It is now over 30 years since we were gynaecological oncology Fellows together in the late 1970s at the University of California in Los Angeles. Since that time, there have been enormous improvements in the way women with gynaecological cancers have been managed in most parts of the world.
Undoubtedly, the biggest single improvement has been the progressive sub specialisation in gynaecological oncology in many centres in Europe and Asia, following the lead of the USA in 1973. Australia was an early adopter of this important change, with the then RACOG officially recognising gynaecological oncology as a subspecialty in 1985. This soon led to accreditation of grandfathers and establishment of approved training centres. Gynaecological oncologists cannot work in isolation, so the next step was the establishment of gynaecological cancer centres in all major cities and the development of multidisciplinary teams of medical specialists, oncology nurses and paramedical personnel with a particular interest and expertise in gynaecological cancer. With the concentration of expertise in major centres, all modalities of treatment can be used optimally as each new case is discussed at multidisciplinary tumour board meetings. In addition, patients can be offered the psychosocial support, which is so important in the patient’s journey.
The founding of the International Gynaecologic Cancer Society, in 1987, brought together clinicians, scientists and paramedical personnel from around the world, bound by a common interest in gynaecological malignancies. This society has done much to improve the standard of gynaecological cancer care and to facilitate dialogue between professionals internationally.
Thirty years ago, surgery was all performed by open laparotomy and teaching was done as a master-and-apprentice model. In the past 20 years, minimally invasive surgery has been progressively introduced, initially with the laparoscope and, more recently, with the daVinci robot. Use of these devices has led to longer operating times, but faster postoperative recoveries. Indications for these approaches have been progressively expanded, but it will be some time before properly controlled trials determine their exact role. Learning curves are certainly longer than for open surgery, and it is no longer acceptable to ‘practise’ these skills on patients. The necessary surgical skills should be acquired outside the operating room on various inanimate and animal practice models.
The incidence of cervical cancer has fallen in developed countries, with better cervical screening, and will continue to fall further with the introduction of the HPV vaccine. The incidence of ovarian and endometrial cancers continues to rise as the population ages as well as with the obesity epidemic sweeping Western countries.
As cure rates improve for most cancers, quality-of-life issues have become increasingly important. Conservative vulvar resections have been progressively introduced for invasive vulvar cancer and these have been shown to decrease morbidity, without compromising survival. The possibility of using sentinel node biopsies rather than full lymphadenectomy has been investigated for early vulvar, cervical and endometrial cancers to decrease the incidence of lower limb lymphoedema. Although theoretically attractive, these procedures carry a definite false negative rate and most patients, properly informed, are not prepared to risk death from recurrent disease.
With women now delaying childbearing until well into their 30s, there is an increasing demand for fertility-sparing surgery, which was not a major issue 30 years ago. The introduction of the radical trachelectomy for early cervical cancers and accumulating data on uterine and ovarian conservation for unilateral ovarian and early endometrial cancers has enabled selected women to maintain their childbearing capability while being treated effectively for their malignancy.
Ovarian cancer remains a major diagnostic and therapeutic problem. A successful screening test has remained elusive. Although median survival times have been prolonged and survival rates for all stages have improved somewhat over the past 30 years, overall five-year survival remains below 50 per cent. Cisplatin was introduced into routine clinical practice in the late 1970s, and proved to be a major therapeutic advance. It was replaced by the equally effective, but less toxic, carboplatin in most regimens. The introduction of the taxanes, in the 1990s, incrementally improved survival rates. Efforts are underway to find new cytotoxic drugs that are well tolerated and agents that aim to control growth through blocking other targets, such as the vascular endothelial growth factor, tyrosine kinase receptors and other molecular pathways.
The major hope for the future is the explosion in genetic and molecular research, particularly since the completion of the Human Genome Project in 2003. The discovery in the mid- 1990s of germline mutations BRCA1 and BRCA2 defined those women at substantially higher risk of developing ovarian cancer. For these women, prophylactic removal of fallopian tubes and ovaries is presently the best course of action. The elucidation of other germline mutations – such as the recent discovery of ARID1, which predisposes to clear cell and endometrioid tumours will hopefully lead to targeted therapies for women with those tumours. Although many relevant cellular pathways have been elucidated and therapies that specifically target those pathways are being developed, there is a long road ahead to find better ways to individualise treatments based on tumour type and the inherent biologic behaviour of different types of ovarian malignancies. Further genetic and molecular research is likely to lead to major screening, prognostic and therapeutic advances in the future.