For more than a decade, the field of gynecologic oncology has witnessed a movement toward surgical de-escalation through the increased use of minimally invasive surgical techniques and sentinel lymph node techniques. At the 2025 Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s Cancer, Alexa Kanbergs, MD-ScM, MS, a gynecologic oncology fellow at MD Anderson Cancer Center in Houston, shared findings from a cohort study,1 conducted with colleagues and published in JAMA Network Open,2 on this trend in surgical care for gynecologic cancers.
“Historically, cancer treatment paradigms prioritized maximal surgical resection to ensure oncologic control,” Dr. Kanbergs said in an SGO press release. “The belief was that more extensive surgery correlated with better survival outcomes.” However, more recently, innovations in technology have allowed for more precise imaging and defined molecular pathology, she noted, as well as a deeper understanding of tumor biology.
Study Details
This study focused on the prospectively collected data from the National Cancer Database (NCDB) on 1,218,490 patients who were diagnosed with clinical stage I to IV endometrial, ovarian, cervical, or vulvar cancer between January 2004 and December 2020. There were 686,458 patients with endometrial cancer, 301,123 patients with ovarian cancer, 166,779 patients with cervical cancer, and 64,130 patients with vulvar cancer.
“As the field shifts toward less-invasive techniques, it is essential to ensure that the next generation of gynecologic oncologists is still adequately trained in more complex, rare, or radical procedures.”— ALEXA KANBERGS, MD-ScM, MS
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In the 16-year period, the clinical researchers observed a decrease in the number of people undergoing oncologic surgeries as follows: from 83.7% to 79.1% for those with endometrial cancer; from 72.0% to 67.9% for those with ovarian cancer; from 47.4% to 39.9% for those with cervical cancer; and from 81.1% to 72.6% for those with vulvar cancer. They also observed an increase in the use of laparoscopic and other minimally invasive methods from 45.8% to 82.2% for those with endometrial cancer (average annual percent change [AAPC] = 4.6%). In addition, the study authors saw an increase in sentinel lymph node dissection as follows: from 0.7% to 39.6% for patients with endometrial cancer (AAPC = 51.8%); from 0.2% to 10.6% for patients with cervical cancer (AAPC = 44.0%); and from 12.3% to 36.9% for patients with vulvar cancer (AAPC = 10.7%). There was also a reduction in the rate of completed lymphadenectomy in all cancer types except ovarian cancer.
“For me, the most surprising finding was the limited percentage of patients with low-risk endometrial cancer who had ovarian preservation,” Dr. Kanbergs stated. “This was unexpected, given that current guidelines provide support for ovarian preservation in low-risk cases.”
Evolution in Surgical Training
Although these study results show a trend toward less-invasive surgery for gynecologic cancers, are gynecologic oncology graduates ready for such a shift? According to Dr. Kanbergs, a recent survey showed that 76% of new physicians admitted feeling comfortable to perform a radical hysterectomy, and 60% said they felt confident to complete a laparoscopic para-aortic lymphadenectomy.
“De-escalation strategies have significant implications. For physicians, it necessitates an evolution in surgical training and daily practice,” she explained. “As certain procedures become less common, maintaining proficiency in more radical surgeries becomes a challenge, particularly for trainees and early-career gynecologic oncologists. As the field shifts toward less-invasive techniques, it is essential to ensure that the next generation of gynecologic oncologists is still adequately trained in more complex, rare, or radical procedures.”
Future studies are also needed to examine the correlation between these trends and patient outcomes, such as safety, adverse events, recovery, quality of life, and satisfaction measures. Finally, Dr. Kanbergs concluded, equitable access to care is an important factor to analyze and ensure as surgical de-escalation in gynecologic oncology continues to grow.
DISCLOSURE: Dr. Kanbergs reported no conflicts of interest.
REFERENCES
1. Kanbergs A, Melamed A, Viveros-Carreño D, et al: Surgical de-escalation within gynecologic oncology. 2025 SGO Annual Meeting on Women’s Cancer. Abstract.
2. Kanbergs A, Melamed A, Viveros-Carreño D, et al: Surgical de-escalation within gynecologic oncology. JAMA Netw Open 8:e2453604, 2025.
