Sheathing the knife in gynaecological cancer

And other new trends in the management of these conditions.

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Two distinct approaches to gynaecological cancer management are aiming to improve outcomes for patients.   

Gynaecological cancers – including cervical, ovarian, uterine, vaginal and vulvar – are a significant problem in Australia and have far worse outcomes compared to other types of cancer. The Australian Cancer Database estimates 6600 people were diagnosed with and 2200 people died due to a gynaecological cancer in 2022, compared with over 20,000 breast cancer diagnoses and around 3000 breast cancer deaths during the same year.  

A topical session at the recent Clinical Oncology Society of Australia Annual Scientific Meeting in Melbourne discussed some of the hot topics in the field of gynaecological cancer, including new developments in surgical treatments and whether circulating tumour DNA (ctDNA) has a role in managing gynaecological cancers. 

Surgeons are sheathing the knife 

Associate Professor Simon Hyde, director of gynaecological oncology at the Mercy Hospital for Women spoke how surgeons were “getting better” at taking a more conservative, evidence-based approach to the surgical management of cervical cancer. 

The shift away from more aggressive surgical approaches started in response to the LACC (laparoscopic approach to cervical cancer) trial, which found minimally invasive radical hysterectomy led to lower rates of disease-free and overall survival and similar quality of life compared to open surgery in women with early stage cervical cancer. 

“There was a lot of discussion when [the findings] were released,” Professor Hyde explained. 

“There’s been a variety of different studies which have confirmed the LACC trial, but everyone keeps trying to find a study to justify doing minimally invasive surgery because we like to do minimally invasive surgery.” 

One study that confirmed the results of the LACC trial was the SHAPE trial, whose findings were presented at the ASCO meeting earlier this year. This prospective randomised trial of 700 women with low-risk early-stage cervical cancer found the simple hysterectomy recurrence rate was non-inferior to that of radical hysterectomy. 

“We don’t operate on anything that’s got significant volume of disease anymore; they all get referred for chemoradiation because their outcomes are better,” Professor Hyde noted. 

Similarly, the ConCerv trial found certain patients with early-stage and low risk cervical carcinoma could be offered a simple hysterectomy with lymph node assessment and have similar outcomes to more aggressive approaches.  

ctDNA can help guide treatment 

Dr Rachel Delahunty, a medical oncologist at the Mercy Hospital for Women, feels there is a real role for ctDNA detected through liquid biopsies in gynaecological cancer.  

“This is exciting for gynaecological cancers. It can potentially quantify tumour burden on the genomic profile of the tumours – the genes that are driving the cancer to grow. This could [also] be a really great thing for surgeons; there’s [often] nothing to biopsy at the time of relapse when we want [the] important genomic information.  

Liquid biopsies can also be used as predictive biomarkers, according to Dr Delahunty, who shared the results of a 2019 study identifying BRCA reversion mutations detected in ctDNA taken from women with high-grade ovarian carcinoma were associated with decreased clinical benefit from the PARP inhibitor rucarparib. 

Specifically, patients without the revision mutations had a median of nine months progression-free survival, compared to the two months for patients who carried the BRCA mutations.  

Knowing which patients have these specific revision mutations could change practice by sparing these women from ineffective and potentially toxic therapy, Dr Delahunty said, noting that this type of ctDNA approach could be rolled out fairly quickly in a clinical setting.  

Dr Delahunty also highlighted a 2021 study displaying the presence of HPV ctDNA after chemoradiation was a useful marker for predicting which women were at risk of their cervical cancer recurring. 

“This is a really nice study [showing] we can potentially salvage these women with surgery or immunotherapy,” Dr Delahunty told delegates.