Perioperative Care of the Surgical Cancer Patient: Gynecologic Cancers

Introduction

According to the American Cancer Society (ACS), there will be >900,000 new all-cause cancer cases in American women by 2020, approximately a third of whom will die as a result. The most prevalent gynecologic cancers among women are ovarian cancer, endometrial cancer, cervical cancer, and vulval cancer. Cancer therapies are increasingly complex, and for solid tumors, surgical management remains the cornerstone of treatment. The perioperative period is considered a time of maximum vulnerability in patients with cancer, as outlined in most enhanced recovery protocols.

Ovarian Cancer

An estimated 23,000 new cases of ovarian cancer were diagnosed in the United States in 2020.

Most (90%) were epithelial ovarian cancers, the most common of which is serous carcinoma (52%). Ovarian cancer incidence rates have decreased by approximately 1% per year in the past 50 years among women aged <65 years, but only since the early 1990s in older women. An estimated 14,000 deaths occurred in 2020—accounting for 5% of cancer deaths among women—more than any other gynecologic cancer.

The most important risk factor besides age is a strong family history of breast or ovarian cancer. Women who have tested positive for inherited mutations in cancer susceptibility genes such as BRCA1 or BRCA2 are at increased risk. Modifiable factors associated with increased risk include excess body weight, menopausal hormone therapy (estrogen alone or combined with progesterone), and cigarette smoking. Factors associated with lower risk include pregnancy, fallopian tube ligation or removal (salpingectomy), and use of oral contraceptives.

At first presentation, 75% have metastatic cancer to the peritoneal cavity or liver, corresponding to stage 3 cancer (according to the International Federation of Gynecology and Obstetrics [FIGO]). Surgery aims to achieve maximal reduction of tumor volume. The degree to which this can be achieved correlates with survival ; therefore surgery needs to be extensive. Surgery is often accompanied by 3–6 cycles of prior (neoadjuvant) platinum-based chemotherapy. Second laparotomy (or “interval debulking”) may be required for resection of recurrent disease, or where optimal tumor debulking could not be achieved initially. Survival from ovarian cancer depends on the extent of disease, but currently women with stage 3 disease might only expect 30%–35% survival at 5 years. Women predisposed to ovarian cancer (e.g., carriers of BRCA gene mutations) are increasingly being offered prophylactic salpingo-oophorectomy.

Debulking of ovarian cancer is normally performed via a full mid-line laparotomy. The need for optimal cytoreduction often requires prolonged surgery. Excision of the uterus, ovaries, and adnexa is standard, accompanied by omentectomy and sampling of peritoneal deposits and lymph node chains. Wider spread of disease may necessitate bowel resection and/or splenectomy and can involve difficult dissections.

Cervical Cancer

An estimated 13,500 cases of invasive cervical cancer were diagnosed in the United States in 2020, and there were an estimated 4250 deaths. Almost all cervical cancers are caused by persistent infection with certain types of human papillomavirus (HPV). Several factors are known to increase the risk of both persistent HPV infection and progression to cervical cancer, including a suppressed immune system, a high number of childbirths, and cigarette smoking. Long-term use of oral contraceptives is also associated with increased risk that gradually declines after cessation. Precancerous cervical lesions may be treated with a loop electrosurgical excision procedure (LEEP), which removes abnormal tissue with a wire loop heated by electric current. Precancerous lesions may also be surgically treated by cryotherapy (the destruction of cells by extreme cold), laser ablation (destruction of tissue using a laser beam), or conization (the removal of a cone-shaped piece of tissue containing the abnormal tissue). Invasive cervical cancers are generally treated with surgery or radiation combined with chemotherapy. Chemotherapy alone is often used to treat advanced disease.

Endometrial Carcinoma

An estimated 62,000 cases of cancer of the uterine corpus were diagnosed in the United States in 2020. Cancer of the uterine corpus is often referred to as endometrial cancer because more than 90% occurs in the endometrium. Many of these tumors are associated with excess body weight and insufficient physical activity.

Obesity is the main risk factor for uterine cancer, as well as factors that increase estrogen exposure, including the use of postmenopausal estrogen, late menopause, nulliparity, and a history of polycystic ovary syndrome. Tamoxifen, which may be given as treatment for breast cancer, slightly increases risk of endometrial cancer because it has estrogen-like effects on the uterus. Medical conditions that increase risk include Lynch syndrome and type 2 diabetes.

Surgical management ranges from simple hysterectomy with oophorectomy and lymph node sampling to radical hysterectomy. Adjuvant pelvic radiotherapy and brachytherapy are commonly used in women with residual cancer or patients deemed unfit for surgery.

Vulval Cancer

Vulvar cancer comprises approximately 6% of gynecologic cancers and less than 1% of all cancers in women. It is estimated that 1300 deaths from vulvar cancer occur in a given year. The 5-year survival rate for women with vulvar cancer is 71%. Survival rates depend on several factors, including the type of vulvar cancer and the stage of disease at the time it is diagnosed. Incidence peaks in patients aged >65 years and older patients present with later stage disease. Surgical strategies range from laser therapy to wide local excision and radical vulvectomy with groin node dissection.

Perioperative Considerations