Surgical Deescalation Within Gynecologic Oncology
Authors: Alexa Kanbergs, Alexander Melamed, David Viveros-Carreño, Chi-Fang Wu, Roni Nitecki Wilke, Abigail Zamorano, Kimeera Paladuga, Laura Havrilesky, Jose Alejandro Rauh-Hain, Nuria Agusti
Journal: JAMA Network Open (2025)

Importance The goal of surgical deescalation is to minimize tissue damage, enhance patient outcomes, and reduce the adverse effects often associated with extensive or traditional surgical procedures. This shift toward less invasive techniques has the potential to revolutionize surgical practices, profoundly impacting the methods and training of future surgeons. Objective To evaluate adoption of surgical deescalation within the field of gynecologic oncology using The National Cancer Database. Design, Setting, and Participants This cohort study used prospectively collected data from the National Cancer Database from January 2004 to December 2020. Eligible participants included women in the US who received a diagnosis of clinical stage I to IV endometrial, ovarian, cervical, or vulvar cancer within this time frame. Data were analyzed between January and June 2024. Exposure Diagnosis of stage I to IV endometrial, ovarian, cervical, or vulvar cancer. Main Outcomes and Measures The primary outcome was surgical deescalation, which included evaluation of receipt of surgical intervention, the surgical approach, the type of lymph node assessment, and salvage interventions for disease-affected organs. A Poisson model was applied to estimate the average annual percentage change (AAPC) in the receipt of surgical treatment. Results A total of 1 218 490 patients (mean [SD] age at diagnosis, 61.2 [13.7] years) were included. Over the study period, the percentage of patients undergoing 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 11 −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 minimally invasive surgery increased from 45.8% to 82.2% for those with endometrial cancer (AAPC, 4.6%; 95% CI, 4.5% to 4.8%) and from 13.3% to 37.0% for those with ovarian cancer (AAPC, 9.4%; 95% CI, 9.0% to 9.7%). Sentinel lymph node dissection increased from 0.7% to 39.6% for patients with endometrial cancer (AAPC, 51.8%; 95% CI, 50.5% to 53.2%), from 0.2% to 10.6% for patients with cervical cancer (AAPC, 44.0%; 95% CI, 39.3% to 48.9%), and from 12.3% to 36.9% for patients with vulvar cancer (AAPC, 10.7%; 95% CI, 8.0% to 13.5%) cancers, whereas the rate of complete lymphadenectomies decreased in all 3 groups. The rate of fertility-sparing surgery for patients with cervical cancer younger than 40 years rose from 17.8% to 28.1% (AAPC, 3.1%; 95% CI, 2.3%-3.9%). Conclusions and Relevance These findings suggest that over the past 15 years, the field of gynecologic oncology has moved toward surgical deescalation through an overall reduction in the number of patients who undergo surgery, increased use of minimally invasive surgical techniques, and increased use of sentinel lymph node techniques. 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.