willing to give advice when asked.
Secondly, I believe that ‘early endometrial cancer’, in most situations, is best treated in a gynaecological cancer unit. Most units nowadays will offer laparoscopic hysterectomy with surgical staging, if appropriate. Correct surgical staging may decrease the need for adjuvant radiation, which has its own unique long-term morbidities. Indeed, recognising that persistent ‘perimenopausal bleeding’ should lead to endometrial biopsy or sampling in the first instance before proceeding to a hysterectomy is a simple rule of thumb.
Lastly and not without some controversy, I believe women who require risk-reducing surgery should be cared for within a multidisciplinary care setting. Although ‘risk-reducing BSO’ (bilateral salpingo-oophorectomy) is not a difficult surgical procedure by any means, I believe the intense counselling needed, particularly in those young women who have had previous breast cancer or have a BRCA or mismatch repair gene mutation, is best provided in a dedicated unit with strong links to an hereditary cancer clinic, menopause ‘after cancer’ subspecialist, and other dedicated oncology colleagues.
It is with much interest and optimism that I look forward to continuing my work as a gynaecological oncologist and working with my professional colleagues. It is the ‘team’ approach to patient care that drew me to this subspecialty in the first place and I believe that one of the most important members of the ‘team’ is the general gynaecologist looking after women in the community.
I would like to thank Professor Don Marsden and Professor Ian Hammond for their assistance in writing this article.