Aher gynecologist-oncologist, Eva Chalas, MD, professor at Department of Obstetrics and Gynecology at NYU Long Island School of Medicine, specializes in treating people with gynecological cancers, such as ovarian and endometrial cancers, and complex gynecological conditions. As Physician Director of the Perlmutter Cancer Center at NYU Langone Hospital on Long Island, Dr. Chalas leads a multidisciplinary team dedicated to improving services in the areas of cancer prevention, early detection, and treatment.
She discusses the challenges faced by people with gynecological cancers, trends in gynecological cancer treatment, and more.
What are some of the challenges you see for people with gynecological cancers?
A cancer diagnosis and subsequent treatment can challenge people in ways they might not expect. In the older population, I see many patients in their 80s and sometimes even 90s who have a fairly good quality of life and yet are affected by cancer. These patients are usually very difficult because they tend to have multiple medical comorbidities. Our elderly patients are often alone. They usually outlive their partners or spouses, and any children they may have taken away or are busy with their own lives. It is both a medical and a social challenge.
What I often see is that because the family no longer lives together, the children sometimes don’t understand how compromised their mother is because these people seem to have good performance status or good maneuvering ability and to continue to operate. Patients and their children don’t realize that the stress of surgery could tip them over very easily because they operate on a very limited scale.
For example, if an elderly person performs daily activities that do not require a high level of complexity in terms of decision-making, they may do very well for a long time. But when they come to a crisis in which their body is stressed by the cancer or its treatment, we know that these patients are at a very high risk for perioperative delirium and a much higher risk for falls and things like that. Family members expect everything to go well because their mother is a high achiever, yet they fail to realize that she has very little reserve.
Our young patients have similar social challenges because many of them also live alone.
Social circumstances have a profound effect on how well a person with cancer tolerates the procedure and where they are referred after surgery. We often find that we are not able to send them home after they have achieved their goals in the hospital, as they are not comfortable returning to an empty house. Often we refer patients to a subacute rehabilitation center simply because they are afraid to be home alone, and our physiotherapists feel like they don’t have the support they need at home.
Can you talk about some of the trends you are seeing in the treatment of people with gynecological cancers?
We’ve always had a very high implementation of minimally invasive surgery because we understand that, again, since cancer tends to affect older people, the less we disturb them physiologically, the better off they are and the more recover quickly. Many of our patients require additional treatment, whether it’s radiation or chemotherapy, a combination of the two, or targeted therapies. Whatever the treatment, it is something other than surgery. So in those circumstances, if we can do the procedure with minimally invasive surgery, we tend to do it.
Nearly 90% of our endometrial cancer patients undergo minimally invasive surgery. Many of them go home the same day despite the extent of the surgery, and they go home very well. We have started implementing this procedure for people with ovarian, fallopian tube or peritoneal cancer who are suitable candidates where possible because we realize it is in the interest of the patient. As long as this does not compromise the extent of surgery offered, we proceed with the minimally invasive approach.
There is also growing interest in targeted therapies. Although gynecological cancers are not in the same category as other cancers, such as melanoma and lung cancers, which allow for more targeted therapies, we have the capacity to offer some, and others are being explored in clinical research. It’s exciting to me that we can offer patients such approaches when appropriate.
Have you found that certain targeted therapies work better for people with gynecological cancers?
Some targeted therapies work very well and can either prevent recurrence or delay recurrence in patients. One of them is the class of drugs called PARP inhibitors. PARP is an enzyme involved in DNA repair, and blocking its action with a PARP inhibitor can help prevent cancer cells from repairing their damaged DNA.
Pembrolizumab, a checkpoint inhibitor, has been shown to be very effective in certain types of endometrial cancer as well as certain other gynecological malignancies. There is also another medicine called lenvatinib, which blocks certain proteins that can prevent cancer cells from growing and killing them, which has been shown to be effective, especially in combination with pembrolizumab, for patients with endometrial cancer.
The bevacizumab monoclonal antibody, which we have been using for many years, is still very effective.
There are other targeted therapies in the works or currently being studied for which we do not yet have results, but we hope they will prove to be of additional value in the therapeutic armamentarium for the treatment of these ailments.
What should people expect when they see you for cancer care?
Patients should expect to be greeted with respect and expertise at all levels. They will also be greeted with a team approach to care, which I think is the key issue. No doctor knows everything, and it’s important to have different perspectives, which is how our diagnostic management groups work. It is a team care approach with access to everything a patient would need.
NYU Langone Hospital—Long Island is a tertiary care facility, which means we provide specialist care. If a patient needs quaternary services, or even more specialized care, these are available at NYU Langone’s Manhattan location. As part of the NYU Langone system, we can offer the full range of what is available in medical care. Time and time again we have had patients who have gone elsewhere for advice and come back to us and said that what we recommended was what other doctors recommended.