Advanced Treatments in Gynaec Oncology

Advanced treatment in gynaecologic oncology now rests on four pillars: cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC) for advanced ovarian cancer, laparoscopic and robotic cancer surgery with sentinel lymph node mapping, molecular testing that guides targeted therapy and immunotherapy, and HPV vaccination that prevents cervical cancer. Dr. Archit Pandit, Director Surgical Oncology, Fortis Escorts, Okhla, New Delhi, India, set out how each one changes outcomes.

His audience was general practitioners and specialists across Africa, and his argument was practical, down to where general practitioners fit in. India and Africa share a high burden of cervical cancer and the same sensitivity to cost, and in both, general practitioners decide how early a cancer is caught. This guide covers the four gynaecological cancers, the red flags that should trigger a referral, the treatment standards his team follows, the costs he quoted and the routes by which doctors abroad can work with an Indian cancer team. Two companion articles go deeper: one on HIPEC, robotic surgery and sentinel lymph node mapping, and one on genetic testing, targeted therapy and HPV vaccination.

The four gynaecological cancers

Gynaecological cancers are the cancers of the female reproductive tract. Dr. Pandit groups them into four, each with its own diagnostic problem.

Cervical cancer. Dr. Pandit's starting point is that cervical cancer is preventable. India and Africa both carry a high incidence, which he links to shared socioeconomic conditions, the burden of sexually transmitted infection and limited sexual health education among young people. Regular Pap smears (cells from the cervix examined for abnormal changes), HPV (human papillomavirus) testing and vaccination are the tools that change that trajectory.

Ovarian cancer. Ovarian cancer is generally diagnosed at stage 3 or 4, when it has already spread through the abdomen or beyond it. This late presentation is why HIPEC, a treatment aimed at disease spread across the abdominal lining, has had its greatest impact here.

Endometrial cancer. Dr. Pandit calls endometrial cancer "very interesting" because it is rising in both societies for the same reason: children are less physically active, childhood obesity is increasing, and obesity is a major risk factor for cancer of the uterine lining.

Vulval and vaginal cancers. These are the rarest of the four, but he singles them out as important to both India and Africa, because many are caused by HPV, a sexually transmitted infection.

Early detection: the general practitioner's role

Dr. Pandit's closing message was that general practitioners are crucial for early detection and for referring patients to an oncology centre in time. Rather than a list of 30 or 40 symptoms that not everyone can remember, he asks them to hold on to four red flags: bleeding after menopause, a pelvic mass, an abnormal Pap smear or positive HPV test, and a family history of ovarian, breast or endometrial cancer. Each is explained, with the screening, genetic testing and vaccination that sit behind it, in the companion article on early detection.

Treatment standards: NCCN guidelines and the tumour board

Every treatment decision in Dr. Pandit's team follows international guidelines and is made jointly at a tumour board. Dr. Pandit leads a team of four to five cancer surgeons at Fortis, each focused on a defined area. He personally looks after gastrointestinal and gynaecological cancers, while a colleague covers head, neck and breast cancers. All the cancer surgeons in his team trained at the All India Institute of Medical Sciences (AIIMS). He also works with Fortis La Femme, a Fortis hospital dedicated to women's healthcare across obstetrics, gynaecology, preventive medicine and gynaecologic oncology.

Three features of the team's practice stand out in his account:

• Ethical care first. He describes ethical care as of the utmost importance and not open to compromise.
• International treatment guidelines. Every treatment decision follows the guidelines of the National Comprehensive Cancer Network (NCCN), the US body whose cancer guidelines are widely used as a reference worldwide.
• The tumour board. Each case is discussed at a round-table meeting of specialists, where the team brings the world literature to the table and decides treatment together.

He also stresses cost. India and Africa, he notes, share the same sensitivity to price, and India offers advanced cancer care that is affordable and delivered to international standards.

Advanced treatments in gynaecologic oncology at a glance

Dr. Pandit organises the field into surgical, diagnostic, medical and preventive advances. Each is covered in depth in a companion article; the summary here is deliberately brief.

• Surgery. Laparoscopic and robotic-assisted cancer surgery has been performed in India for about two decades. Combined with fertility-sparing techniques and sentinel lymph node mapping with indocyanine green (ICG) dye (finding and removing the first node to which a tumour drains), it has reduced complications and shortened hospital stays. HIPEC has become what he calls a game changer for advanced ovarian cancer. Detail: the companion article on HIPEC, robotic surgery and sentinel nodes.
• Diagnosis. PET-CT (a whole-body scan that shows whether and where a cancer has spread) for staging, genetic testing for BRCA, homologous recombination deficiency (HRD) and microsatellite instability (MSI), next-generation sequencing, and artificial intelligence applied to Pap smears and radiology.
• Medical oncology. Targeted therapies, such as PARP inhibitors (drugs that stop cancer cells repairing their DNA) for BRCA-positive ovarian cancer, and immunotherapies for MSI-high tumours and cervical cancer.
• Prevention. HPV vaccination of girls and boys, including a low-cost Indian-made vaccine. Detail: the companion article on early detection, genetic testing and targeted therapy.

