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We have thoroughly enjoyed preparing this year’s themed edition. With Guest Editors Rob Bristow, Nick Reed and Jonathan Ledermann, we encouraged submissions of original work and reviews from key international researchers. We have been delighted by their response. We would also like to thank our trainee editors, Vanessa Harry and Emma Crosbie for their helpful advice. The accepted papers range from tumour biology, through screening and diagnosis, to a range of treatment options (particularly surgical management).

Cervical cancer prevention

  1. Top of page
  2. Cervical cancer prevention
  3. Reducing cervical cancer morbidity
  4. From the laboratory to the clinic
  5. Intraperitoneal chemotherapy and surgical radicality
  6. Improving survival outcomes and centralisation of services

Cervical cancer is still the commonest gynaecological malignancy globally and is likely to remain so until developing countries can afford to introduce mass vaccination policies. In the meantime, a pilot programme in Mali of screening by visual inspection has been demonstrated by Teguete and colleagues to be effective (see page 220). Vaccination is expensive and individual countries have to decide whether improving screening or vaccination is their most appropriate strategy for reducing the mortality from cervical cancer. The papers by Yamamoto et al. on page 177 and Sharma et al. on page 166 have demonstrated that human papillomavirus vaccination programmes with subsequent screening are beneficial and cost effective in Japan and Thailand, particularly given the low screening coverage in these two countries. We have published a number of papers in BJOG suggesting that excisional treatment for pre-invasive disease of the cervix increases the risk of preterm birth. Reilly et al. on page 236 report that in a retrospective study the odds ratio for preterm birth was increased in women who underwent only colposcopy (odds ratio 1.54, 95% CI 1.32–1.80) and that this was similar to that in women with a single excisional treatment (odds ratio 1.77, 95% CI 1.47–2.13). They suggest that this similarity could be the result of the risk factors for abnormal smears and preterm birth being the same. Reassuringly, Kalliala et al. on page 227 find that previous treatment for cervical intraepithelial neoplasia did not impact adversely on fertility.

Reducing cervical cancer morbidity

  1. Top of page
  2. Cervical cancer prevention
  3. Reducing cervical cancer morbidity
  4. From the laboratory to the clinic
  5. Intraperitoneal chemotherapy and surgical radicality
  6. Improving survival outcomes and centralisation of services

Some women who develop cervical cancer will previously have screened negative. Fortunately, a number of developments have resulted in reductions in treatment-related morbidity. In selected women we can preserve fertility by preserving the uterine corpus. Introduced some years ago by D’argent, their laparo-vaginal approach was mainly reserved for women with tumours <2 cm in size. In this edition, Saso et al. on page 187 present their series of abdominal radical trachelectomies, allowing a fertility-preserving procedure in more women, in particular those with larger tumours, or with difficult vaginal access, or where surgeons carry out the procedure too infrequently to be skilful at the vaginal procedure. This may become a historical debate as more of us move towards a total laparoscopic radical trachelectomy.

In this respect, Koehler et al. on page 254 present their surgical philosophy and their progression from a laparoscopic assisted radical vaginal hysterectomy (LARVH) to a vaginal assisted laparoscopic radical hysterectomy (VALRH). Although many have moved to a total laparoscopic radical hysterectomy, these pioneers of laparoscopic surgery have maintained a vaginal element to the procedure and suggest that this is both beneficial to the woman and more consistent with basic oncological principles.

There is good evidence of reduced morbidity associated with a minimally invasive surgical approach, but much of the morbidity associated with surgery for cervical cancer is related to radical surgery to the para-colpos and upper vagina in addition to the pelvic lymphadenectomy. On page 129, Eiriksson and Covens present their scrutiny of the literature on sentinel node assessment and suggest that in a significant proportion of women it can replace pelvic lymphadenectomy, citing evidence of both reliability in identifying lymph node metastases and reduced morbidity.

What about reducing morbidity for the surgeon? Although laparoscopic sentinel node assessment compared with laparoscopic pelvic lymphadenectomy is a relatively quick procedure, more complex radical laparoscopic procedures take significantly longer than the open approach and can become a struggle for any aging gynaecological oncologist. The da Vinci Robotic platform allows the surgeon to be seated and provides a magnified high-resolution three-dimensional image using EndoWrist instruments in an ergonomically friendly environment. Robotic surgery has been available for some years, but few centres have had the funds or managerial support to purchase the equipment. Although the evidence supports its clinical value in allowing a minimally invasive approach in more difficult and complex disease, significant uncertainty remains as regards both its cost-effectiveness and the best approach to training. The latter has been systematically and comprehensively reviewed by Schreuder et al. on page 137 and this is essential reading for all clinicians and managers planning to invest in this technology.

