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Robot to the Rescue

Story by Mary Ann Littell  •  Portraits by John O'Boyle         View the complete magazine | Subscribe to Cancer Connection


Low-tech screening for cervical cancer coupled with high-tech treatment has Luisa Manriquez-Fernandez back to taking care of her busy family, thanks to a dedicated team at Rutgers Cancer Institute.  

"Making time for me" isn't in Luisa Manriquez-Fernandez's vocabulary. Raising three children, life is a whirl of activity: school, homework, sports, play dates, college applications, and other family activities. Like many busy parents, she puts her own needs last. 

That includes her Pap smear. Simple and inexpensive, this cervical cancer screening detects abnormal cells before they turn into cancer.  According to the American Cancer Society, the Pap smear is the main reason cervical cancer deaths have dropped by more than 50 percent over the past four decades. Unfortunately, too many women overlook this screening, only to regret it later. 

In July 2017 Manriquez-Fernandez went for a Pap smear at Planned Parenthood in Hamilton, New Jersey, where she lives. "I hadn't had one since my twins were born nine years ago," she notes. "Unfortunately, I waited too long. The test was abnormal, so the doctor did a biopsy and found malignant cells. They said I'd need to see a specialist. I was shocked."

At forty-four, Manriquez-Fernandez says she's rarely had a sick day until now. She works part-time as a cook at a Trenton cafe specializing in Central American food. She's also a mother of three: 22-year-old daughter Yesenia, who studies biology and dental hygiene at Rowan University with a goal of becoming a dentist; and twin boys, Gabriel and Axel. She works mostly mornings and early afternoons so she can be home for her family.

Manriquez-Fernandez knows the devastation cancer causes, having watched her own mother succumb to colon cancer in 2000, five years after the family emigrated from Chile to New Jersey. "My mother was diagnosed in 1995 and had a tough time. Losing her like that…it was very sad," she says. 

She admits that she was initially somewhat in denial about her illness. "It hadn't really hit me that I had cervical cancer. I looked up the symptoms online and didn't have any of them. I felt fine." Cervical cancer frequently presents without symptoms, particularly in the early stages. It is the third most common gynecologic cancer in the United States, killing an estimated 4,200 women a year, according to the American Cancer Society. Manriquez-Fernandez had also tested positive for high-risk human papillomavirus, or HPV, which causes virtually all cases of cervical cancer. 

Luisa Manriquez-Fernandez with Hipps and Girda 

When Luisa Manriquez-Fernandez (left) was referred to Rutgers Cancer Institute, she first saw Linda Hipps, MD, FACOG, (top right) who serves as a bridge between the general gynecology program and the Gynecologic Oncology Program. "Everyone here is focused on making each patient's care the best it can be," says her surgeon, Eugenia Girda, MD (bottom right).

She was referred to Rutgers Cancer Institute of New Jersey, where she saw Linda Hipps, MD, FACOG in September 2017. As a general gynecologist-not an oncologist-in the Gynecologic Oncology Program, Dr. Hipps serves as a bridge between the two services. She's often the first stop at Rutgers Cancer Institute for gynecologic patients referred from community physicians and hospitals.

The 'bridge' concept is a strategy Rutgers Cancer Institute and other National Cancer Institute (NCI)-designated centers utilize as a way of opening doors to care. Anyone with cancer knows that finding treatment can be a complex and time-consuming process involving a myriad of scans, tests, second opinions, and referrals; getting a definitive diagnosis; and locating the right specialists. The bridging physician serves as the ultimate patient navigator, seamlessly transitioning patients into care. 

"Once you're in our system, we'll take care of you in an efficient, timely manner," says Hipps, who is also an assistant professor of obstetrics, gynecology and reproductive sciences at Rutgers Robert Wood Johnson Medical School. "When I see a patient I explain what treatment she needs and refer her to one of my colleagues. It's a great example of team care."

Hipps performed a colposcopy, an excisional biopsy done microscopically, and made the diagnosis of early-stage cervical cancer. "What I hoped was just a few cancerous cells turned out to be far more serious that I thought," says Manriquez-Fernandez. "Now I had to see an oncologist and that made me even more terrified."

"At least 50 percent of cervical cancers in the U.S. are diagnosed in women who have not had a Pap smear in more than five years," explains Hipps. "It's so important for women to get that Pap test regularly, including HPV screening." Current guidelines call for Pap tests every three years for women ages 21 to 29; and every five years for women ages 30 to 65. Women with a history of cervical cancer and/or HPV infection may need more frequent screening. (For more information, see ACOG.org/Patients/FAQs/Cervical-Cancer-Screening.)

