Oncologist: Early diagnosis would improve cure rates

The benefits of robotic-assisted surgery on gynecologic cancers can make the difference on the patient's fertility, quality of life and even survival, according to gynecologic oncologist Dr. John Bomalaski.

"The primary reason we offer robotic surgery for cancer staging is that, in those patients that need other therapies like radiation or chemotherapy, they can tolerate those therapies better, they can get their therapies started much faster and, more importantly, they are less likely to stop their therapies early because of other problems," he said. "For those patients who don't need any additional therapy, it's pretty much icing on the cake. They feel better faster.''

Bomalaski talked about his specialty and the need for earlier detection for better treatment outcomes.

QUESTION: Did you always expect to go into medicine as a career?

Bomalaski: Yes. My father was a psychiatrist; my brother is a pediatric urologist.

Q: Where and when did you choose your specialty?

Bomalaski: When I went to medical school, everything I did I was just, "gosh, this is cool. I could do this." Ultimately, it came down to who did I see, who did I look up to. It was one of the physicians I met that was a GYN oncologist.

Q: Has you job changed over your career?

Bomalaski: If I look back now to my GYN oncology training in residency and in fellowship to now, there's a substantial difference with minimally invasive surgery, with the range of chemotherapies and the supporting agents for people who are getting chemotherapy — all those are changing. A lot of the chemo is the same but it's the supporting drugs that have gotten better.

Q: What has improved during your career, is it in the area of better diagnostics?

Bomalaski: If you look at the aspects of our practice, the largest part is the surgical component, next is the medical treatment component (chemotherapy, biological treatments) and next is the diagnostic, because most patients have either suspicion or diagnosis before we treat them.

Q: What cancers do you treat most often?

Bomalaski:The most common is uterine cancer; the second type would be ovarian and next is cervical. A good portion of our practice is the evaluation and treatment of pelvis masses, precancer and surgeries for patients who have difficult surgeries for various reasons. The importance of getting the right surgery initially is so important for ovarian cancer. We're very aggressive to remove as much of the visible cancer as possible and it's very important that they are done in the right scenario and in the right way. Essentially, that's really what GYN oncology training is: treatment of these more complex, more difficult type of surgeries.

Q: What is the goal for younger women? Is it the ability to still have children?

Bomalaski: For young patients who still wish to preserve fertility, we address the need of treating the cancer in the best potential way and hopefully be able to maintain fertility, but we're not going to jeopardize somebody's life to do it. The way I explain it to patients is that our primary goal is them and our secondary goal is fertility. It doesn't make sense to achieve your secondary goal if you can't achieve your first. It depends a lot on the scenario. There are many of cancers where we can preserve fertility. There are some cancers that we know we're going to have to disrupt fertility and there are other reproductive options for those patients like ovarian donation.

Q: Has your job changed much with the advent of robotic-assisted surgery using the da Vinci system?

Bomalaski: The best way to think of it is that it's just a tool. It doesn't do the surgery, it's just a tool. Whether we're talking about tools that are in our hands, or long tools that are laparoscopic or robotic, they have the same idea of the surgery. The technique may have changed a little bit but the ultimate goal of the surgery is the same. It really changes just how we get to the places to do it. Minimally invasive surgery doesn't mean minor surgery. It means the way we get in there is small and ultimately recovery is much faster.

Q: What is it about robotics that helps: the reach, the optics or is it the precision?

Bomalaski: I think it's a combination of all those. The 3-D visualization definitely helps. Straightforward laparoscopic surgery in the past was just 2-D, like looking at a TV set, and it was very difficult to have depth perception. Robotic surgery with da Vinci allows you to do very precise, difficult surgery in a very small space. You can see better and your articulation is better, too. The way to think of it is that straightforward laparoscopy is like having your arms in casts and doing things where robotic is freeing it up where you have a wrist and it goes all the way around.

Q: What about surgeon fatigue?

Bomalaski: Yes. After three or four difficult laparoscopic cases, I was pretty wiped out at the end of the day, but robotically you're not. It's not to replace laparoscopic surgery; it's replacing open surgery.

Q: What is on the horizon in your field?

Bomalaski: With every tool that we have, we realize there are limitations to that, too, and there are people out there that are looking at how to overcome those limitations. There are limitations to it now.

Q: What area of your specialty would you most like to see progress made?

Bomalaski: Ultimately, better means of diagnosing would result in better cure rates and prevention. Better means of preventing cancers and better means of early detection. Our bad cancer is ovarian cancer. Over 80 to 90 percent are discovered in advance disease. If we had a means of detecting ovarian cancer at an earlier stage, then we would have a higher likelihood of better outcomes.

Q: What are some common symptoms with gynecologic cancers?

Bomalaski: Symptoms of ovarian cancer are very subtle and are common GI symptoms: bloating, fullness, constipation, pressure, abdominal pain. All those symptoms can be common from another illness, but when the work up doesn't show those, then it's important for ovarian cancer to be somewhere in the thought process. It doesn't necessarily have to be first, but it needs to be in the thought process. Endometrial cancer is shown by postmenopausal bleeding.

Q: What is your favorite part of your job?

Bomalaski: You can't always cure every patient but you can make any patient's life better, and in doing that, I think it's very rewarding. My favorite part is when you get the feedback from patients that you're doing a good job. When you hear from a patient that this is one of the worst experiences that they've ever gone through but, because we were there for them, we made it better. I also love OR and surgery.

John Bomalaski, 51, gynecologic oncologist

Hometown: Indianapolis; raised in Jasper, Indiana

City of residence: Merritt Island

Family: Wife, Laura; son, Ryan, 26; daughters Julia, 24, Michelle, 22, Andrea, 20.

Hobbies: Running, fishing, cards

Education: Bachelor's degree in chemistry, Depauw University, Greencastle, Indiana; Indiana University School of Medicine, Indianapolis; residency in OB/GYN, Indiana University School of Medicine; fellowship in gynecologic oncology, University of South Florida, Tampa

Contact: Health First Cancer Institute; 321-752-0944 or hfcancer.org