What are the latest developments in General Gynaecology, Uro (Urogynaecology) Gynaecology, and Gynae (Gynaecological) Oncology based on recent Randomized Controlled Trials (RCTs)?

Latest Developments in Gynaecological Oncology, General Gynaecology, and Urogynaecology: 2024-2025 RCT Updates

The most significant recent development in gynaecological oncology is the risk-stratified approach to adjuvant therapy in endometrial cancer, with molecular classification now guiding treatment decisions rather than relying solely on traditional histopathological features.

Gynaecological Oncology Advancements

Endometrial Cancer Management

Recent evidence has revolutionized the treatment approach for endometrial cancer with risk stratification based on both traditional and molecular factors:

• Risk Stratification Evolution:

  • Current guidelines define high-risk endometrial cancer as stage III-IVA without residual disease or stage I-IVA p53-abnormal or non-endometrioid carcinomas without residual disease with myometrial invasion 1
  • Molecular classification (POLE-mutated, mismatch repair deficient, p53-abnormal, no specific molecular profile) now guides adjuvant therapy decisions 1

• Adjuvant Therapy Updates:

  • For intermediate-risk endometrial cancer (Stage I endometrioid, G1-2, ≥50% myometrial invasion, LVSI negative):
    • Adjuvant brachytherapy is recommended
    • No adjuvant treatment is an option for patients <60 years old
    • For G3 or LVSI positive cases: Combined or sequential chemotherapy should be considered 1

• Combined Modality Treatment:

  • PORTEC-3 trial demonstrated significant improvement in 5-year overall survival and failure-free survival with combined chemoradiotherapy versus radiotherapy alone for high-risk endometrial cancer 1
  • Greatest benefit observed in stage III and serous histology patients 1
  • For stage I-II non-serous cancers, the absolute improvement was modest (2% in 5-year OS and 4% in FFS) 1

Hormone Replacement Therapy in Gynaecological Cancer Survivors

The British Gynaecological Cancer Society and British Menopause Society have published new guidelines (2024) addressing the management of menopausal symptoms following gynaecological cancer treatment 2:

• Key Recommendations:
  • Benefits and risks of HRT are now stratified by cancer type
  • Guidance provided on optimal timing of HRT initiation after cancer treatment
  • Vaginal estrogens are considered safe and effective for urogenital symptoms in most women, including those for whom systemic HRT is contraindicated 2

General Gynaecology and Urogynaecology Updates

Long-term Survivorship Care

The Gynecologic Cancer InterGroup (GCIG) has established consensus guidelines for long-term survivorship in gynecologic cancer 1:

• Definition: Long-term survival defined as at least five years from diagnosis, regardless of disease recurrences
• Key Findings: More than 50% of gynecological cancer survivors experience ongoing health concerns/long-term side effects
• Common Issues: Neurologic symptoms, sleep disturbance, fatigue, sexual dysfunction, bowel and urinary problems, and lymphedema
• Recommendations:
  • Screening for second primary cancers
  • Lifestyle counseling (nutrition, physical activity, mental health)
  • Addressing quality of life concerns 1

Menopausal Symptom Management

Recent evidence supports a more nuanced approach to managing menopausal symptoms in gynecological cancer survivors:

• Non-hormonal Options:

  • Cognitive behavioral therapy, hypnosis, SSRIs, SNRIs, clonidine, and gabapentin have shown efficacy for vasomotor symptoms 3
  • These options should be considered first-line for patients with estrogen-sensitive cancers 3

• Hormonal Options:

  • Low-dose vaginal estrogens are highly effective for genitourinary symptoms with minimal systemic absorption 4
  • Systemic HRT may be considered for most gynecological cancer survivors except those with estrogen receptor-positive cancers 5

Clinical Implications and Future Directions

1. Personalized Medicine: Treatment decisions should now incorporate molecular classification alongside traditional risk factors

2. Quality of Life Focus: Increased emphasis on survivorship care and managing treatment-related side effects

3. Research Gaps:

   • Need for larger randomized trials on HRT safety in gynecological cancer survivors
   • Further investigation of non-hormonal therapies for symptom management
   • Biomarker-driven clinical trials for targeted therapies in advanced/recurrent disease 1

Common Pitfalls to Avoid

• Overlooking Molecular Classification: Failing to incorporate molecular markers into risk stratification for endometrial cancer
• Underestimating Survivorship Issues: Not addressing long-term side effects that significantly impact quality of life
• Withholding HRT Unnecessarily: Denying HRT to appropriate candidates based on theoretical rather than evidence-based concerns
• Inadequate Follow-up: Not implementing comprehensive surveillance for both recurrence and second primary cancers

The field of gynecological oncology continues to evolve rapidly, with increasing emphasis on personalized treatment approaches and quality of life considerations alongside traditional survival outcomes.