The low-tech Pap smear detected Manriquez-Fernandez's cancer. Now high-tech surgery would offer a cure. In early November 2017, she saw Eugenia Girda, MD, who's one of five surgeons in Rutgers Cancer Institute's Gynecologic Oncology Program. This team is highly trained in robotic techniques. This specialty differs from other specialties in that gynecologic oncologists take a multidisciplinary, 'one-stop shop' approach to treatment, from diagnosis and surgery through chemotherapy if needed. 

"This patient needed a robotic radical hysterectomy with lymph node dissection. It's quite a complex procedure," explains Dr. Girda, who is also an assistant professor of obstetrics, gynecology and reproductive sciences at Rutgers Robert Wood Johnson Medical School. "In a regular hysterectomy, only the uterus and cervix are removed. In the radical hysterectomy we remove the cervix and uterus, as well as all the connective tissue along the cervix and uterus, known as the parametrium.  This often involves a meticulous and 'radical' dissection around vital organs and blood vessels, making this a much more technically challenging procedure." 

Because Manriquez-Fernandez is relatively young with early-stage disease, Girda would try to preserve her ovaries. A final decision would be made during the procedure.  

"Both doctors were so warm and helpful. They explained everything to me very clearly," notes Manriquez-Fernandez. "Dr. Girda even drew diagrams for me. She gave me her direct phone number and told me to contact her any time if I had questions." 

Manriquez-Fernandez had heard of robotic surgery but didn't know much about it. This type of procedure offers many benefits over traditional open surgery, which requires a long incision. These advantages include shorter hospitalization and recovery time. There is less pain and blood loss and fewer complications, such as infections. "The recovery time for an open procedure is approximately six weeks, but our robotic surgery patients often return to normal activity within three weeks," observes Girda.

She describes other advantages in coming to an NCI-designated Comprehensive Cancer Center: "We offer the latest technologies, including 4-D visualization, which allows very precise surgery and fine dissections. We have a multi-specialty team caring for patients. Our surgeons are highly trained experts at what they do. We also have a gynecologic pathologist on our team who assesses only gynecologic cancers. And each division has its own tumor board to share knowledge about complex cases. Everyone here is focused on making each patient's care the best it can be." 

The four-hour procedure was performed in early December 2017 at Robert Wood Johnson University Hospital, an RWJBarnabas Health facility. Five small incisions are made in the abdomen, through which robotic instruments and a tiny camera are inserted. Girda manipulates the instruments at a computer console. Great care must be taken in removing the parametrium, which is near vital blood vessels. The surgeon must maneuver around the bladder and rectum too.

Luisa Manriquez-Fernandez 

"It was amazing. I'd just had major surgery, but only had five small incisions that healed very quickly," says Luisa Manriquez-Fernandez.

Manriquez-Fernandez's fallopian tubes were removed with the uterus to reduce the risk of developing ovarian cancer in the future. The ovaries were not removed because the risk of having an ovarian malignancy was exceptionally low (less than 5 percent). "We always try to keep the ovaries whenever possible," states Girda. "Removing them puts the patient in surgical menopause, meaning she will not produce estrogen. Lack of estrogen is linked to higher risk for osteoporosis and heart disease." 

The ovaries were relocated-brought out of the pelvis and sutured them to the side of the abdominal cavity. "Sometimes patients need radiation therapy," explains Girda. "If we leave the ovaries where they are anatomically, they'd be in the path of the radiation and would become nonfunctional, putting the patient into early menopause." Lymph nodes were also removed and sent to pathology, and the results were negative.

After spending a few hours in recovery, Manriquez-Fernandez's fiancé, Jeiner Alfaro, brought her home. "I was in some pain and very tired so I went straight to bed," she says. "The next day I felt better. It was amazing-I'd just had major surgery, but only had five small incisions that healed very quickly. I've talked to women who had open surgery hysterectomies and their recovery was much more difficult."

Over the next few days she felt a few twinges of pain, but they disappeared. Three weeks after the surgery she was pretty much back to normal. "I have not gone back to work yet because my job requires a lot of lifting bags of ingredients and heavy pots and pans," says Manriquez-Fernandez.  "Dr. Girda says that for the first two months following the surgery I should not lift anything heavier than ten pounds."

Best of all, Manriquez-Fernandez is cancer-free. "Her prognosis is very good," says Girda. "She needs no further treatment, no chemotherapy or radiation." Manriquez-Fernandez plans to return to work in the spring. She'll receive vigilant follow-up care, with visits to Girda every three months for two years. 

"If this type of cancer recurs, that tends to be in the first two years," says Girda. "When that happens the gynecologic oncologist is trained to manage the patient's chemotherapy. We can tap into the resources of Rutgers Cancer Institute, including clinical trials and the availability of targeted therapies."

"When my mother got cancer she really suffered and there were no treatments for her," says Manriquez-Fernandez. "What I went through was very easy compared to that. I only wish this new technology had been there for her." ■

 

 

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