Gynecologic malignancies continue to represent a significant clinical challenge, with substantial epidemiologic trends demanding attention. Most concerning is the trajectory of endometrial cancer, with approximately 69,000 new cases yearly and projections suggesting incidence will nearly double to 122,000 cases annually by 2030.
Two experts from Baptist Health Cancer Care, Thomas Morrissey, M.D., director of gynecologic oncology at Lynn Cancer Institute and Ryan Kahn, M.D., a gynecologic oncologist at Miami Cancer Institute, recently sat down to discuss advances in care. (Listen to the entire Doc-to-Doc podcast here.)
“It's clear that we're moving into a new era of gynecologic cancer care,” Dr. Morrissey says. “We're learning when to scale back, when to be aggressive, and how to tailor treatments in smarter, more targeted ways. It's not just about survival anymore. It's about quality of life, long-term outcomes, and making each decision count.”
In Ovarian Cancer, Which Treatment Comes First?
The landmark TRUST trial has definitively addressed the sequencing controversy in advanced ovarian cancer treatment. This multicenter study demonstrated primary cytoreductive surgery (primary debulking surgery) followed by post-operative IV chemotherapy resulted in a significantly longer median progression-free survival and a numerically longer overall survival compared to neoadjuvant chemotherapy followed by interval cytoreductive surgery at expert centers in non-frail ovarian cancer patients. Although statistical significance in the primary endpoint was not reached, this is the first randomized trial to show a benefit of primary surgery over neoadjuvant chemotherapy followed by neoadjuvant surgery.
The critical determinant remains surgical expertise and institutional capability. Data consistently demonstrate that specialized gynecologic oncology centers achieve superior cytoreduction rates, with complete gross resection correlating directly with survival benefit. Suboptimal debulking (residual disease >1cm) offers minimal survival advantage over chemotherapy alone, underscoring the importance of appropriate patient selection and surgeon experience.
“Patients need to see a gynecologic oncologist at a center that has the ability to make the maximal attempt at an initial surgery, because that gives the patient the best overall outcome,” Dr. Morrisey says. “If you do a big operation but you're only able to remove 80 or 90 percent of the tumor, you’re really not helping them very much.”
For carefully selected patients — those with extensive disease burden that cannot be completed resected, or those with significant comorbidities — neoadjuvant chemotherapy followed by interval debulking remains a viable strategy. However, the default approach should prioritize primary surgery when complete cytoreduction is technically feasible.
Ovarian Cancer: Refined Predictive Algorithms
Ovarian cancer is the second most common gynecological cancer, affecting about 25,000 women yearly in the United States. One of the big challenges in ovarian cancer surgery is determining which patients will benefit from surgery first.
Current imaging modalities, including CT and PET scanning, demonstrate limitations in detecting peritoneal disease <5mm, particularly in bowel serosa and mesenteric surfaces. Integration of clinical factors — including CA-125 levels, performance status, and comorbidity indices — with imaging findings provides more accurate surgical planning than imaging alone.
As a fellow at Memorial Sloan Kettering Cancer Center, Dr. Kahn participated in improving upon a scoring algorithm that combines scan results with patient information to predict whether a surgeon will likely be able to remove all visible cancer. These algorithms, validated at high-volume centers, predict the likelihood of achieving complete gross resection with >80% accuracy while avoiding futile procedures in unsuitable candidates.
The evolution toward artificial intelligence-enhanced predictive modeling promises further refinement in patient selection. “With new technology, including artificial intelligence and better data analysis, these tools will only keep improving in the future,” Dr. Kahn says.
Cervical Cancer: De-escalation Without Compromise
The SHAPE trial represents a paradigm shift toward surgical de-escalation in early-stage cervical cancer. For tumors <2cm with favorable histology and negative lymph nodes, simple hysterectomy achieved equivalent oncologic outcomes to radical hysterectomy while significantly reducing genitourinary morbidity.
This finding addresses longstanding concerns about bladder dysfunction, sexual function, and quality of life following radical procedures. The five-year disease-free survival rates were non-inferior between approaches, with simple hysterectomy patients experiencing substantially fewer Grade 3+ urological complications.
There has been recent literature suggesting minimally invasive (laparoscopic or robotic-assisted) radical hysterectomies for cervical cancer have a slightly higher risk of the cancer coming back compared to open surgery, with worse survival outcomes. The ROCC trial, in which Miami Cancer Institute is a participating site, is investigating techniques to contain the cancer during minimally invasive surgery to see if outcomes are similar to open surgery. This has the potential to lead to reduced post-operative pain and expedited recovery, which is also being studied.
Emerging Therapeutic Landscape
Beyond surgical refinements, the gynecologic oncology landscape is being transformed by targeted therapeutics. PD-1/PD-L1 checkpoint inhibitors have demonstrated significant activity in endometrial cancers, especially microsatellite instability-high, and are increasingly integrated into first-line treatment protocols.
Antibody-drug conjugates (ADCs) represent another promising avenue, delivering cytotoxic payloads directly to tumor cells while sparing healthy tissue. Early trial data suggest meaningful survival benefits across multiple gynecologic malignancy subtypes, with acceptable toxicity profiles.
The integration of molecular profiling into treatment algorithms is becoming standard practice, with tumor sequencing informing both surgical planning and adjuvant therapy selection. This precision medicine approach promises to further optimize outcomes while minimizing treatment-related morbidity.
