Oncogynecology in Russia
How to be treated for cancer without crossing state borders
Vladimir Nosov, oncogynecologist - about robots in the operating room, gender inequality and some features of Russian medicine. Alexey Aleksenko was talking.
Photo: Maxim Novikov
According to statistics, almost one fifth of all cases of cancer in women in Russia are due to ovarian, cervical and uterine body cancer. Oncogynecology is engaged in their treatment and prevention – a branch of medicine at the junction of oncology, gynecology and endocrinology. Vladimir Nosov is the only specialist in Russia certified and licensed in obstetrics, gynecology and oncogynecology in the USA. In recent years, doctors of his specialty have learned what recently seemed unthinkable: to save patients not only life, but also the opportunity to have children. We talked about how oncogynecologists achieve such a result.
Over the past decades, statements about breakthrough discoveries in therapeutic oncology have been made many times, Nobel Prizes have been awarded. Some researchers predicted that soon an oncologist surgeon would be needed only to take a biopsy from a patient.
All new methods of treatment, such as targeted therapy or immunotherapy, are relevant most often in the case of relapses when the tumor has returned, or as an additional treatment after surgery. As for surgeons, they figure in the early stages of the disease. But we must understand that the "man with a scalpel" is also not the same as he was 20 years ago. There have been tremendous changes in surgery over the past decades.
How does today's oncosurgery differ from the one that was at the turn of the millennium?
Firstly, surgery has become minimally invasive: endoscopic techniques are increasingly being used, that is, penetration into the abdominal cavity through a small puncture. In Russia, the path of this technology in oncology was particularly thorny. To this day, old oncologists tell patients that laparoscopy will kill them, that it will spread cancer cells throughout the body, that it worsens prognoses, that without open access it is impossible to accurately determine the boundaries of the tumor. In America, Europe and Israel, endoscopic surgery has already become the standard twenty years ago. This process is slower in our country. It has moved forward largely thanks to the efforts of Academician Leyla Vagoevna Adamyan, who has been working on this topic in gynecology for several decades.
And then came robotic surgery. I performed my first operation using a robotic system in 2008, when I was still working in the USA at the University of California Medical Center. In Russia, this technology began to be introduced years later, EMS doctors were among the first in the country. Robotic surgery provides several additional advantages: in addition to the convenience for the surgeon, thanks to more powerful optics and incredible capabilities of instruments, the operation takes place with minimal blood loss, more thin nerve endings are preserved, which are very important for the subsequent normal functioning of the pelvic organs.
Ɔ. Do you mean to say that a robot removes a cancerous tumor?
In fact, the robot is only an intermediary between the surgeon and his instrument. He does not make independent decisions, but represents a kind of additional protection – he extinguishes sudden movements, analyzes the movements of the surgeon and selects the most accurate ones from them.
How do these technological innovations affect the effectiveness of treatment?
The robot will "improve" the surgeon's hands and eyes several times. Partly because of this, we began to carry out more organ-preserving operations. In the case of oncogynecology, this is especially important, because it is often about, among other things, keeping a woman able to give birth to a child.
So you are offering a woman a choice: to risk her life, but keep the opportunity to have children?
No, we do not offer to choose between your own life and the birth of a child, it would be unethical. We say: let's save the reproductive function in addition to treatment. And it won't steal a single percent of your forecast. Often such a conversation is not easy, because the patient is confused, he is stunned by the diagnosis. You talk about preserving organs and you hear in response: "No, no, I would like to survive on my own." But those who agree with our arguments are always grateful afterwards that we convinced them to follow this path.
Ɔ. What happens to those who have finally decided?
When we finish treatment and when it is oncologically safe, we refer patients to our colleagues-reproductologists. Today they have much more tools to get pregnant in even difficult situations. If a patient has hormone-sensitive cancer, we spend one or even two "emergency" IVF cycles before starting chemotherapy, which is very likely to seriously damage the function of the ovaries, without wasting time, we extract mature eggs from the ovaries and save them. At the same time, special drugs are used that, while maintaining high efficiency, do not increase estrogen levels above natural physiological parameters, so as not to stimulate the estrogen receptors of the tumor.
If there is no time for stimulation, you can remove the ovary or part of it before starting radiation or chemotherapy and freeze the tissue. After treatment, if there are no contraindications from an oncological point of view, we plant the tissue back or get the eggs in the laboratory.
Finally, if the patient is planning radiation therapy on the pelvic area, we have the opportunity to remove the ovaries from the zone of future radiation before the start of treatment. Then after the end of treatment, again in the absence of contraindications, IVF can be performed and mature eggs can be obtained. Then they are fertilized and in the form of an embryo are planted by a surrogate mother. Thus, we preserve the possibility for a woman to have biological children in the future.
If you have a brave, highly educated and "evidence–based" reproductologist, a competent embryologist and a progressive erudite oncogynecologist who knows when it is safe, such a group of specialists can work wonders for people who at the beginning of this path believe that reproductive function is lost forever.
Sexism in nature
It seems that nature is very unfair to women: nevertheless, male reproductive oncological diseases appear more often in old age.
Yes, for men, the most common diagnosis is prostate cancer, and it comes later. In young women, the most common cause of malignant tumors is papillomavirus, or HPV. This is a disease of young women. Risk factors – early sex, a large number of sexual partners, many children, long-term use of contraceptives. By the way, condoms in no way protect against papillomavirus. Men are an effective carrier, but penile cancer is a rare diagnosis in our country. Cervical cancer is diagnosed much more often. But here's what I want to say: since 2001, there has been a vaccine for the prevention of infection with papillomavirus. It is used from the age of nine in girls and boys. Vaccinated patients practically do not suffer from cervical cancer. This is a huge breakthrough in medicine. But in Russia, vaccination coverage is depressingly low, about 7-8 percent versus 75 percent in the Scandinavian countries, Australia and New Zealand. According to the latest data, HPV vaccination is effective up to 45 years.
