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Baltimore, MD

Dr. Robert Bristow is an associate professor in Johns Hopkins School of Medicine's Department of Gynecology and Obstetrics and the director of the Kelly Gynecologic Oncology Service at the Johns Hopkins Ovarian Cancer Center. For Cervical Cancer Awareness Month in January, Bristow discussed the move toward robot-assisted minimally invasive surgery and how to reduce cervical cancer rates. More than 11,000 new cases of cervical cancer will be diagnosed in the United States this year, and 3,870 people are expected to die from the disease.

What kinds of gynecologic cancers are there, and are you more focused on cervical cancer?

The three main gynecologic cancers are ovarian, endometrial and cervical cancer. Endometrial is uterine cancer, and that's the most common. Ovarian is the second-most common, but has the highest mortality rate. Ovarian cancer by itself has a higher mortality rate than cervical and uterine combined. It tends to present at a more advanced stage. It's harder to detect early and harder to treat in an advanced stage.

Cervical and uterine tend to present at an earlier stage, and therefore have a higher cure rate.

One of my principal areas of interest is surgery and surgical techniques and research, and one of the things I have been very excited about in the last 12 to 18 months is [the] push to start doing surgeries for cervical cancer and uterine cancer using a minimally invasive approach using the robot.

How does it work?

With standard laproscopic surgery, which is known as keyhole surgery, you are doing an operation in the abdomen through three or four very small incisions using instruments that are a foot or a foot-and-a-half long.

There is a fairly flat learning curve for that. It takes a long time to get proficient in operating that way, because you are operating at the end of a stick, and all your motions with your hands are in reverse.

The robotic surgery is a system set up with computer-enhanced instruments that are similar to the laproscopy instruments but the surgeon sits at a console 10 or 15 feet away from the patient.

The advantage is the instruments are wristed so they can move like the human wrist, so you have about 270 degrees of motion. There are two optical tubes so when you sit down at the console, you are seeing it in three dimensions.

It really expands our capabilities in terms of what we are able to do from a technical standpoint. It's faster and it's also better for the patients.

Patients have virtually no pain after this procedure. You go and see them the day after the surgery and they are up packing their bags getting ready to get out of the hospital after a radical hysterectomy for cervical cancer, where they would normally be in the hospital for three or four days.

So what is the catch?

Part of the catch is for a hospital, there is a big capital investment and the expense to invest in the robot. And there is a learning curve to it.

It's much easier to learn than straight laproscopy, but you can't take someone without any prior experience and sit them down at the console and expect them to be able to do the operation in a reasonable amount of time.

You are using this with cervical and uterine cancer and some early ovarian cancers. Why not more ovarian cancers?

About 70 percent of ovarian cancers present with advanced disease where the tumor has spread out of the ovaries and the uterus and is in the colon or the liver. The goal for those surgeries is to do a debulking, which is basically to get all the cancer out you can see. That is not a procedure that lends itself readily to the keyhole surgery.

How did you get interested in this field of gynecologic oncology?

I ultimately decided to go into obstetrics/gynecology for a selfish reason. It was the rotation I had as a medical student I had the most fun on. I originally wanted to go into just obstetrics, because that was the most enjoyable to me.

Then I came to Hopkins for my residency and the first rotation I did was oncology. I started on July 1, and by the Fourth of July, I knew this was what I wanted to do.

The patients were so sick and so challenging, and they were really the patients that needed someone to take care of them. I really gravitated to that.

Isn't it hard to cope with patients that don't always have good outcomes?

It has a lot to do with your perspective and the old adage of whether the glass is half-empty or -full.

We are always going to hope to cure the cancer, but realistically we aren't going to be able to do that for everybody. We may not even do that for most people.

The question becomes how are you going to help the folks that aren't going to survive their cancer really survive in the time they have left and have a good quality of life.

Have screening techniques improved for cervical cancer?

I think we are getting better. The Pap test is the conventional test for cervical cancer. It has its limitations. It's not a perfect test, and the reason women get annual tests is because it can miss some signs of early cancers. But if you string together enough tests in a row, you will be likely to pick them up.

One of the things that came out about five years ago or so is the idea of testing for the human papillomavirus, or HPV, which is a causative agent for about 90 percent of cervical cancers. Now that can be coupled with the Pap test to identify a higher-risk population of women who may benefit from a more aggressive screening program.

So I think those two testing tools are probably as good as we really need to identify precancer and be able to treat it.

But the big problem we have with cervical cancer is access to screening techniques.

If you could guarantee that every woman in Maryland could get a Pap test plus or minus an HPV test for her whole life, we could probably eradicate cervical cancer.