Gynecologic Oncology Practices Evolve With Surgical De-Escalation Trends

Over the past 15 years, gynecologic oncology has shifted toward surgical de-escalation, characterized by a reduction in procedures, greater adoption of minimally invasive techniques, and increased reliance on sentinel lymph node (SLN) methods.¹

The authors of the JAMA Network Open study explained that surgical de-escalation aims to minimize tissue injury while preserving tissue integrity during cancer-related operations. Studies over the past decade have validated de-escalation approaches for various gynecological cancers and procedures, like limiting organ removal or resection to only those necessary to maintain oncologic outcomes.

However, no studies have comprehensively analyzed de-escalation trends across the surgical spectrum offered by gynecologic oncologists. Therefore, the researchers conducted a study to evaluate the evolution of surgical management practices within this field.

To do so, they collected data from the National Cancer Database (NCDB), which contains data on about 70% of US patients with incident cancer.² The researchers identified all women who received a diagnosis of ovarian, cervical, endometrial, or vulvar cancer between January 1, 2004, and December 31, 2020.¹ Data were analyzed between January and June 2024.

The primary outcome was surgical de-escalation, which they assessed by evaluating trends in minimally invasive surgery (MIS), SLN biopsy, and surgical radicality. Trends in MIS, like laparoscopy and robotic surgery, were analyzed across all stages and histologic grades of cervical, endometrial, or ovarian cancers.

For SLN evaluation, the researchers grouped patients into 2 cohorts: those who exclusively underwent SLN evaluation and those who underwent a lymphadenectomy regardless of a prior SLN dissection (SLND); SLND was defined as the examination of less than 4 lymph nodes, while lymphadenectomy involved 4 or more. They performed the initial analyses to identify the removal, biopsy analysis, or aspiration of regional lymph nodes during primary site surgery or a separate surgical event.

Additionally, the researchers analyzed surgical radicality trends by identifying preserved organs or structures. Among patients with cervical cancer, they compared the use of radical vs simple hysterectomy for those with low-risk early-stage disease. For those with endometrial cancer, they analyzed ovarian preservation.

Lastly, fertility-sparing surgery (FSS), defined as retaining the uterus and at least 1 ovary, was assessed for patients with cervical and ovarian cancers. Overall, a Poisson model was used to estimate the average annual percentage change (AAPC) in receiving surgical treatment.

From the NCDB, the researchers identified 1,218,490 eligible patients, including 686,458 with endometrial cancer (56.3%), 301,123 with ovarian cancer (24.7%), 166,779 with cervical cancer (13.7%), and 64,130 with vulvar cancer (5.2%). The percentage of those undergoing any surgical treatment decreased from 2010 to 2020.

More specifically, the percentage of patients who underwent surgery decreased from 47.4% to 39.9% for those with cervical cancer (AAPC, -1.3%; 95% CI, -1.6 to -1.1), from 72.0% to 67.9% for those with ovarian cancer (AAPC, -0.5%; 95% CI, -0.6 to -0.4), from 83.7% to 79.1% for those with endometrial cancer (AAPC, -0.5%; 95% CI, -0.7 to -0.4), and from 81.1% to 72.6% for those with vulvar cancer (AAPC, -1.3%; 95% CI, -1.6 to -0.9).

The use of MIS for patients who underwent any surgical treatment, regardless of cancer stage, increased from 45.8% to 82.2% between 2010 and 2020 for those with endometrial cancer (AAPC, 4.6%; 95% CI, 4.5-4.8) and from 13.3% to 37.0% for those with ovarian cancer (AAPC, 9.4%; 95% CI, 9.0-9.7).

Among those who underwent lymph node assessment between 2012 and 2020, SNLD increased from 0.2% to 10.6% (AAPC, 44.0%; 95% CI, 39.3-48.9) for patients with stage I or IIA cervical cancer, from 0.7% to 39.6% for those with stage I or II endometrial cancer (AAPC, 51.8%; 95% CI, 50.5-53.2), and from 12.3% to 36.9% for those with stage IB or stage II vulvar cancer with a tumor size smaller than 4 cm (AAPC, 10.7%; 95% CI, 8.0-13.5). However, the rate of complete lymphadenectomies decreased in all 3 groups.

Regarding surgical radicality, the rate of extended procedures, like radical hysterectomies, increased among patients with cervical cancer from 58.1% in 2012 to 68.8% in 2020 (AAPC, 2.0%; 95% CI, 0.0-4.0). Conversely, the rate of simple hysterectomy declined from 42.0% to 31.2% (AAPC, -2.8%; 95% CI, -5.2 to -0.4). Despite this trend, the total number of hysterectomies performed in this population decreased, with radical hysterectomies declining from 173 cases in 2012 to 141 cases in 2020.

Lastly, the researchers discovered an increase in FSS from 2004 to 2020 among patients younger than 40 years with cervical cancer and small tumors (>2 cm) who received surgical treatment, rising from 17.8% to 28.1% (AAPC, 3.1%; 95% CI, 2.3-3.9). Conversely, they found that the percentage of patients younger than 40 with stage IA or IC ovarian cancer who underwent surgery wavered greatly over time and did not demonstrate a clear trend.

The researchers acknowledged their study’s limitations, including those associated with using retrospective databases, namely potential inaccuracy, variability, and underreporting in surgical and treatment codes. Despite their limitations, they expressed confidence in their findings, using them to suggest areas for future research.

“Future research should focus not only on understanding the impact of surgical escalation on patients (including disease outcomes, quality of life, and equitable access to these services) but also on surgical training,” the authors wrote.

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. Boffa DJ, Rosen JE, Mallin K, et al. Using the National Cancer Database for outcomes research: a review. JAMA Oncol. 2017;3(12):1722-1728. doi:10.1001/jamaoncol.2016.6905