As a gynecologic oncologist, Eva Chalas, MD, professor in the Department of Obstetrics and Gynecology at NYU Long Island School of Medicine, specializes in treating people with gynecologic cancers, such as ovarian and endometrial cancers, and complex gynecologic conditions. As physician director of Perlmutter Cancer Center at NYU Langone Hospital—Long Island, Dr. Chalas leads a multidisciplinary team in enhancing services in the areas of cancer prevention, early detection, and treatment.
She discusses the challenges people with gynecologic cancers face, trends in treating gynecologic cancers, and more.
What are some of the challenges that you are seeing for people with gynecologic cancers?
A cancer diagnosis and the treatment that follows can present a challenge for people in ways they might not expect. In the older population, I’m seeing a lot of patients who are octogenarians and sometimes even nonagenarians who have a pretty good quality of life and yet are affected by a cancer. These patients typically are very challenging because they tend to have multiple medical comorbidities. Our older patients are often alone. They typically outlive their partners or spouses, and any children they might have moved away or are busy with their own lives. It’s a challenge both medically and socially.
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 individuals appear to have good performance status or a good ability to maneuver and continue to function. The patients and their children don’t realize that the stress of surgery could push them over the edge very easily because they’re functioning on a very limited scale.
For example, if an older person is doing day to day activities that don’t require a high level of complexity in terms of decision-making, they can get by very well for a long period of time. But when they get to a crisis in which their body is stressed from cancer or its treatment, we know that these patients are at very high risk of perioperative delirium and a much higher risk for falls and things like that. Family members have expectations that everything is going to go great because their mom is such a high-performing individual, and yet they don’t realize that she has very little reserve.
Our younger patients have similar social challenges because many of them live alone as well.
Social circumstances have a profound effect on how well a person with cancer tolerates the procedure and where they are discharged to after surgery. We often find that we are unable to discharge them to their home after they have met their milestones in the hospital because they are not comfortable returning to an empty house. Many times, we discharge patients to a subacute rehabilitation center just because they are afraid to be at home alone, and our physical therapists feel like they do not have the support at home that they need.
Can you talk about some of the trends you are seeing in treatment of people with gynecologic cancers?
We have always had very high implementation of minimally invasive surgery because we understand that, again, since cancer tends to affect people who are older, the less we disturb them physiologically the better off they are and the faster they will recover. Many of our patients must receive additional treatment, whether it be radiation or chemotherapy, a combination of the two, or targeted therapies. Whatever the treatment, it is something else besides surgery. So, in those circumstances, if we can perform the procedure by minimally invasive surgery, we tend to do that.
Close to 90 percent of our patients with endometrial cancer have minimally invasive surgery. Many of them go home on the same day despite the extent of surgery, and they go home doing very well. We have begun implementing that procedure for people with ovarian, fallopian tube, or peritoneal cancers who are appropriate candidates whenever possible because we realize that it is to the patient’s benefit. As long as it doesn’t compromise the extent of surgery that is offered, then we proceed with the minimally invasive approach.
There is also an increasing interest in targeted therapies. Even though gynecologic cancers aren’t in the same category of other cancers, such as melanoma and lung cancers, that allow for more targeted therapies, we do have the ability to offer some, and more are being explored in the clinical research setting. It’s exciting for me that we can offer patients such approaches when appropriate.
Have you found that some targeted therapies work better for people with gynecologic cancers?
There are certain targeted therapies that are working very well and are either preventing recurrence or delaying recurrence in patients. One of these 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.
The checkpoint inhibitor pembrolizumab has proven to be highly effective in certain types of endometrial cancer and also in some other gynecologic malignancies. There is also another drug called lenvatinib, that blocks certain proteins that might help keep cancer cells from growing and kill them, that has been shown to be effective, particularly in combination with pembrolizumab, for patients with endometrial cancer.
The monoclonal antibody bevacizumab, which we have been using for many years, is still very effective.
There are other targeted therapies in the pipeline or being studied currently for which we do not yet have results, but we are hoping that these will prove to be of additional value in the armamentarium for treatment of these conditions.
What should people expect when they see you for cancer care?
Patients should expect that they will be met with respect and with expertise across the board. They also will be met with a team approach to care, which in my opinion is the key issue. No one physician knows everything, and it is important to have different perspectives, which is how our diagnosis management groups work. It is a team approach to care with access to everything that a patient would need.
NYU Langone Hospital—Long Island is a tertiary care center, meaning we provide specialized care. If a patient needs quaternary services, or even more specialized care, those are available at NYU Langone locations in Manhattan. As part of the NYU Langone system, we can offer the entire gamut of what is available in medical care. Time and again, we have had patients who have gone elsewhere for opinions and have come back to us and told us that what we recommended is what other doctors recommended.