At the EMC, we strongly recommend it to our patients and their children.
Another gender injustice is associated with the BRCA1 and VRCA2 genes, which have received wide publicity thanks to Angelina Jolie. These genes are part of a fundamental biological mechanism common to both sexes, but for some reason their effect on breast cancer is much stronger than on all other cancers.
Yes, in men, mutations of these genes increase the risk of prostate cancer by up to 30%, as well as breast cancer tenfold, but in absolute numbers, the latter is not very significant. And in women with a mutation of the first type, the probability of getting breast cancer is 60-80 percent: two out of three carriers of the mutation will get breast cancer, in the case of ovarian cancer, this probability is about 50 percent. If a mutation is detected, patients automatically fall into a high-risk group and an individual intensive and earlier screening plan is developed for them. Breast examination is a little easier: MRI is alternated with ultrasound or mammography every six months. This usually allows you to detect cancer at an early stage. In the case of ovaries, everything is more complicated: there are still no tools for early diagnosis in the world. Ovarian cancer sometimes develops to the third stage in a few months. The best thing in terms of diagnosis is periodic ultrasound and cancer marker CA-125, and in terms of prevention – regular monitoring by an oncogynecologist and constant intake of oral contraceptives. It is known that this reduces the risk of ovarian cancer, including in carriers of the mutation. However, the main measure that reduces the risk, even if not to zero, but close to it, is preventive surgery.
Ɔ. Have you ever had patients who wished to have preventive surgery based on genetic tests?
They happen all the time. I have been interested in this topic since my days working in the USA. From 2005 to 2008, I worked at Cedar Sinai Hospital in Los Angeles. There are large settlements of Jews in this area, including Ashkenazi, and they have such mutations about 10 times more often than non-Ashkenazi. Therefore, we have seen a lot of mutation carriers (so far healthy and already ill). Then my interest in the genetic background of ovarian and breast cancer was born. Since then, many patients have come to me for counseling about the risks, as well as for treatment when mutations have already been identified.
Ɔ. Are such operations carried out in Russia?
If there are genetic risks, at the request of the patient, after a detailed consultation, preventive removal of appendages can be carried out. Of course, in this case, the patients sign a consent that they will not be able to have their own biological children. Women come either because they have already been diagnosed with breast cancer, or oncological diseases are found in relatives of the first generation – mothers or sisters. We refer such patients to genetic counseling. They usually don't even need to be convinced that this is important.
How often do Russian oncologists generally consider the option of preventive surgery?
Not often. For many, the benefits of this are not yet obvious. After all, this is a new concept: a risk-reducing procedure.
Where exactly to operate
Ɔ. In certain circles, there is an opinion that with an oncological diagnosis it is necessary to go to Germany or Israel. It's true?
This was true until recently. But about five years ago I noticed a certain fracture. Previously, by default, if there was a minimum amount of money, people left, had an operation, then returned and came to Russian oncologists for observation. Now patients are more likely to seek a second opinion. Many people come to us. They understand that our competitors are just foreign clinics, not city hospitals. In the EMC, almost every specialization has a doctor who has worked in Europe, the USA or Israel, and not just interned, but was part of that system. Young doctors study with him, he develops protocols and treatment algorithms.
And when they ask me if I need to take my mother to Germany, I answer: "Germany is already here." I'm not talking about our equipment, which is often better than what I see in the States. Sometimes after surgery, patients leave for a second opinion and then say: "You know, the doctor was impressed with the result of the operation, sang your praises." It's nice to hear this, especially since the cost of treatment is significantly lower.
But, working in Russia, you are bound by the clinical recommendations of the Ministry of Health, which you must follow under pain of prosecution.
Fortunately, they limit us only from below. They set the minimum of research and treatment that we have to offer. There is no restriction from above.
As far as I know, some modern methods are not available in Russia.
There is nothing in the field of radiation therapy that we cannot offer to our patients. In chemotherapy, there is also no, if we do not talk only about a few targeted drugs that have not yet been registered in Russia. The absolute majority of European standards of postoperative treatment are available in Russia, at least in the EMC.
How does the cost of treatment in your clinic compare with that of foreign competitors?
On average, robotic and laparoscopic operations in Germany and Israel cost twice as much as they cost in our country.
Ɔ. And if we compare it with private clinics in Russia?
We have a different philosophy. Often a person goes to a private clinic and pays 3,000 rubles for an appointment – it's not very expensive. But, before receiving a diagnosis and recommendations for treatment, he must come three or four times. And we are working for a reputational advantage. Our admission fee includes initially the most informative consultations and there is no motivation for doctors to "knock out" extra money from patients for unnecessary examinations.
Finally, please formulate the most important thing that you would like to say to your potential patients.
Probably, I would like to convey to them the idea of organ preservation in oncogynecology. Often these are young patients, they get lost, go in circles from the oncologist to the reproductologist and back, do not reach the doctor who will coordinate and implement all this. And this story only works if you run it from beginning to end. You see, a radical approach to tumor removal is not a new concept, it is 150 years old. Of course, now we have a much better understanding of the mechanisms of metastasis, we know the ways of spread, we take into account the probability of lymph node damage. But the organ-preserving philosophy itself was born recently. Even ten years ago, we had the courage to do much less than we do now. And there have already accumulated a lot of stories of preservation of reproduction and the birth of children in our patients. They gave birth, despite the fact that ten years ago such an outcome was absolutely incredible.
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