From the laboratory to the clinic

  1. Top of page
  2. Cervical cancer prevention
  3. Reducing cervical cancer morbidity
  4. From the laboratory to the clinic
  5. Intraperitoneal chemotherapy and surgical radicality
  6. Improving survival outcomes and centralisation of services

Ovarian cancer is still the most lethal of all gynaecological malignancies so we have included articles to improve our understanding of its aetiology and behaviour. The commentary by Ahmed et al. on page 134 suggests that most disease may be of fallopian tube origin. The classification by genetic subtypes potentially allows treatment with a more individualised and specific regimen of systemic agents rather than the universal use of carboplatin and taxol chemotherapy, so helping to reduce treatment-related morbidity as well as potentially improving survival. It also allows us to group together cancers of different anatomical sites into one category under the terminology of high grade serous cancers.

The article by Sharma et al. on page 207 presents original data from the United Kingdom Collaborative Trial of Ovarian Cancer Screening on over 48,000 postmenopausal women receiving annual transvaginal ultrasound scans, and provides reassuring evidence that ovaries with inclusion cysts commonly seen during such investigations are not associated with an increased risk of ovarian cancer. This questions our current understanding of ovarian cancer aetiology and its relationship to ovarian surface epithelial cells.

Intraperitoneal chemotherapy and surgical radicality

  1. Top of page
  2. Cervical cancer prevention
  3. Reducing cervical cancer morbidity
  4. From the laboratory to the clinic
  5. Intraperitoneal chemotherapy and surgical radicality
  6. Improving survival outcomes and centralisation of services

Ovarian cancers or high-grade serous cancers have a propensity to spread via the peritoneal cavity and present as peritoneal carcinomatosis. This suggest that delivering chemotherapy intraperitoneally after the completion of surgical cytoreduction might be effective. Although not a new idea, it is only recently that this has been shown to improve progression-free and overall survival. However, use of intraperitoneal chemotherapy has been limited largely because of the complications associated with its delivery, most of which are related to port-catheters and problems associated with blockage, infection, leakage and visceral injury. Although not widely considered a standard treatment, if we are to develop this treatment option in the future we will need to address the complexities associated with port-catheters and, in this respect, we thank Bill Helm for his comprehensive review of the current literature, which on page 150 provides a thorough account of the different types of port-catheters and their associated risks and benefits. Intraperitoneal chemotherapy is most effective in women with <1 cm residual deposits. Achieving high rates of optimal cytoreduction requires training in ‘debulking’ procedures in the mid and upper abdomen as well as in the pelvis. Fleury et al. on page 202 present their personal series of extending the surgical approach above the upper abdomen and into the chest! Not surprisingly, they show that many women whose disease was considered initially to be confined to the abdomen (stage 3C), on thoracoscopy have evidence of disease above the diaphragm. They suggest that the potential benefits of achieving complete cytoreduction in the abdomen may be lost if deposits remain in the chest and present a case for recommending routine thoracoscopy, with a view to extending cytoreduction to the thorax. They also question the rationale of intraperitoneal chemotherapy in women with deposits outside the peritoneal cavity.

Standardising the quality of surgery and defining ‘radicality’ is a complex area of investigation. The National Institute for Health and Clinical Excellence have recently made recommendations regarding the value of ‘systematic’ complete para-aortic node dissection and advised against its performance as a staging procedure in early-stage ovarian cancer. Pomel et al. on page 249 have found that there is an uncertainty as to how it should be defined, and provide a detailed illustrated guide to how the procedure can be performed. In addition, they present a novel definition and classification system with a photographic series of commonly seen anatomical anomalies that one would need to be familiar with if carrying out the procedure. We recommend that the reader go online and take advantage of their Supporting Information files (not available in the print version).

Other controversies in early-stage ovarian cancer include the use of intraoperative frozen section analysis to identify which women presenting with an adnexal mass have malignant disease, thereby allowing a complete staging procedure at the time of the initial laparotomy. Cross et al. on page 194 present a series of over 1400 women undergoing intraoperative frozen section analysis performed over a 10-year period, providing information on test statistics including sensitivity, specificity, negative and positive predictive values, and pre-test and post-test likelihood ratios, to determine diagnostic test accuracy. They also provide information and guidance on introducing and delivering a ‘pathologist on stand-by’ service for those centres that are keen to introduce this diagnostic aid.

Improving survival outcomes and centralisation of services

  1. Top of page
  2. Cervical cancer prevention
  3. Reducing cervical cancer morbidity
  4. From the laboratory to the clinic
  5. Intraperitoneal chemotherapy and surgical radicality
  6. Improving survival outcomes and centralisation of services

Finally, Crawford and Greenberg on page 160 present their detailed population-based analyses of the effects of centralisation of care on survival outcomes in endometrial and ovarian cancer. Introduced in the UK in the late 1990s, the development of Cancer Networks (the ‘hub and spoke’ model) met with considerable resistance. Although it seemed intuitively right, the evidence to support such health care re-organisations was best described as weak, and they not only needed a significant investment of resources, but also required people to travel away from their immediate locality, making it difficult for friends and families to visit. Now, a number of years on, data are beginning to emerge reassuring all of the interested parties, patients in particular, that the energies and efforts required to implement the principles of centralisation of cancer services appear to have been justified.