Radiotherapy, targeted therapy and CAR-T cell therapy

Fortis offers seven radiation techniques, which Dr. Pandit listed when asked whether the hospital provides chemoradiotherapy and modern radiotherapy: 3D conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), arc therapy, CyberKnife, tomotherapy and brachytherapy (radiation delivered from a source placed inside or next to the tumour). Broader benchmarks are on the Jivo Healthcare page for radiotherapy costs.

Beyond routine chemotherapy, his team has access to targeted therapy and immunotherapy. He added that CAR-T cell therapy, in which a patient's own immune cells are engineered to attack a cancer, is now available in India, and described it as one of the most advanced treatments in the world. Its approved uses are currently in blood cancers, such as certain leukaemias and lymphomas.

Complex cases referred from abroad

Dr. Pandit showed several cases from patients referred from African countries to illustrate the complexity his team takes on, gynaecological and otherwise.

• A very large benign ovarian tumour. A young patient arrived with an ovarian germ cell tumour (a tumour arising from the egg-forming cells), which proved not to be cancerous, weighing around 7 to 8 kg and occupying about 70% of the abdominal girth on CT. She had been unable to breathe comfortably. After surgery her weight fell from 85 kg to 78 kg, and, in his words, her life completely changed.
• A very large abdominal tumour. The team removed an abdominal tumour weighing about 10 kg and measuring about 40 cm from a woman referred from Africa.

Minimally invasive lung surgery for a gynaecological cancer that had spread to the chest is described in the companion surgical article. The common thread, he said, is that the team treats a wide variety of patients from Africa, takes care to manage their costs and handles very complex tumours.

Cost of gynaecologic cancer surgery and HIPEC in India

Dr. Pandit put laparoscopic cancer surgery at Fortis at about $5,000 to $5,500 and cytoreductive surgery with HIPEC at about $11,000 to $12,000. He gave the following indicative ranges, in US dollars, in answer to questions from doctors in Zambia, Zimbabwe and Ethiopia. As the doctor who asked noted, cost depends on the complexity of the surgery.

In the same answer he described his team's endometriosis work: these operations are difficult and many gynaecologists prefer not to undertake them, so his team receives many referrals. He then cited a range of about $5,000 to $6,500. Focused ultrasound therapy is generally used for certain small fibroids; his own field is cancer surgery, but the treatment is offered at Fortis. For broader benchmarks, see the Jivo Healthcare pages on cytoreductive surgery with HIPEC costs and radical hysterectomy costs.

Cross-border referral, second opinions and observerships

Doctors in Africa can work with Dr. Pandit's team through virtual consultations and second opinions, direct referral, and observerships and fellowships, whether or not the patient ever travels.

• Virtual consultations and second opinions. His team is available online on an agreed day and time to discuss patients, the clinical evidence and the way forward, irrespective of whether the patient comes to India. The aim, he said, is to help in whichever way possible.
• Cross-border referral. Patients who need surgery or specialist treatment can be referred directly. He told the session that his team usually responds to a patient query within one hour.
• Observerships and training. Gynaecologists, surgeons and general physicians can join training and observership programmes. Doctors on the medical side can come as observers, with an overview of preventive health checks, medical oncology and surgical oncology; hands-on surgical training for foreign doctors is generally limited to surgeons and gynaecologists. He also runs fellowship programmes for gynaecologists who want to learn laparoscopic radical hysterectomy.
• The tumour board. For a visiting doctor, he considers taking part in the tumour board the most valuable experience, because that is where every case is discussed and every decision is made.

The questions doctors put to him in the session, with his full answers on cost, focused ultrasound, HIPEC eligibility and observerships, are collected in the Live Discussion.

Related gynaecologic oncology guides

Other Jivo Healthcare masterclasses approach the same field from different angles. Dr. Punyashree R M's overview of gynaecological cancers concentrates on symptoms, screening and the basics of each cancer, and Dr. Alka Dahiya's guide to robotic surgery in gynaecologic oncology examines the robotic platform and patient selection in detail. More specialists and topics are listed under oncology and obstetrics and gynaecology.